Citation Nr: 1319090 Decision Date: 06/12/13 Archive Date: 06/21/13 DOCKET NO. 12-26 243 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been received to reopen the service connection claim for open angle glaucoma. 2. Entitlement to service connection for peripheral visual field loss in both eyes to include as secondary to service-connected type II diabetes mellitus with erectile dysfunction. 3. Entitlement to service connection for asbestosis due to asbestos exposure. 4. Entitlement to disability rating in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD). 5. Entitlement to special monthly compensation (SMC) based on need for regular aid and attendance of another person or by reason of being housebound. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD B. Berry, Counsel INTRODUCTION The Veteran served on active duty from December 1965 to December 1967. These matters come to the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in August 2010 by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The issue of entitlement to a compensable disability rating for service-connected erectile dysfunction has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to SMC based on need for regular aid and attendance of another person or by reason of being housebound is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. An unappealed November 2007 Board decision denied the Veteran's claim of entitlement to service connection for glaucoma. 2. Evidence associated with the claims file subsequent to the November 2007 Board decision, considered in conjunction with the record as a whole, is not new and material and does not raise a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for glaucoma. 3. The preponderance of the evidence shows that the Veteran's peripheral visual field loss is not caused by or aggravated by his service-connected type II diabetes mellitus. 4. The preponderance of the evidence shows that the Veteran's current asbestosis is not etiologically related to active military service. 5. The evidence of record shows that the Veteran's service-connected PTSD is manifested by deficiencies in most areas of social functioning and occupational functioning including sleep disturbance with nightmares of Vietnam, recurrent thoughts of the stressor incident, avoidant behavior, anxiety, hypervigilence, irritability and depressed mood; the Veteran was assigned GAF scores that ranged from 38 to 48. CONCLUSIONS OF LAW 1. The November 2007 Board decision, which denied entitlement to service connection for glaucoma, is final. 38 U.S.C.A. § 7104 (West 2002); 38 C.F.R. § 20.1100 (2012). 2. The evidence received subsequent to the November 2007 Board decision is not new and material, and therefore, the claim of entitlement to service connection for glaucoma is not reopened. 38 U.S.C.A. §§ 5107, 5108, 7104 (West 2002); 38 C.F.R. §§ 3.104, 3.156 (2012). 3. Peripheral visual field loss is not proximately due to or aggravated by service-connected type II diabetes mellitus. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012) 4. Asbestosis was not incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 5. The criteria for a 70 percent disability rating for service-connected PTSD have been met for the entire period of the appeal. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In this case, the duty to notify was satisfied through a letter dated in July 2010, which preceded the rating action on appeal. Regarding VA's duty to assist, the Board finds that VA has fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of the Veteran's claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The claims file contains the Veteran's service treatment records, private treatment records, a VA examination dated in August 2010, a January 2011 field examination, Social Security disability records and lay statements from the Veteran and his family. The August 2010 VA examination report reflects that the examiner obtained an oral history of the Veteran's service-connected PTSD and evaluated the Veteran. The examiner documented in detail the findings of the examination, the claimed symptoms and the effect the Veteran's symptoms have on his occupational functioning and daily activities. Nonetheless, the August 2010 examiner noted that she was not provided with the claims file to review in conjunction with the examination; however, she reviewed his VA treatment records. In some instances, the United States Court of Appeals for Veterans Claims (Court) has held that a failure to review the claims file renders a VA examination inadequate for rating purposes. See, e.g., Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992) ("The [VA] examiner should have the Veteran's full claims file available for review."), but see Snuffer v. Gober, 10 Vet. App. 400, 403-04 (1997) (review of claims file not required where it would not change the objective and dispositive findings made during a medical examination). See also 38 C.F.R. §§ 4.1, 4.2 (2012). However, the Court held in Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008), that when VA undertakes to provide a medical examination or obtain a medical opinion, the relevant inquiry is whether "the examiner providing the report or opinion is fully cognizant of the claimant's past medical history." In this case, the VA examiner reviewed the Veteran's current VA treatment records, obtained a history of the Veteran's PTSD and evaluated the Veteran's current symptoms. The Board finds that the examiner was apprised of the Veteran's relevant medical history as it pertains to his current claim. Based on the foregoing, the Board concludes that the VA examination is adequate for rating purposes. The Veteran was not provided with a VA examination regarding his claim to reopen entitlement to service connection for glaucoma and entitlement to service connection for peripheral visual field loss and asbestosis. VA has a duty to provide a VA examination when the record lacks evidence to decide the Veteran's claim and there is evidence of (1) a current disability or symptoms of a current disability, (2) an in-service event, injury, or disease, and (3) some indication that the claimed disability may be associated with the established event, injury, or disease. See 38 C.F.R. § 3.159(c)(4), McLendon v. Nicholson, 20 Vet. App. 79 (2006). With respect to the claim to reopen, VA is not required to provide an examination or obtain a medical opinion unless new and material evidence is presented or secured. See 38 C.F.R. § 3.159(c)(4)(iii). The evidence of record does not indicate that the Veteran's peripheral visual field loss is related to service or is otherwise caused by or aggravated by a service-connected disability. Regarding the Veteran's service connection claim for asbestosis there is no credible evidence of exposure to asbestos in service or evidence indicating that the Veteran's asbestosis is related to active military service. Accordingly, VA is not required to provide the Veteran with a VA examination in conjunction with his claim to reopen or his service connection claims. The record also presents no basis for further development to create any additional evidence to be considered in connection with the matters currently under consideration. Under these circumstances, the Board finds that the Veteran is not prejudiced by appellate consideration of the claims on appeal at this juncture, without directing or accomplishing any additional notification and/or development action. II. New and Material Evidence The Veteran originally filed a service connection claim for glaucoma in May 2000. A rating decision dated in October 2000 denied the Veteran's claim for glaucoma. The Veteran submitted a statement in September 2001 asserting that he has glaucoma in both eyes and he is almost legally blind and he is currently being treated at the VA hospital in Birmingham, Alabama. A rating decision dated in March 2002 denied the Veteran's claim. The Veteran appealed the March 2002 rating decision and a November 2007 Board decision denied the Veteran's claim of entitlement to service connection for glaucoma on the basis that it was not incurred in or aggravated during active military service including as a result of Agent Orange exposure and it was not proximately due to or the result of his service-connected diabetes mellitus. The relevant evidence of record at the time of the November 2007 Board decision consisted of service treatment records, private treatment records, VA treatment records, a July 2000 VA eye examination, a July 2005 VA examination for diabetes mellitus, Social Security disability records, statements from the Veteran in support of his claim and a transcript of the August 2007 Board hearing. The November 2007 Board decision was not appealed and it is final based on the evidence then of record. 38 U.S.C.A. § 7104; 38 C.F.R. § 20.1100. A finally decided claim will be reopened in the event that new and material evidence is presented. 38 U.S.C.A. § 5108. "New" evidence means existing evidence not previously submitted to the VA. "Material" evidence means existing evidence that by itself or when considered with previous evidence of record relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. When determining whether the claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). Competency of new evidence, however, is not presumed. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." In determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA's duty to assist or through consideration of an alternative theory of entitlement. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Veteran submitted a statement in January 2009 stating that would like to expand his service connection claims to include glaucoma in both eyes. VA construed this as a request to reopen his claim of entitlement to service connection for glaucoma. Evidence associated with the claims file since the November 2007 Board decision includes VA treatment records, private treatment records and statements by the Veteran. The Board finds that this evidence is considered new in that it was not of record at the time of the November 2007 Board decision. Nonetheless, the Board concludes that the evidence is not material. In this regard, the Board observes that the VA and private treatment records received by the Board since the November 2007 Board decision address the Veteran's ongoing treatment for glaucoma. This is similar to the evidence contained in the record at the time of the November 2007 Board decision. The medical records do not indicate that the Veteran's current glaucoma is related to his active military service to include exposure to Agent Orange or that it is related to a service-connected disability Based on the foregoing, the Board finds that the Veteran's lay statements and treatment records are cumulative and redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and does not raise a reasonable possibility of substantiating the claim. The benefit of the doubt doctrine is not for application, because new and material evidence to reopen the finally disallowed claim has not been received. Thus, having determined that new and material evidence has not been received, the Veteran's request to reopen the service connection claim for glaucoma is not warranted. III. Merits of the Claims for Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Pursuant to 38 C.F.R. § 3.303(b), a claimant may establish the second and third elements by demonstrating continuity of symptomatology for specific chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection also may be established on a secondary basis for a disability that is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Similarly, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). Peripheral Visual Field Loss The Veteran seeks service connection for peripheral visual field loss in both eyes. Specifically, he asserts that his bilateral peripheral visual field loss is secondary to his service-connected diabetes mellitus. As the Veteran does not contend and the evidence does not otherwise indicate that his peripheral visual field loss is directly related to active military service, the theory of entitlement to service connection for peripheral visual field loss on a direct basis will not be considered. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) (where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory). In assessing whether the Veteran is entitled to service connection for peripheral visual field loss, the evidence of record must show that the Veteran has a current diagnosis of the claimed disability. VA treatment records provide a current diagnosis of peripheral visual field loss in both eyes. Thus, the Board finds that the Veteran has a current diagnosis of the claimed disability. With respect to whether the Veteran's service-connected peripheral visual field loss is secondary to his service-connected diabetes mellitus, the Board observes that the record does not contain any medical opinion indicating that the Veteran's peripheral visual field loss was caused by or aggravated by the Veteran's service-connected diabetes mellitus. The record contains a letter form the Veteran's VA physician dated in January 2009 asserting that the Veteran has severe peripheral visual field loss that is secondary to his nonservice-connected advanced glaucoma. Furthermore, the record contains a March 2008 VA examination with respect to the Veteran's diabetes mellitus. The examiner provided the opinion that the Veteran's visual impairment is due to glaucoma and that it is not caused by diabetes mellitus. Accordingly, there is no evidence of record to support the Veteran's contention that his peripheral visual field loss is secondary to his service-connected diabetes mellitus. The Board recognizes that the Veteran contends that his bilateral peripheral visual field loss is caused by or aggravated by his service-connected diabetes mellitus. Lay persons can provide an account of observable symptoms, such as problems with peripheral vision. See Clyburn v. West, 12 Vet. App. 296, 301 (1999); Caldwell v. Derwinski, 1 Vet. App. 466, 469 (1991). However, the Veteran's lay assertions that his peripheral visual field loss is related to a service-connected disability have no probative value because this opinion requires special medical knowledge. The Veteran is not a licensed health care professional; therefore, the lay evidence offered by the Veteran is not competent medical evidence and does not prove a relationship between the Veteran's bilateral peripheral visual field loss and his service-connected diabetes mellitus. In this case, the record does not contain any competent or probative medical evidence or opinion that would indicate the Veteran's current bilateral peripheral visual field loss is related to his service-connected diabetes. Thus, the Board finds that the preponderance of the evidence is against the Veteran's service connection claim for peripheral visual field loss. Accordingly, the Board concludes that service connection for a back disability is not warranted. Asbestosis The Veteran contends that he currently has asbestosis due to exposure to asbestos during active military service. He specifically asserts that he was exposed to asbestos from staying in bunkers that were built during World War II and in Vietnam as an ammunition specialist. As noted above, in order for the Veteran to be entitled to service connection for asbestosis, the medical evidence must show a diagnosis of the claimed disability. An October 2008 private treatment records shows that the Veteran has a current diagnosis of asbestosis. Thus, the Veteran has a current diagnosis of the claimed disability. A review of the Veteran's service treatment records show that there were no complaints of, treatment for or a diagnosis of a lung or respiratory disorder during military service. The Veteran's separation examination dated in December 1967 reveals that the Veteran's lungs and chest were evaluated as normal. He denied symptoms of a respiratory disorder, such as shortness of breath, in the December 1967 report of medical history. The first evidence of a diagnosis of asbestosis was in 1999, approximately 32 years after military service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is evidence against a claim of service connection). With respect to the Veteran's claim of exposure to asbestos in service, there is no specific statutory guidance, nor has the Secretary promulgated any regulations in regard to such claims. However, VA has issued a circular on asbestos-related diseases. DVB Circular 21- 88-8, Abestos-Related Diseases (May 11, 1988) (DVB Circular) provides guidelines for considering compensation claims based on exposure to asbestos. The information and instructions from the DVB Circular have been included in a VA Adjudication Procedure Manual, M21-1 (M21- 1), Part VI, 7.21. The aforementioned provisions of M21-1 have been rescinded and reissued as amended in a manual rewrite (MR) in 2005. See M21-1MR, Part IV, Subpart ii, Chap. 1, Sec. H, Para. 29, entitled "Developing Claims for Service Connection for Asbestos-Related Diseases," and Part IV, Subpart ii, Chap. 2, Sec. C, Para. 9, entitled "Service Connection for Disabilities Resulting from Exposure to Asbestos." VA must analyze an appellant's claim of entitlement to service connection for asbestosis or asbestos- related disabilities under the administrative protocols under these guidelines. Ennis v. Brown, 4 Vet. App. 523, 527; McGinty v. Brown, 4 Vet. App. 428, 432 (1993). The guidelines provide that the latency period for asbestos-related diseases varies from 10 to 45 years or more between first exposure and development of disease. An asbestos-related disease can develop from brief exposure to asbestos or as a bystander. The guidelines identify the nature of some asbestos- related diseases. The most common disease is interstitial pulmonary fibrosis (asbestos). Asbestos fibers may also produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, lung cancer, and cancers of the gastrointestinal tract. In adjudicating asbestos-related claims, it must be determined whether development procedures applicable to such claims have been followed. See Ashford v. Brown, 10 Vet. App. 120 (1997). The Manual guidelines provide, in part, that the clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal disease; that rating specialists are to develop any evidence of asbestos exposure before, during and after service; and that a determination must be made as to whether there is a relationship between asbestos exposure and the claimed disease, keeping in mind the latency period and exposure information. The adjudication of a claim for service connection for a disability resulting from asbestos exposure should include a determination as to whether: (1) service records demonstrate the Veteran was exposed to asbestos during service; (2) development has been accomplished sufficient to determine whether the Veteran was exposed to asbestos either before or after service; and (3) a relationship exists between exposure to asbestos and the claimed disease in light of the latency and exposure factors. M21-1MR, Part IV, Subpart ii, Chap. 2, Section C, Subsection (h). See also VAOPGCPREC 4-2000 (Apr. 13, 2000); 65 Fed. Reg. 33,422 (2000). The Veteran's service records do not indicate that the Veteran was exposed asbestos during military service. The Veteran's military occupational specialty while stationed in Vietnam was an ammunition storage specialist. Based on the nature of the Veteran's military occupational specialty, the Board finds that the Veteran's statements of exposure to asbestos are not consistent with the circumstances of the Veteran's service. 38 U.S.C.A. § 1154(a). Furthermore, the Veteran's private treatment records indicate that the Veteran had extensive exposure to asbestos after military service. Specifically, a March 1999 private treatment record shows that the Veteran had direct, ambient and bystander exposure to asbestos materials as a laborer between 1969 and 1981. It was documented that his heaviest exposure to asbestos was in a power plant from 1970 to 1974. As the preponderance of the evidence shows that the Veteran was not exposed to asbestos during active military service and the Veteran had extensive post- service exposure to asbestos, the Board finds that the Veteran's asbestosis is not related to active military service. Accordingly, entitlement to service connection for asbestosis is denied. IV. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C.A. § 5107(b). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When evaluating a mental disorder, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126. The Veteran's service-connected PTSD is currently assigned a 50 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). PTSD is rated pursuant to the General Rating Formula for Mental Disorders. Id. Under this rating criteria, a 50 percent rating is prescribed for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment 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; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is prescribed for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating is prescribed for total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. The use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (GAF) Scale is used to report the clinician's judgment of the individual's overall level of functioning. The GAF Scale is to be rated with respect only to psychological, social, and occupational functioning. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 1994 (DSM-IV) at 44. GAF scores range from 1-100 with the higher numbers representing higher levels of functioning. A score ranging from 31-40 represents "[s]ome impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school)." Id. at 32. A GAF score ranging from 41-50 reflects 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). As an initial matter, the Board notes that the Veteran is not only diagnosed with a PTSD, but dementia. The Veteran's disability picture at the time of his evaluations may have been influenced to some extent by his dementia. However, the Board is precluded from differentiating between symptomatology attributed to a non service-connected disability and a service-connected disability in the absence of medical evidence which does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (when it is not possible to separate the effects of a service-connected condition from a nonservice-connected condition, 38 C.F.R. § 3.102, which requires that reasonable doubt on any issue be resolved in favor of the Veteran, dictates that such signs and symptoms be attributed to the service-connected condition). The VA examiner in August 2010 determined that there is difficulty in differentiating the effects of the Veteran's PTSD versus dementia on psychosocial functioning. Accordingly, the Board will attribute the symptoms discussed in the psychiatric evaluations to the Veteran's PTSD unless the medical evidence indicates otherwise. The Board emphasizes, however, that considering the symptoms of the nonservice-connected disorders does not mean that those disorders are service-connected. Nor does it mean that the diagnostic codes specific to the nonservice-connected disorders are for application. It means only that, in the context of the diagnostic codes relevant to the actual service-connected disorder, any overlapping symptoms are to be assumed to be attributable to the service-connected disorder. The medical evidence of record consists of VA treatment records and a VA examination report dated in August 2010. The Veteran provided additional information about his PTSD symptoms through his own lay statements as well as lay statements from his family. The Board finds that this evidence, the most pertinent of which is summarized below, shows that the Veteran's condition as a whole more closely approximates the criteria for a 70 percent disability rating. The evidence of record shows the Veteran's PTSD has a moderate to severe effect on his ability to function appropriately and effectively. The Veteran experiences sleep disturbances approximately two to three times a week. See August 2010 VA examination. He has difficulty falling or staying asleep. The Veteran feels tired and weak during the day. He experiences recurrent and intrusive distressing recollections and dreams of his stressor event, including images, thoughts or perceptions. The Veteran has intermittent, passive suicidal ideation with no current intent or plan. He makes efforts to avoid thoughts, feelings or conversations associated with the trauma. He avoids activities, places or people that arouse recollections of the trauma. VA treatment records reveal that the Veteran's general appearance during the appeal period has been clean and neat. See VA treatment records dated in November 2009, August 2009 and October 2008. He was alert and oriented times four. Affect was bland, appropriate and congruent with mood. His mood was dysthymic and anxious. Speech was regular and logical. Thought content was relevant. Judgment and insight was intact. Memory and concentration were intact. During the August 2010 VA examination, the Veteran was clean, neatly groomed and appropriately dressed. His speech was clear and coherent. The Veteran was cooperative with the examiner. His affect was flat and his mood was depressed. He described his mood as not real good. The examiner noted that the Veteran had a short attention span. The Veteran was intact to person and place. However, he was not intact to time during the examination as the Veteran estimated the date as July 2010 and the examination took place in August. Thought process and content was unremarkable. He did not experience delusions. The Veteran was unable to interpret proverbs. The examiner determined that the Veteran's remote and recent memory was moderately impaired and his immediate memory was mildly impaired. The medical evidence of record indicates that the Veteran has hypervigilence, impaired impulse control, difficulty adapting to stressful circumstances and depression. VA treatment records show that the Veteran experiences hypervigilence, such as, frequently checking over his shoulder as if someone is behind him. The Veteran has fair impulse control. He has outbursts of irritability and anger. VA treatment records indicate that Veteran is volatile and yells often. The Veteran reported during the August 2010 VA examination that he secludes himself when he is angry and he denied engaging in physical altercations. An August 2009 VA treatment record reveals that the Veteran reported that every once in a while it seems like he will hear things. VA treatment records also show that the Veteran has severe anxiety, pervasive sadness and anhedonia. He also has low morning energy. His interest and pleasure in previously enjoyed activities are markedly decreased See November 2007 VA treatment record. The evidence shows that the Veteran exhibits some inability to establish and maintain effective relationships. The Veteran has been married three times and he has been married to his current wife since 2001. During the VA examination in August 2010, the Veteran described his relationship with his wife as "so, so." The Veteran and his wife reside alone together. He talks to his two grown children every once in awhile and he maintains contact with his parents. The Veteran has two brothers, who are both deceased. The Veteran has feelings of detachment and estrangement from others. See VA examination dated in August 2010. He also isolates himself from others. The Veteran reported that he likes to keep to himself. See VA treatment records dated in August 2009 and February 2009. The Veteran indicating that he keeps to himself to avoid becoming explosive with others. See November 2007 VA treatment record. His outings are limited to attending doctor's appointments, group, and an occasional errand to Wal-Mart at night and with his wife. Although he primarily spends time alone, he will occasionally see friends. With respect to employment, the evidence shows that the Veteran was last employed in 1999 doing construction work. The evidence of record indicates that the Veteran is no longer working due to his non-service connected blindness, as well as, his service-connected PTSD, diabetes mellitus, and peripheral neuropathy. A VA treatment record dated in February 2008 indicates that the Veteran is unemployable due to his cognitive impairment as well as severe PTSD and depressive illness. The Board recognizes that the Veteran's PTSD symptoms of hypervigilence, irritability, anxiety and anhedonia would have a significant impact on his ability to be employed. Furthermore, VA treatment records reveal that the Veteran symptoms appear to be globally severe and make it difficult for the Veteran to function emotionally, interpersonally, function in the workplace and maintain basic socialization and support system. The Veteran's GAF score ranged between 38 and 48 throughout the entire claims period. This range in GAF score reveals serious symptoms to major impairment in social and occupational activities. Thus, the Veteran's GAF score is consistent with the Veteran's overall disability picture including symptoms reported at the VA examination, in the medical records and discussed in the lay evidence indicating that the Veteran's disability picture more closely approximates a 70 percent rating. In finding that a 70 percent rating is warranted, the Board declines to grant a 100 percent rating. The claims file is negative for evidence of characteristics such as gross impairment in thought processes or communication; grossly inappropriate behavior; persistent danger of hurting self or others, disorientation to place; or memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Specifically, as noted above, the evidence of record shows that the Veteran was alert and his speech was clear and coherent. Thought process and content were unremarkable. VA treatment records show that until the VA examination in August 2010 the Veteran was fully oriented. However, during the VA examination the Veteran demonstrated that he was not oriented to time as he indicated that it was July 2008 instead of August 2008. He has moderately impaired remote and recent memory and his immediate memory is slightly impaired. The evidence of record does not suggest that the Veteran has memory loss for names of close relatives or his own name. Judgment, inteligence and insight were adequate. Although the evidence indicates that he has had some passive suicidal ideation, overall, the evidence does not show that the Veteran is in persistent danger of hurting himself or others. The Veteran's PTSD causes severe impairment in social functioning, but not total social impairment as he maintains a relationship with his wife, grown children and parents. Furthermore, he will occasionally see friends. Accordingly, the evidence reveals that the Veteran's symptoms do not more closely approximate total occupational and social impairment due to PTSD. Thus, the criteria for a 100 percent rating have not been met. The Board has considered whether staged ratings are appropriate. The competent medical evidence of record shows that the Veteran's PTSD symptoms have not been so severe as to warrant a 100 percent disability rating at any time during the course of this appeal. The increase to a 70 percent disability rating is supported by the evidence throughout the appeal period. As such, a staged rating is not warranted. The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected psychiatric disability. The Veteran's disability is manifested by impairment in social and occupational functioning. The rating criteria contemplate these impairments; hence, referral for consideration of an extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER The claim to reopen the issue of entitlement to service connection for glaucoma is denied. Entitlement to service connection for peripheral visual field loss in both eyes as secondary to service-connected type II diabetes mellitus with erectile dysfunction is denied. Entitlement to service connection for asbestosis due to asbestos exposure is denied. Entitlement to a 70 percent disability rating for service-connected PTSD is granted. REMAND After careful review of the evidence, the Board finds that additional development is necessary before proceeding to evaluate the merits of the Veteran's SMC claim. Unfortunately, the evidence presently of record is not adequate to render a determination regarding that claim on appeal. In this regard, the RO did not provide the Veteran with an examination for housebound status or permanent need for regular aid and attendance. The claims file contains VA Form 21-4138, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance; however, it was filled out by the Veteran's private physician. The physician did not list the Veteran's service-connected PTSD or bilateral peripheral neuropathy of the upper and lower extremities in the complete diagnosis section. Thus, it appears that the physician may not have been aware of all of the Veteran's disabilities as part of the examination. An August 2010 VA examination evaluated the Veteran's current service-connected PTSD symptoms; however, the examiner did not evaluate the Veteran's symptoms to determine whether he needed aid and attendance. Thus, the Board finds that the Veteran must be provided with a VA examination to determine whether the Veteran is in need of the regular aid and attendance of another person, or bedridden, solely due to his service-connected disabilities. The Veteran must be advised of the importance of reporting to the scheduled VA examination and of the possible adverse consequences, to include the denial of the claim, of failing to so report. See 38 C.F.R. § 3.655 (2012). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine whether he meets the requirements for special monthly pension based on the need for regular aid and attendance or by reason of being housebound. The claims folders, to include this Remand, must be reviewed by the examiner and the examiner should indicate that such review took place in the examination report. The examination should take into account all of the Veteran's service-connected disabilities (PTSD, rated at 70 percent; type II diabetes mellitus, rated at 20 percent; peripheral neuropathy of the right upper extremity, rated at 10 percent; peripheral neuropathy of the left upper extremity, rated at 10 percent; peripheral neuropathy of the right lower extremity, rated at 10 percent; and peripheral neuropathy of the left lower extremity, rated at 10 percent). The examiner should also specifically take into consideration the Veteran's need for assistance to perform the needs of nature, of the limits on his movements inside his house, his need for a companion when he goes outside his home and his functional limitations due to his service-connected disabilities. The examination report should contain sufficient information to determine whether it is at least as likely as not (i.e., at least a fifty percent or more probability) that the Veteran is in need of regular aid and attendance, that is, whether he is helpless or is so nearly helpless as to require the regular aid and attendance of another person, due solely to his service-connected disabilities. The Board notes for the record that the criteria for establishing the need for aid and attendance include consideration of whether the appellant is blind or is so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; or whether he is a patient in a nursing home because of mental or physical incapacity; or whether he establishes factually a need for aid and attendance under the criteria set forth under 38 C.F.R. § 3.352(a) (inability to dress/undress, or to keep ordinarily clean/presentable; frequent adjustment of special prosthetic/orthopedic appliances requiring the aid of another; inability to feed himself; inability to attend to wants of nature; or incapacity, physical or mental, that requires assistance on a regular basis to protect from hazards/dangers incident to daily environment). If the Veteran is in need of aid and attendance due to his nonservice-connected disabilities, that should also be noted. In addition to the foregoing, the examination report should contain sufficient information to determine whether it is at least as likely as not that the Veteran is housebound, in that the appellant is bedridden or substantially confined to his home or immediate premises by reason of permanent disabilities, due solely to his service-connected disabilities. The examiner should provide an explanation for all opinions given. 2. Upon completion of the foregoing and any other development deemed necessary, readjudicate the Veteran's claim of entitlement to SMC based on need for regular aid and attendance of another person or by reason of being housebound, based on a review of the entire evidentiary record. If the benefit sought on appeal remains denied, provide the Veteran and his representative with a supplemental statement of the case and the opportunity to respond thereto. Thereafter, subject to current appellate procedure, the case should be returned to the Board for further consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter 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). ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs