Citation Nr: 1318952 Decision Date: 06/11/13 Archive Date: 06/21/13 DOCKET NO. 07-22 019 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus, type II, and/or coronary artery disease. 2. Entitlement to an initial rating in excess of 10 percent for coronary artery disease. 3. Entitlement to an initial rating in excess of 30 percent prior to August 2, 2007, for posttraumatic stress disorder. 4. Entitlement to a rating in excess of 10 percent for right lower extremity peripheral neuropathy. 5. Entitlement to a rating in excess of 10 percent for left lower extremity peripheral neuropathy. 6. Entitlement to a total disability rating based on unemployability due to service-connected disability. REPRESENTATION The Veteran is represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. Pflugner, Counsel INTRODUCTION The Veteran served on active duty from January 1969 to August 1970. This case comes to the Board of Veterans' Appeals (Board) from a June 2012 memorandum decision issued by the United States Court of Appeals for Veterans Claims (Court) that vacated a portion of a November 2010 Board decision that denied the issues of entitlement to service connection for hypertension, a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to August 2, 2007, and ratings in excess of 10 percent for right and left lower extremity peripheral neuropathy. The Court remanded these issues to the Board for consideration consistent with the June 2012 memorandum decision. With respect to the issue of entitlement to an initial rating in excess of 10 percent for coronary artery disease, this claim was previously before the Board in November 2010 at which time it was remanded for additional development. This claim has been remitted to the Board for further appellate review. In the June 2012 memorandum decision, the Court did not disturb the Board's November 2010 decision to deny a rating in excess of 70 percent on and after August 2, 2007, for the Veteran's PTSD. The Court similarly did not disturb the Board's decision with respect to the Veteran's claim of entitlement to increased ratings for his service-connected diabetes mellitus, type II. As a matter of history, with respect to the issue of entitlement to a rating in excess of 30 percent prior to August 2, 2007, for PTSD, this matter originally came before the Board in November 2010 on appeal from a March 2004 rating decision by a Department of Veterans Affairs (VA) Regional Office in Huntington, West Virginia (RO). During the pendency of this appeal, via an October 2007 rating decision, the rating assigned to the Veteran's PTSD was increased to 70 percent, effective August 2, 2007. The following issues were also before the Board for the first time in November 2010 on appeal from a July 2006 rating decision by the RO: service connection for hypertension, to include as secondary to diabetes mellitus, type II, and/or coronary artery disease; an initial rating in excess of 10 percent for coronary artery disease; a rating in excess of 10 percent for right lower extremity peripheral neuropathy; and a rating in excess of 10 percent for left lower extremity peripheral neuropathy. In the November 2010 decision, the Board found that a rating in excess of 30 percent prior to August 2, 2007, and a rating in excess of 70 percent on and after August 2, 2007, both for PTSD, was not warranted. The Board further found that service connection for hypertension was not warranted, and found that a rating in excess of 10 percent was not warranted for either the Veteran's right or left lower extremity peripheral neuropathy. The Veteran appealed these decisions to the Court. As mentioned above, in a June 2012 memorandum decision, the Court vacated the portion of the Board's November 2010 decision pertaining to these issues, and then remanded the issues to the Board for additional consideration. In the November 2010 decision, the Board also remanded the issue of entitlement to an initial rating in excess of 10 percent for coronary artery disease. After undertaking the directed development, the RO re-adjudicated the Veteran's claim, continuing the denial of an initial rating in excess of 10 percent; issued an October 2011 supplemental statement of the case; and then remitted the claim to the Board for further appellate review. Consequently, all of the above-captioned claims are properly before the Board for further appellate review. Subsequent to the Court's June 2012 memorandum decision, the Veteran submitted a statement wherein he asserted that he was entitled a total rating for his service-connected PTSD. In support of this assertion, he submitted additional evidence, and specifically elected not to waive RO consideration thereof. 38 C.F.R. § 20.1304(c) (2012). Upon review of this evidence, the Board finds that it consisted of, in relevant part, reports demonstrating treatment for PTSD after August 2, 2007. The Board finds that this evidence is not pertinent to the issue of entitlement to a rating in excess of 30 percent prior to August 2, 2007, for the Veteran's service-connected PTSD. As such, the Board will address that claim on the merits herein. Given that the Court did not disturb the Board's November 2010 decision insofar as it pertained to the Veteran's claims of entitlement a rating in excess of 70 percent on and after August 2, 2007, for PTSD, or increased ratings for diabetes mellitus, type II, these claims are no longer pending before VA. The Board finds that the evidence submitted by the Veteran after the Court issued the June 2012 decision constitutes a new claim of entitlement to a rating in excess of 70 percent for the Veteran's PTSD and a new claim of entitlement to a rating in excess of 40 percent for his diabetes mellitus, type II. As these issues have not been adjudicated by the RO, the Board does not have jurisdiction over them, and they are referred to the RO for appropriate action. 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. Rice v. Shinseki, 22 Vet. App. 447 (2009). Prior to August 2, 2007, the Veteran did not argue, and the record does not otherwise reflect, that his PTSD rendered him totally unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised prior to August 2, 2007 and, thus, said claim will not be addressed herein. With that said, however, the Board finds that the Veteran's assertion that he is entitled to the maximum 100 percent rating for his service-connected PTSD reasonably raises the issue of entitlement to TDIU. Id. As the matter of a entitlement to a TDIU is inextricably intertwined with the outcomes of other issues remanded to the RO, it too is remanded for appropriate action by the RO. As will be discussed in the REMAND section below, the Board finds that the evidence submitted by the Veteran subsequent to the Court's June 2012 memorandum decision is pertinent the non-PTSD claims presently within the Board's jurisdiction. Because the Veteran specifically elected not to waive RO jurisdiction of this evidence, and given that the additional development of these claims is required, the issues of entitlement to service connection for hypertension, to include as secondary to diabetes mellitus, type II, and/or coronary artery disease; entitlement to an initial rating in excess of 10 percent for coronary artery disease; entitlement to a rating in excess of 10 percent for right lower extremity peripheral neuropathy; and entitlement to a rating in excess of 10 percent for left lower extremity peripheral neuropathy, will be addressed in the REMAND portion of the decision below and are remanded to the RO via the Appeals Management Center in Washington, DC. FINDING OF FACT Prior to August 2, 2007, the Veteran's PTSD was manifested by depressed mood, anxiety, irritability, hypervigilance, insomnia, nightmares, difficulty adapting to stressful circumstances, difficulties establishing and maintaining effective relationships, and some memory and insight deficits, and he was assigned GAF scores of, predominately, 45. CONCLUSION OF LAW The criteria for an initial rating of 50 percent, but not more, prior to August 2, 2007, for PTSD were met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Because the March 2004 rating decision granted the Veteran's claim of entitlement to service connection for PTSD, such claim is now substantiated. His filing of a notice of disagreement does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3). Rather, the Veteran's appeal as to the initial rating assignment triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The October 2005 statement of the case, under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," set forth the relevant diagnostic codes for rating the disability at issue and included a description of the rating formulas for the current evaluation and for all other higher evaluations. The Veteran was, thus, informed of what was needed to achieve a higher schedular rating. Thus, the Board finds that the Veteran has been informed of what was necessary to achieve a higher rating for the service-connected disability at issue. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996). The RO has obtained the Veteran's service treatment records and his identified VA and private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Further, there was no indication in the record that additional evidence relevant to the issue being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 120. Additionally, the Veteran was provided a VA examination in February 2004. The examiner took into account the Veteran's statements and relevant treatment records, and performed thorough clinical evaluations, which allowed for fully-informed evaluations of the claimed disability. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As such, the Board finds that VA's duty to assist has been satisfied. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination) (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). Historically, the Veteran served on active duty from January 1969 to August 1970. In June 2003, the Veteran submitted a claim of entitlement to service connection for PTSD. In a March 2004 rating decision, service connection for PTSD was granted and a 30 percent rating was assigned thereto, effective June 10, 2003. The Veteran perfected an appeal of this decision seeking a higher initial rating. During the pendency of this appeal, in an October 2007 rating decision, the rating assigned to the Veteran's service-connected PTSD was increased to 70 percent, effective August 2, 2007. In a November 2010 decision, the Board denied the Veteran's claim of entitlement to an initial rating in excess of 30 percent prior to August 2, 2007, and his claim of entitlement to a rating in excess of 70 percent on and after August 2, 2007, for his PTSD. The Veteran appealed the Board's decision to the Court. In a June 2012 memorandum decision, the Court vacated the Board's November 2010 decision, in relevant part, as it pertained to the issue of entitlement to an initial rating in excess of 30 percent prior to August 2, 2007, for the Veteran's PTSD; the Court did not disturb the Board's decision as to the issue of entitlement to a rating in excess of 70 percent on and after August 2, 2007, for PTSD. Specifically, with respect to the Veteran's claim of entitlement to an initial rating in excess of 30 percent prior to August 2, 2007, for PTSD, the Court found that the Board did not make any specific findings regarding whether the Veteran experienced deficiencies in most areas or had occupational and social impairment with reduced reliability and productivity due to certain symptoms. Further, the Court found that the Board failed to consider a June 2005 progress note, which indicated a Global Assessment of Functioning (GAF) score of 45. As such, the Court remanded the Veteran's claim of entitlement to an initial rating in excess of 30 percent prior to August 2, 2007, for PTSD for further consideration consistent with its June 2012 holdings. As such, the Board will address the merits of this claim herein. Generally, disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. This involves a factual determination of the current severity of the disability. Staged ratings are appropriate whenever the factual findings show distinct periods in which a disability exhibits symptoms that warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). PTSD is rated at 30 percent when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, and recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. In evaluating the evidence, the Board will consider the GAF scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). A GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. Id. A GAF score of 51-60 indicates moderate symptoms or moderate difficulty in social, occupational or school functioning. Id. A GAF score of 41-50 is assigned where there are, "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. In March 2002, a VA mental health physician performed an initial evaluation for depression and possible PTSD. The physician noted the Veteran's reports of daily nightmares and flashbacks of events in combat in Vietnam. The Veteran also reported daily feelings of depression, insomnia, irritability, and loss of interest in activities. The Veteran was working full-time in a VA pharmacy and reportedly got along well with family members. There was no history of previous psychiatric care or suicidal or homicidal ideations. On examination, the physician noted a mildly anxious mood, but no thought or cognitive deficits. The physician diagnosed chronic depression and possible PTSD, assigned a GAF score of 60, and prescribed anti-depressive medication. The Veteran participated in VA individual and group counseling programs for the next year. Counselors noted the same symptoms except that the Veteran reported that he separated from his spouse in 2001, but continued to visit his two sons. VA treatment reports dated during this period of time demonstrated that the Veteran's GAF score dropped first to between 55 and 60, and then dropped to 55. In an August 2003 letter, the Veteran's mother noted that he appeared to be depressed, distracted, and socially isolated after returning from Vietnam. She also observed the Veteran's irritability, unjustified anger, hypervigilance, insomnia, and flashback experiences. The Board concludes that the mother is both competent to report the observed symptoms and credible because they are consistent with those reported and observed in clinical settings. In February 2004, a VA psychiatrist noted the Veteran's reports of nightmares, flashbacks, insomnia, auditory hallucinations, hypervigilance, difficulty concentrating, exaggerated startle response, and a desire to remain apart from other people. The Veteran reported that the symptoms occurred daily and caused severe nervousness. The Veteran reported that he had been separated from his spouse for one year because of continuous arguments regarding financial decisions. The Veteran lived with his mother and visited his two sons regularly but had no close friends. On examination, the psychiatrist noted an anxious and depressed mood and affect. There were no thought process deficiencies, but there was a possibility of some cognitive deficits. Memory and grooming were fair, and insight was limited. The psychiatrist provided diagnosis of PTSD, related to combat trauma, and major depression, and assigned a GAF of 50 at the time of the examination. The psychiatrist then opined that intermittent symptom exacerbations would likely reduce the Veteran's GAF score to 45. VA counseling records showed that the Veteran participated in group therapy sessions through February 2005. Additionally, the Veteran underwent periodic individual assessments through July 2007 from a VA mental health clinic psychiatrist who continued to prescribe medications. These treatment records demonstrated no change in the Veteran's PTSD symptoms, and further demonstrated that the assigned GAF scores were predominately 45. Included among the group and individual group therapy records was a June 2005 treatment report. As discussed in the Court's June 2012 memorandum decision, in the November 2010 decision, the Board did not specifically discuss the June 2005 VA treatment report. The Court vacated the Board's November 2010 decision as it pertained to the issue of entitlement to an initial rating in excess of 30 percent prior to August 2, 2007, for the Veteran's service-connected PTSD. The Court then remanded the claim to the Board for additional consideration. According to the June 2005 treatment report, the Veteran stated that he was "not doing too well." He endorsed being under "a lot of stress," and that he had started working in a new area of the hospital. He stated that this was "very stressful" for him, which was made worse by intrusive thoughts, recurrent nightmares, and flashbacks. Due to these symptoms, the Veteran stated it was more difficult for him to focus at times. A mental status examination demonstrated the following symptoms: calm; cooperative; mildly anxious mood; appropriate affect; and no evidence of overt delusion. The Veteran denied any active suicidal or homicidal ideation. The assessment was PTSD, and a GAF score of 45 was assigned. Additionally, in the "plan" portion of the treatment report, the doctor indicated that the Veteran's condition was "stable," and that the Veteran would be continued on his medications. A May 2007 treatment report demonstrated that the Veteran reported that the therapy was helping and that he continued to work full time at the VA pharmacy. The VA psychiatrist noted that judgment, insight, and cognition were intact and assigned GAF scores of 45. There were no longer any reports of hallucinations and no reports of suicidal or homicidal ideations. On August 2, 2007, the Veteran underwent a VA examination to ascertain the severity of his PTSD. The examiner reviewed the claims file and observed that the Veteran continued to participate in group therapy at a VA Veterans Center and regularly underwent psychiatric medication checks. The Veteran endorsed racing thoughts, depressed and anxious mood, passive and action suicidal ideations two to three times per week, and feelings of worthlessness most of the day, every day. He engaged in a physical confrontation with his spouse and experienced homicidal thoughts as a result of "road rage." The Veteran also reported a continuation of previously noted symptoms including nightmares, irritability, lack of anger control, memory deficits and hypervigilance. Additionally, he experienced panic attacks four times per week after nightmares or intrusive thoughts. The Veteran reported being separated from his spouse for the last eight months with increasing conflicts with his sons. He experienced decreased energy and missed three weeks of work in the last year with increased stress and disagreements with supervisors. He had no social contact other than at the Veterans Center. Upon examination, the examiner noted that the Veteran's speech was clear and coherent, with intact orientation, judgment, and insight. There were no personal hygiene deficits. The Veteran continued to work, albeit with increased absences, and was able to shop, perform chores, and accomplish the activities of daily living. The examiner diagnosed severe PTSD and major depression. The examiner then assigned a GAF of 44 and noted that the Veteran was "just barely hanging on to his ability to work, and that his functioning will likely decline further if he were to ever become unable to work." A VA psychologist noted that he also met with the Veteran and concurred with the examiner's findings. Prior to August 2, 2007, the Veteran was assigned GAF scores ranging from 60 to 45, but were predominately 45. These scores indicated that the Veteran experienced serious symptoms or serious impairment in social, occupational, or school functioning. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record relevant to this time period and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered, but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2012); VAOPGCPREC 10-95. Prior to August 2, 2007, the Veterans PTSD was marked by the following symptoms: depressed mood, anxiety, irritability, hypervigilance, insomnia, nightmares, difficulty adapting to stressful circumstances, difficulties establishing and maintaining effective relationships, and some memory and insight deficits. Based on the above, including, specifically, the June 2005 treatment report and the various GAF scores assigned, the Board finds the symptoms associated with the Veteran's service-connected PTSD more closely approximated the criteria for a 50 percent rating, but not more, for the entire period prior to August 2, 2007. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411; Fenderson, 12 Vet. App. at 126. The Board finds that an initial rating in excess of 50 percent is not warranted prior to August 2, 2007, because evidence of record did not demonstrate that the symptoms associated with the Veteran's service-connected PTSD more closely approximated the criteria for a higher rating. 38 C.F.R. § 4.7. Specifically, the Board finds that, prior to August 2, 2007, a 70 percent rating is not warranted because the manifestation of the Veteran's PTSD did not more nearly approximate occupational and social impairment with deficiencies in most areas due to 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, or effectively; spatial disorientation; or neglect of personal appearance and hygiene. 38 C.F.R. § 4.130, Diagnostic Code 9411. Additionally, the Board finds that, prior to August 2, 2007, a 100 percent rating is not warranted because the manifestations of the Veteran's service-connected PTSD did not more nearly approximate total occupational and social impairment, due to such symptoms as persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time and place; and memory loss for names of close relatives, own occupation, or own name. Id. Consequently, the Board finds that the criteria for an initial evaluation of 50 percent, but not more, for the Veteran's service-connected PTSD have been met throughout the appellate period prior to August 2, 2007. Id. In making the above determination, the Board acknowledges the use of the term "such as" in 38 C.F.R. § 4.130, Diagnostic Code 9411, which 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). Accordingly, the evidence considered in determining the level of impairment under Diagnostic Code 9411 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms associated with the Veteran's PTSD that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. Id. While the Veteran's PTSD may be manifested by only some symptoms that are associated with the 70 percent rating or the maximum rating of 100 percent, the Board finds that the Veteran's PTSD disability picture prior to August 2, 2007, did not more nearly approximate the criteria for either of those ratings. 38 C.F.R. § 4.7. As such, the Board finds that the criteria for a 50 percent rating, but not more, for the Veteran's service-connected PTSD have been met for the entire appellate period prior to August 2, 2007. 38 C.F.R. § 4.130, Diagnostic Code 9411. Generally, evaluating a disability using either the corresponding or an analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, the Rating Schedule contemplates then the Veteran's disability picture, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture prior to August 2, 2007, is not so unusual or exceptional in nature as to render the assigned rating inadequate. The Veteran's service-connected PTSD is evaluated as mental disorder pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by his disability. Id. Prior to August 2, 2007, the Veterans PTSD was marked by the following symptoms: depressed mood, anxiety, irritability, hypervigilance, insomnia, nightmares, difficulty adapting to stressful circumstances, difficulties establishing and maintaining effective relationships, and some memory and insight deficits. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability picture represented by the disability rating already assigned. Ratings in excess of 50 percent are provided for certain manifestations of PTSD, but the evidence demonstrated that those manifestations are not present prior to August 2, 2007. The criteria for assigned ratings reasonably describe the Veteran's disability level and symptomatology prior to August 2, 2007. Consequently, the Board concludes that a schedular evaluation is adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). Finally, in reaching this decision, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against an evaluation in excess of 50 percent prior to August 2, 2007, for Veteran's PTSD, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An initial rating in excess of 50 percent, but not more, prior to August 2, 2007, for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND As discussed in the Introduction, following the issuance of the Court's June 2012 memorandum decision, the Veteran submitted evidence that the Board finds to be pertinent to his claims of entitlement to service connection for hypertension, to include as secondary to diabetes mellitus, type II, and/or coronary artery disease; entitlement to an initial rating in excess of 10 percent for coronary artery disease; entitlement to a rating in excess of 10 percent for right lower extremity peripheral neuropathy; and entitlement to a rating in excess of 10 percent for left lower extremity peripheral neuropathy. The Veteran specifically did not waive RO review of this evidence, and further requested that these claims be remanded for RO consideration in accordance with 38 C.F.R. § 20.1304. As such, the Board finds that a remand is required in order for the RO to re-adjudicated said claims, to include consideration of the evidence the Veteran's submitted without a waiver of RO review. In a statement submitted along with the un-waived evidence, the Veteran essentially asserted that his service-connected coronary artery disease, right lower extremity peripheral neuropathy, and left lower extremity peripheral neuropathy had worsened. As such, in order to satisfy VA's duty to assist, the Board finds that a remand is required with respect to these claims in order to afford the Veteran a VA examination or VA examinations. Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (holding that VA's duty to assist includes providing a thorough and contemporaneous medical examination). Additionally, as discussed by the Court in the June 2012 memorandum decision, the March 2006 VA examination afforded to the Veteran pursuant to his claim of entitlement to service connection for hypertension addressed only whether there was an etiologically relationship between the Veteran's hypertension and his diabetes mellitus, type II, to include on the basis of aggravation. The March 2006 VA examiner was not requested and did not provide an opinion as to whether the Veteran's hypertension was due to or aggravated by his service-connected coronary artery disease. As such, the Board finds that the March 2006 VA examination is inadequate for purposes of determining the Veteran's entitlement to service connection for hypertension. Further, the Board finds that the evidence of record is otherwise inadequate to assess properly whether the Veteran's hypertension was due to or aggravated by his coronary artery disease. See Littke v. Derwinski, 1 Vet. App. 90, 93 (1990). Once VA undertakes the effort to provide an examination, it must provide an adequate one or, at a minimum, notify the veteran why one will not or cannot be provided. Barr, 21 Vet. App. at 311. Thus, in order to satisfy VA's duty to assist with respect to the Veteran's claim of entitlement to service connection for hypertension, the Board finds that a remand is warranted in order to afford the Veteran another VA examination. After all appropriate examinations, the RO should readjudicate the matters on appeal and issue a determination as to whether a TDIU is warranted. Accordingly, the case is REMANDED for the following action: 1. The Veteran must be afforded a VA examination to determine the nature and etiology of his hypertension. The claims file must be made available to and reviewed by the examiner. All necessary and appropriate tests must be performed and their results documented. The examiner must fully describe all manifestations of any hypertension. After examining the Veteran, and reviewing his service and post-service treatment records, and with consideration of the Veteran's assertions, the examiner must provide an opinion as to whether it is: a. at least as likely as not (a 50 percent probability or greater) that the Veteran's hypertension is due to his service-connected diabetes mellitus, type II, and/or coronary artery disease. b. at least as likely as not (a 50 percent or greater probability) that the Veteran's hypertension was aggravated by his service-connected diabetes mellitus, type II, and/or coronary artery disease, to include any medication prescribed to treat those disabilities. A complete rationale for all opinions must be provided. If the examiner cannot render a requested opinion, the examiner must so state, and thoroughly explain why that opinion could not be provided. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. The term "aggravated" means that the disorder underwent a permanent worsening beyond the natural course of that disorder. 2. The Veteran must be afforded an appropriate VA examination to determine the severity of his service-connected coronary artery disease. The claims folder and a copy of this remand must be made available to the examiner for review in conjunction with the examination. All indicated testing must be conducted. All pertinent symptomatology and findings must be reported in detail. The evaluation of coronary artery disease must include METs testing by exercise or an estimate of METs if for medical reasons testing by exercise cannot be done. The VA examiner is asked to describe, if any, cardiac hypertrophy or dilatation or left ventricular dysfunction with ejection fraction. 3. The Veteran must be afforded an appropriate VA examination to determine the severity of his service-connected right and left lower extremity peripheral neuropathy. The claims folder and a copy of this remand must be made available to the examiner for review in conjunction with the examination. All indicated testing must be conducted. All pertinent symptomatology and findings must be reported in detail. The examiner must address with the Veteran's right or left lower extremity peripheral neuropathy is manifested by complete or incomplete paralysis of the sciatic nerve. The examiner must also opine as to whether the incomplete paralysis, if any, is mild, moderate, moderately severe, or severe with marked muscular atrophy. 4. The RO must notify the Veteran that it is his responsibility to report for the examinations and to cooperate in the development of his claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for one of the aforementioned examinations, documentation must be obtained and associated with the Veteran's claims file that shows that notice scheduling the examination was sent to the Veteran's last known address. Documentation must also be obtained and associated with the Veteran's claims file that indicates whether any notice that was sent was received or returned as undeliverable. 5. The RO must review the resulting examination reports to ensure compliance with this remand. If any deficiencies are discovered, the RO must undertake corrective actions prior to remitting the claims to the Board. 6. After completing the above actions, and any other indicated development, the claims must be re-adjudicated, to include consideration of all the evidence submitted since the November 2010 Board decision. The RO should also make a determination as to the claim for a TDIU. If any benefit remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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). ______________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs