Citation Nr: 1319586 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 11-25 012 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for age-related macular degeneration. 2. Entitlement to a rating in excess of 50 percent for adjustment disorder with mixed anxiety and depressed mood. 3. Entitlement to a rating in excess of 60 percent for coronary artery disease bypass grafting residuals. 4. Entitlement to a rating in excess of 20 percent for peripheral neuropathy of the right lower extremity. 5. Entitlement to a rating in excess of 20 percent for hearing loss. 6. Entitlement to a total rating based upon individual unemployability (TDIU) due to service-connected disabilities prior to September 30, 2008. REPRESENTATION Appellant represented by: Osborne E. Powell, Jr., Esquire ATTORNEY FOR THE BOARD John Kitlas, Counsel INTRODUCTION The Veteran served on active duty from March 1948 to September 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Board notes that additional records have been added to the record since the RO last adjudicated this case via the July 2011 Statement of the Case (SOC), to include a private medical opinion dated in May 2013 regarding the macular degeneration claim. In addition, there are electronic, paperless treatment records on the Virtual VA system dated through May 3, 2013. The record also indicates that such records were last added to the Virtual VA system on May 14, 2013. However, in a statement dated May 23, 2013, the Veteran's attorney stated that they were waiving the right to have the case remanded to allow the RO to consider the additional evidence submitted in conjunction with that statement "or any evidence previously submitted." As such, the Board finds that the Veteran has waived initial consideration of such evidence by the RO pursuant to 38 C.F.R. § 20.1304(c) (2012), and there is no prejudice to the Veteran by the Board proceeding with adjudication of this appeal. The record also reflects that the Veteran initially requested a hearing before personnel at the RO in conjunction with this appeal. However, he withdrew his formal hearing request via a March 2011 statement from his attorney and that he wished to proceed with an informal hearing process. As part of his September 2011 Substantive Appeal he indicated that no Board hearing was desired. The Board notes that the RO initially found that new and material evidence had not been received to reopen the macular degeneration claim. However, the RO subsequently reopened the claim via the July 2011 SOC. Despite the determination reached by the RO, the Board must find new and material evidence in order to establish its jurisdiction to review the merits of a previously denied claim. See Barnett v. Brown, 83 F. 3d 1380 (Fed. Cir. 1996); Jackson v. Principi, 265 F. 3d 1366 (Fed. Cir. 2001). The Board further notes that the TDIU issue was not included in the July 2011 Statement of the Case (SOC), as the RO noted the issue was moot after the Veteran had been awarded a 100 percent schedular combined rating effective from the September 2008 date of claim. However, the Board notes that the notice of disagreement filed with the March 2009 rating decision concerning the denial of TDIU was also filed within one year of the April 2008 rating decision denying TDIU. The Veteran's attorney has argued that TDIU is warranted for the period prior to September 30, 2008. Such argument was provided shortly after the July 2011 notice from the RO that the TDIU claim was deemed moot. Accordingly, the issue of entitlement to TDIU prior to September 30, 2008 remains on appeal, and issuance of an SOC on this issue is necessary. For the reasons addressed in the REMAND portion of the decision below, the Board finds that further action is required with respect to the TDIU claim. Accordingly, these claims are REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. Service connection was previously denied for age-related macular degeneration by a June 2005 rating decision. The Veteran was informed of that decision, including his right to appeal, but did not appeal. That decision is final. 2. The evidence received since the last prior denial of service connection for age-related macular degeneration was not previously submitted to agency decisionmakers, relates to an unestablished fact necessary to substantiate the claim, is not cumulative nor redundant of the evidence of record at the time of the last prior final denial, and raises a reasonable possibility of substantiating the claim. 3. The competent medical evidence reflects that it is at least as likely as not that the Veteran's current age-related macular degeneration is secondary to his service-connected coronary artery disease, diabetes mellitus, and/or cataracts. 4. The Veteran's service-connected adjustment disorder with mixed anxiety and depressed mood is not manifested by deficiencies in most areas, such as work, school, family relations, judgment, or thinking. 5. The Veteran's service-connected coronary artery disease bypass grafting residuals are not manifested by congestive heart failure, or; a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 6. The Veteran's service-connected peripheral neuropathy of the right lower extremity is not manifested by moderately severe incomplete paralysis. 7. The record indicates that the Veteran has, at worst, Level V hearing for both ears. CONCLUSIONS OF LAW 1. New and material evidence having been received, the claim of entitlement to service connection for age-related macular degeneration is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002 & Supp. 2012); 38 C.F.R. § 3.156 (2012). 2. The criteria for a grant of service connection for age-related macular degeneration are met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.310 (2012). 3. The criteria for a rating in excess of 50 percent for the Veteran's service-connected adjustment disorder with mixed anxiety and depressed mood are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.130, Diagnostic Code 9400 (2012). 4. The criteria for a rating in excess of 60 percent for the Veteran's service-connected coronary artery disease bypass grafting residuals are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.104, Diagnostic Code 7017 (2012). 5. The criteria for a rating in excess of 20 percent for the Veteran's service-connected peripheral neuropathy of the right lower extremity are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012). 6. The criteria for a rating in excess of 20 percent for the Veteran's service-hearing loss are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.85, 4.86, Diagnostic Code 6100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters The Board notes at the outset that VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). For the reasons detailed below, the Board finds that new and material evidence has been received to reopen the claim of entitlement to service connection for age-related macular degeneration, and that service connection is warranted for this disability. As this represents a complete grant of the benefit sought on appeal with respect to this claim, no discussion of VA's duty to notify and assist is necessary. With respect to the Veteran's increased rating claims, the law require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). VA must provide a claimant VCAA notice before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the Veteran was sent preadjudication notice via a letter dated in December 2008, which is clearly prior to the March 2009 rating decision that is the subject of this appeal. He was also sent additional notification via letters dated in February and December 2010, followed by readjudication of the appeal by the July 2011 SOC. In pertinent part, these letters informed the Veteran of what was necessary to substantiate his current appellate claims, what information and evidence he must submit, what information and evidence will be obtained by VA, as well as the information and evidence used by VA to determine disability ratings and effective dates. The Board also notes that the Veteran has actively participated in the processing of his case, and the statements submitted in support of his claims, to include from his attorney, have indicated familiarity with the requirements for the benefits sought on appeal. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) (VA can demonstrate that a notice defect is not prejudicial if it can be demonstrated ... that any defect in notice was cured by actual knowledge on the part of the appellant that certain evidence (i.e., the missing information or evidence needed to substantiate the claim) was required and that the appellant should have provided it.); see also Overton v. Nicholson, 20 Vet. App. 427 (2006). In view of the foregoing, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claims and the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. In any event, the Veteran has not demonstrated any prejudice with regard to the content or timing of any notice. See 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). In addition, the Board finds that the duty to assist a claimant in the development of his case has been satisfied. The Veteran's service treatment records are on file, as are various post-service medical records. Further, the Veteran has had the opportunity to present evidence and argument in support of his claims, and nothing indicates he has identified the existence of any relevant evidence that has not been obtained or requested. Moreover, he was accorded VA medical examinations which, as detailed below, made relevant findings regarding the symptomatology of these disabilities. The Board also observes that such findings are consistent with the treatment records on file, as well as the relevant rating criteria. Further, the audio examinations appear to be in accord with the requirements of 38 C.F.R. § 4.85(a). No prejudice or inaccuracies is demonstrated with respect to these examinations, nor has the Veteran indicated any of the disabilities have increased in severity since the most recent examination. Accordingly, the Board finds that these examinations are adequate for resolution of this case. Consequently, the Board finds that the duty to assist the Veteran has been satisfied in this case. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (The Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (Noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. Macular Degeneration Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Vision loss from a refractive error of the eye is one of the specific conditions that VA does not grant service connection for, as it is not considered a disability for VA purposes. See 38 C.F.R. §§ 3.303(c), 4.9. Such a condition is part of a life-long defect, and is normally a static condition which is incapable of improvement or deterioration. See VAOGCPREC 67-90 (1990). Therefore, the record must indicate an acquired eye disorder, which is indicated in this case by the finding of macular degeneration. Service connection was previously denied for age-related macular degeneration by a June 2005 rating decision. The Veteran was informed of that decision, including his right to appeal, and did not appeal. Therefore, that decision is final. See 38 U.S.C.A. §§ 7104, 7105; 38 C.F.R. §§ 20.1100, 20.1103. Despite the finality of a prior decision, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). The Court has held that, when "new and material evidence" is presented or secured with respect to a previously and finally disallowed claim, VA must reopen the claim. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). Further, the Court has also held that in order to reopen a previously and finally disallowed claim there must be new and material evidence presented since the time that the claim was finally disallowed on any basis, not only since the time that the claim was last disallowed on the merits. Evans v. Brown, 9 Vet. App. 273, 285 (1996) (overruled on other grounds). New evidence means existing evidence not previously submitted to agency decisionmakers. 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(a). In Shade v. Shinseki, 24 Vet. App. 110, 118 (2010), the Court stated that when determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Id. at 118. Thus, pursuant to Shade, evidence is new if it has not been previously submitted to agency decisionmakers and is material if, when considered with the evidence of record, it would at least trigger VA's duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. Id. In this case, the evidence of record at the time of the June 2005 rating decision includes statements from the Veteran, his service treatment records, and post-service medical records which cover a period through 2005. The Veteran essentially contended that he developed eye problems while on active duty, and his service treatment records confirm treatment for eye problems. For example, records dated in July 1957 show treatment for conjunctivitis of both eyes. However, the record does not reflect he was diagnosed with macular degeneration while on active duty. There was also no finding of macular degeneration on a November 1970 VA medical examination. The post-service medical records include findings of macular degeneration made years after his separation from service. For example, an April 2005 VA eye examination, in pertinent part, diagnosed age-related macular degeneration with large macular scar in the left eye; legally blind secondary to macular degeneration; moderate, nonproliferative diabetic retinopathy in both eyes; marginally visually significant cataracts both eyes; and myopia with astigmatism both eyes. However, these records do not contain any competent medical evidence relating the macular degeneration to active service. The June 2005 rating decision, in pertinent part, denied service connection for macular degeneration finding that it neither occurred in nor was caused by service, and that this condtion was not secondary to the Veteran's service-connected disabilities. In addition, it was noted that the macular degeneration was not found to be present to a compensable degree within the first post-service year so as to warrant a grant of service connection on a presumptive basis. The Board is cognizant of the fact that Courts have held that 38 C.F.R. § 3.156(b) requires that VA evaluate submissions received during the year following notice of a rating decision to determine whether they contain new and material evidence, even if the new submission may support a new claim. See Bond v. Shinseki, 659 F.3d 1362, 1367-8 (Fed. Cir. 2011); Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). In this case, the Board notes that during the one year period following notification of the June 2005 rating decision, the Veteran submitted no arguments or evidence specifically in regard to his macular degeneration claim. Although he did submit statements, they were primarily in regard to his claim of service connection for coronary artery disease, which was established by a May 2006 rating decision. The Board also notes that additional medical records were added to the file, and include references to eye problems. However, nothing in these records related the etiology of the macular degeneration to service, which was the basis for the prior denial of June 2005. Thus, the evidence appears to be cumulative and redundant of that which was previously of record, and did not relate to an unestablished fact necessary to substantiate the claim. Consequently, new and material evidence was not received within the appeal period of that decision. The evidence added to the record since the June 2005 rating decision includes additional statements by and on behalf of the Veteran, as well as post-service medical records which cover a period through 2013. In pertinent part, the Veteran has contended that his macular degeneration is secondary to his service-connected coronary artery disease, diabetes mellitus, and/or diabetic cataracts with retinopathy. No such contentions appear to have been advanced at the time of the last prior denial. The Veteran has also submitted medical treatise evidence which indicates that coronary artery disease is a risk factor for macular degeneration. Further, a private medical opinion from E. W. Anderson, M.D., notes, in pertinent part, that coronary artery disease, diabetes mellitus, and cataracts surgery are all known risk factors for age-related macular degeneration. In short, there is competent medical evidence which relates the etiology of the Veteran's current macular degeneration to his active service. Further, the evidence submitted to reopen a claim is presumed to be true for the purpose of determining whether new and material evidence has been submitted, without regard to other evidence of record. Duran v. Brown, 7 Vet. App. 216, 220 (1994); Justus v. Principi, 3 Vet. App. 510, 513 (1992). In view of the foregoing, the Board finds that the evidence received since the last prior denial of service connection for age-related macular degeneration was not previously submitted to agency decisionmakers, relates to an unestablished fact necessary to substantiate the claim, is not cumulative nor redundant of the evidence of record at the time of the last prior final denial, and raises a reasonable possibility of substantiating the claim. Thus, new and material evidence has been received pursuant to 38 C.F.R. § 3.156(a). Accordingly, the claim is reopened. Adjudication of the Veteran's appeal does not end with the determination that new and material evidence has been received. The Board must address the merits of the underlying service connection claim. In the adjudication that follows, the presumption that the evidence received to reopen the claim is true without regard to the other evidence of record no longer applies. The Board also wishes to reiterate the fact that the RO previously determined that new and material evidence had been received, and has addressed the merits of the underlying service connection claim. Nevertheless, pursuant to the holdings of Barnett, supra, and Jackson, supra, the Board must still find new and material evidence in order to establish its jurisdiction to review the merits of a previously denied claim. Inasmuch as the RO has already addressed the merits of the service connection claim, the Veteran is not prejudiced by the Board also addressing the merits of this case. Initially, the Board observes that the issue of whether one disability caused or permanently aggravated another is the type of relationship that competent medical evidence is required. Moreover, this finding is supported by the holding of Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) in which the Federal Circuit held in the context of a claimant contending secondary service connection that the claimant's own conclusory generalized statement that his service illness caused his present medical problems was not enough to entitle him to a medical examination. If such a contention is not sufficient to warrant a medical examination, it is clear that it is not sufficient to warrant a grant of service connection. Here, nothing on file shows that the Veteran has the requisite knowledge, skill, experience, training, or education to render a medical opinion. Consequently, his contentions on this issue are not competent medical evidence. 38 C.F.R. § 3.159(a)(1). The Board notes, however, that there is competent medical evidence which both supports and refutes the Veteran's contention of secondary service connection. For example, the September 2010 VA diabetes mellitus examiner opined that the Veteran's age-related macular degeneration was not related to his service-connected coronary artery disease. In support of this opinion, the examiner stated that review of literature suggested there was an association in people who have age-related macular degeneration have a higher risk of coronary artery disease, but coronary artery disease did not cause macular degeneration. In addition, a September 2010 VA eye examiner opined that it was less likely as not that the Veteran's current macular degeneration of both eyes was caused by or a result of his history of coronary artery disease. In support of this opinion, the examiner stated "[r]ational being, at this time no known risk factor is known with macular degeneration." However, the examiner stated that evidence strongly suggested that smoking was a common risk factor, also family history with macular degeneration, high cholesterol, "@@@ color and obesity" were all risk factors. Also, possible excessive exposure to sunlight could also cause possible progression of macular degeneration. The May 2013 opinion from Dr. Anderson, conversely, indicated that coronary artery disease, diabetes mellitus, and cataracts were all risk factors for macular degeneration. Specifically, Dr. Anderson cited to various medical studies showing that the identified risk factors for macular degeneration included systemic arterial hypertension, coronary artery disease, smoking, iris color, cataract, and hyperopia. Dr. Anderson also provided details as to the results of the studies regarding each of these risk factors. Dr. Anderson stated that the Veteran had a long history of service-connected coronary artery disease to include evidence of an early myocardial infarction and a history of lens opacities with cataract surgery, all of which were identified as risk factors for age-related macular degeneration. Further, Dr. Anderson cited to and summarized studies which indicated an association between diabetes and age-related macular degeneration. Therefore, Dr. Anderson stated the Veteran had at least three service-connected risk factors for the development of age-related macular degeneration. Accordingly, Dr. Anderson opined that it was as likely as not that the combined service-connected diseases of coronary artery disease, history of lens opacities with cataract surgery, and diabetes mellitus, in combination, contributed to the onset of nonservice-connected age-related macular degeneration. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In this case, the September 2010 VA examiners and Dr. Anderson indicated they were familiar with the Veteran's medical history from review of his VA claims folder. Further, these clinicians are presumed to be qualified to render a competent medical opinion. Moreover, none of these opinions appear to be written in equivocal or speculative language. Nevertheless, the Board finds, in this case, that greater probative values is to be assigned to the opinion of Dr. Anderson. The Board notes that while the September 2010 VA eye examiner stated that "no known risk factor is known with macular degeneration," the September 2010 VA diabetes mellitus examiner did indicate there was an association although it was that people with macular degeneration were more likely to develop coronary artery disease and not vice-versa. In any event, these statements appear to be contradictory. Moreover, the VA eye examiner did not cite to any medical literature in support of this statement, while Dr. Anderson cited to various studies regarding what he identified as risk factors for macular degeneration. Further, the VA examiners' opinions appear to be focused on the issue of whether macular degeneration was directly caused by coronary artery disease; i.e., the VA examiners did not address whether the macular degeneration was aggravated by the service-connected coronary artery disease as required by Allen, supra. Moreover, unlike Dr. Anderson, the VA examiners did not address whether the macular degeneration was secondary to the service-connected diabetes mellitus and/or diabetic cataracts with retinopathy. The Board also observes that Dr. Anderson's opinion appears to be supported by the medical treatise evidence submitted by the Veteran. Consequently, the Board finds that Dr. Anderson's opinion is more full and complete than that of the September 2010 VA examiners, and entitled to greater weight. The Board acknowledges that Dr. Anderson indicated that there were other risk factors for age-related macular degeneration in addition to the Veteran's service-connected coronary artery disease, diabetes mellitus, and cataracts. Nevertheless, the law provides that when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The Board further notes that, in Alemany v. Brown, 9 Vet. App. 518 (1996), the Court held that in light of the benefit of the doubt provisions of 38 U.S.C.A. § 5107(b), an accurate determination of etiology is not a condition precedent to granting service connection; nor is "definite etiology" or "obvious etiology." Moreover, in Gilbert v. Derwinski, 1 Vet. App. 49 (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." In Gilbert the Court specifically stated that entitlement need not be established beyond a reasonable doubt, by clear and convincing evidence, or by a fair preponderance of the evidence. Under the benefit of the doubt doctrine established by Congress, when the evidence is in relative equipoise, the law dictates that the appellant prevails. Resolving all reasonable doubt in favor of the Veteran, the Board finds that the competent medical evidence reflects that it is at least as likely as not that the Veteran's current age-related macular degeneration is secondary to his service-connected coronary artery disease, diabetes mellitus, and/or cataracts. Therefore, service connection is warranted for this disability. Increased Ratings Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations applies, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that the rule from Francisco does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability. Rather, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. More recently, the Court held that "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Adjustment Disorder The Veteran's service-connected adjustment disorder with mixed anxiety and depressed mood is evaluated pursuant to Diagnostic Code 9400, which provides that the disability is evaluated under the general rating formula used to rate psychiatric disabilities other than eating disorders, pursuant to 38 C.F.R. § 4.130. When a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication, a noncompensable (zero percent) evaluation is warranted. Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication warrants a 10 percent evaluation. A 30 percent disability rating is in order 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating 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; difficulty in establishing and maintain effective work and social relationships. A 70 percent rating is warranted where there is 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted where there is 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. When evaluating a mental disorder, the rating agency 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. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). The Court has held that 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. In particular, 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. Mauerhan v. Principi, 16 Vet. App. 436 (2002). More recently, in Vazquez-Claudio v. Shinseki, 2012-7114 (Fed. Cir. Apr. 8, 2013), the Federal Circuit held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Further, this holding is of particular significance as the claimant in that case, like the Veteran here, was seeking a rating in excess of 50 percent for PTSD. The Federal Circuit held that in the context of a 70 percent rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. Therefore, to the extent that the Veterans Court implied that the listed "areas" were irrelevant to the 70 percent disability determination, this was error. Although the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in "most areas." The Federal Circuit also stated that entitlement to a 70 percent disability rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation. The 70 percent disability rating regulation contemplates initial assessment of the symptoms displayed by the veteran, and if they are of the kind enumerated in the regulation, an assessment of whether those symptoms result in occupational and social impairment with deficiencies in most areas. In sum, the aforementioned caselaw requires the Board to review the Veteran's specific symptomatology to determine if he has the symptoms identified in the criteria for a higher rating, or symptomatology similar to those enumerated, and, if so, whether such symptomatology results in the level of occupational and social impairment contemplated by the higher rating. Initially, the Board acknowledges that the Veteran does appear to have deficiency of mood in that his service-connected disability is recognized as including depressed mood. There are also findings of anxiety. However, the symptoms of depressed mood and anxiety are part of the specific criteria contemplated by a 30 percent rating. As such, it does not appear he has the type of deficiency of mood contemplated by the 70 percent criteria. Moreover, the 70 percent criteria require that there be deficiencies in most areas, and the record does not reflect the Veteran has deficiencies in areas such as work, school, family relations, judgment, or thinking. The Board observes that the Veteran is not in school, and has not been so for many years. As such, there is no basis to find he has deficiency in school. Regarding work and family relations, the Board notes that while there is evidence of some degree of occupational and social impairment due to the service-connected adjustment disorder, all compensable evaluations under the schedular criteria include such impairment. Here, the March 2007 VA examination noted that the Veteran had been married to his wife for 42 years, and that they had 3 children and 6 grandchildren, and no impairment of family relations was indicated although he was worried about his wife because she had cancer. He also reported that he worked for the Postal Service for over 30 years, and retired in 2005 due to his eyes; i.e., he did not indicate any impairment with work due to the adjustment disorder to include difficulty in adapting to stressful circumstances including work or a worklike setting. Similar findings were noted on the November 2008 VA examination, and no such impairment appears to be demonstrated in the treatment records, although, sadly, there is reference to his difficulty after the death of his wife. Electronic, paperless records from Virtual VA dated in March 2011 note that he reported he "[g]ets along with most people." Thus, it does not appear he has the type of deficiencies in work or family relations contemplated by the 70 percent schedular criteria. Moreover, these findings indicate that his adjustment disorder has not resulted in the inability to establish and maintain effective relationships. In regard to thinking and judgment, the March 2007 VA examination noted that the Veteran's thought processes were logical and goal directed, without evidence of looseness of associations. It was also noted that he demonstrated capacity for abstract reasoning, as evidenced by his interpretation of a proverb and similarities. His judgment to a hypothetical situation was good. On the November 2008 VA examination, his thought process was found to be generally linear. Insight was fair. Virtual VA records dated in March 2011 note that his thoughts were organized, and that his insight and judgment were fair. With respect to specific symptomatology, the Board notes that the Veteran denied suicidal and homicidal ideation/thoughts at both the March 2007 and November 2008 VA examinations. The March 2011 Virtual VA records also show no suicidal ideation. Granted, records dated from November 2012 indicate that he did undergo suicidal evaluation for what was described as fleeting thoughts of suicide. However, the Veteran denied any specific intent or plan, and reported that he had never attempted suicide or self-directed violence. Overall evaluation was that the Veteran was low risk for suicide. Subsequent records continue to show a low risk for suicide. Thus, the reported fleeting thoughts of suicide are not shown to be impacting his social or occupational functioning. Such is supported by the Global Assessment of Functioning scores assigned, as will be addressed below. The Board also notes that nothing in either the March 2007 or November 2008 VA examinations, or the treatment records, indicates he has obsessional rituals which interfere with routine activities, nor near-continuous panic or depression affecting the ability to function independently, appropriately or effectively. There is also no indication of impaired impulse control, to include unprovoked irritability with periods of violence. He consistently denied homicidal ideation/thoughts on the VA examinations and the March 2011 records. There is also no indication of any periods of violence in the record. The Veteran's speech was found to have normal rate, rhythm, and volume on the March 2007 VA examination. The subsequent November 2008 VA examination found spontaneous speech was grammatical, fluent, and free of paraphasias. The March 2011 VA records note that while his speech was slow, it was normal in tone. Nothing else in the record indicates his speech is intermittently illogical, obscure or irrelevant. The Board also finds that there is no indication of spatial disorientation. For example, the Veteran was found to be alert, oriented, and cooperative on the March 200 VA examination. He was found to be generally alert and oriented to person, place, date, date and time, on the November 2008 VA examination. Nothing else in the record otherwise demonstrates spatial disorientation. The March 2007 VA examination found the Veteran to be neatly but casually groomed and dressed. Similarly, the March 2011 records noted that he was neatly groomed. Nothing else in the record demonstrates the Veteran's service-connected adjustment disorder has resulted in neglect of personal appearance or hygiene. The Board has already acknowledged that the Veteran's service-connected adjustment disorder has resulted in some degree of occupational and social impairment, but that all compensable evaluations for psychiatric disabilities include such impairment. Therefore, the issue is whether the level of the Veteran's occupational and social impairment is of such severity as to warrant a rating in excess of 50 percent. Here, as already noted, the Veteran has indicated good family relations, and that he left work in 2005 due to eye problems and not his adjustment disorder. Also of particular importance in evaluating the Veteran's level of occupational and social impairment are the global assessment of functioning (GAF) scores he has been assigned, because such designations are based on a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). In this case, the March 2007 VA examination assigned a GAF score of 65; the November 2008 VA examination assigned a GAF score of 56; the March 2011 records show a GAF score of 75; and records dated in December 2012 show a GAF score of 61. GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging between 61 and 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). See DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition, Washington, DC, American Psychiatric Association, 1994 (DSM-IV); 38 C.F.R. §§ 4.125, 4.130. In short, these records reflect that upon evaluation of the Veteran's service-connected adjustment disorder, competent medical clinicians have determined that it has resulted in mild and, at most, moderate occupational and social impairment. These findings are consistent with the other evidence of record. Therefore, the Board finds that the Veteran's service-connected adjustment disorder with mixed anxiety and depressed mood has not resulted in the level of occupational and social impairment necessary for a rating in excess of 50 percent. See Mauerhan, supra; Vazquez-Claudio, supra. For these reasons, the Board finds that the Veteran does not meet or nearly approximate the schedular criteria for a rating in excess of 50 percent for his service-connected adjustment disorder with mixed anxiety and depressed mood. Coronary Artery Disease The Veteran's coronary artery disease, status post bypass surgery is currently rated under 38 C.F.R. § 4.104, Diagnostic Code 7017. Under this Code, a 100 percent evaluation is warranted for three months following hospital admission for coronary bypass surgery. Thereafter, a 100 percent evaluation is warranted where there is congestive heart failure, or; a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is left ventricular dysfunction with an ejection fraction of less than 30 percent. A 60 percent evaluation is warranted where there is more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 30 percent evaluation is warranted where a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is evidence of cardiac hypertrophy or dilatation on an electrocardiogram, echocardiogram, or X-ray. The Veteran's service-connected coronary artery disease bypass grafting residuals are not manifested by congestive heart failure, or; a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is left ventricular dysfunction with an ejection fraction of less than 30 percent. For example, the March 2007 VA examiner stated that, given the Veteran's exercise ability, his achievable METs was a 5. It was noted that echocardiogram revealed mildly dilated left ventricle with global systolic function depressed at 45 to 50 percent, mild mitral regurgitation, mild pulmonary hypertension, and mild left atrial dilatation. A December 2008 VA examination noted that echocardiogram conducted the prior November revealed a left ventricular ejection fraction of 50 percent. Estimated METs was less than or equal to 3. The September 2010 VA examination noted that echocardiogram showed an ejection fraction of 60 percent. Further, while the Veteran's METs history was noted as being less than 3, the examination itself stated that METs based on cardiac function was at least 5 or greater. In short, the competent medical evaluations generally show the Veteran's METs to be in the 3 to 5 range, and ejection fraction of 45 to 60 percent, which is consistent with the current 60 percent evaluation under Diagnostic Code 7017. There is also no evidence of acute congestive heart failure since the 60 percent evaluation has been in effect. The Board finds the METs and ejection fraction obtained on objective testing to be more probative than estimated METs levels. For these reasons, the Board finds that the Veteran does not meet or nearly approximate the schedular criteria for a rating in excess of 60 percent for his service-connected coronary artery bypass grafting residuals. Neuropathy The Veteran's service-connected peripheral neuropathy of the lower extremities are evaluated pursuant to the criteria found at 38 C.F.R. § 4.124a, Diagnostic Code 8520, which provides the rating criteria for paralysis of the sciatic nerve. Under this Code, a 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve; a 20 percent rating requires moderate incomplete paralysis of the sciatic nerve; a 40 percent rating requires moderately severe incomplete paralysis; a 60 percent rating requires severe incomplete paralysis with marked muscular atrophy; an 80 percent rating requires complete paralysis of the sciatic nerve. When there is complete paralysis, the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The terms "mild," "moderate," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of terminology such as "moderate" or "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The rating schedule provides the following guidance in evaluating the severity of disabilities of peripheral nerves: Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain [at times excruciating] is to be rated on the scale provided for injury of the nerve involved, with a maximum rating equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. See 38 C.F.R. § 4.123. Neuralgia characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. See 38 C.F.R. § 4.124. In this case, the March 2007 VA diabetes mellitus examination found that the Veteran's strength was 5/5. Reflexes were diminished in ankle jerk. Also, sensation was decreased to light touch in the plantar surfaces of the feet. The December 2008 VA diabetes mellitus examination found, in part, no ankle edema or peripheral edema in the upper or lower extremities. Distal motor strength was normal and symmectic in the upper and lower extremities bilaterally. There was evidence of decreased sensation to vibration in the right and left lower extremities, as well as markedly decreased sensation to pinprick and light touch along the dorsum of each great toe and the plantar aspect of each foot. Knee and ankle jerks were 2+ and symmetrical bilaterally. The October 2010 VA neurologic examination, when asked if he had pain in his toes or feet, the Veteran responded "not all the time." When asked if he had tingling in his toes or feet, he responded "now and then." However, he reported no numbness in his toes or feet. On examination, he had good strength in the legs. Sensory examination did reveal decreased sensation to all primary modalities distilling in a stocking type of distribution. Deep tendon reflexes were 1+ both knees and 0 (zero) both ankles. In short, even though there is decreased ankle reflexes and decreased sensation of both lower extremities, there is no indication of loss of strength for either extremity. As such, it appears that the involvement for both extremities is wholly sensory, which is to be rated as mild or at most moderate incomplete paralysis. See 38 C.F.R. § 4.124a. Nothing in the record otherwise indicates that either extremity is manifested by moderately severe incomplete paralysis. Therefore, the service-connected peripheral neuropathy of the right lower extremity does not meet or nearly approximate the schedular criteria for a rating in excess of 20 percent under Diagnostic Code 8520. Hearing Loss The Veteran's hearing loss disability is rated in accordance with the provisions found at 38 C.F.R. §§ 4.85, 4.86. Current VA rating criteria for the evaluation of hearing loss disability provide ratings from zero (noncompensable) to 100 percent, based on the results of controlled speech discrimination tests together with the results of pure tone audiometry tests which average pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz. 38 C.F.R. §§ 4.85, 4.86; Diagnostic Code 6100. The evaluation of hearing impairment applies a rather structured formula which is essentially a mechanical application of the rating schedule to numeric designations after audiology evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). When the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. 38 C.F.R. § 4.86. Further, when the average puretone threshold is 30 decibels at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be considered separately. Id. Initially, the Board notes that it does not doubt the credibility of the Veteran in regard to his account of his own hearing difficulties, as they are clearly within his ability to observe. However, for the purposes of evaluating a hearing loss disability under the relevant schedular criteria, the focus is upon the results of audiological evaluations conducted in accord with the requirements of 38 C.F.R. § 4.85(a). In this case, the only such evaluations appear to be that of the VA examinations conducted in April 2008 and September 2010. Therefore, it appears that only these evaluations are competent evidence for the purpose of determining the appropriate schedular rating. The April 2008 VA audio evaluation revealed pure tone thresholds, in decibels, as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 35 55 55 65 52.5 LEFT 40 60 60 65 56.25 Speech recognition scores were 80 percent for both ears. The September 2010 VA audio evaluation revealed pure tone thresholds, in decibels, as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 40 55 55 65 53.75 LEFT 50 55 60 70 58.75 Speech recognition scores were 72 percent for the right ear, and 68 percent for the left ear. The aforementioned competent audiological evaluations do not show an exceptional pattern of hearing loss to include the puretone threshold of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz ) being 55 decibels or more, nor is the average puretone threshold for either ear shown to be 30 decibels at 1000 Hertz , and 70 decibels or more at 2000 Hertz. As such, the provisions of 38 C.F.R. § 4.86 are not applicable to this case. In regard to the provisions of 38 C.F.R. § 4.85, the Board observes that the results of the April 2008 VA examination correspond to Level IV hearing for both ears under Table VI. These results, in turn, correspond to a 10 percent rating under Table VII. The results from the September 2010 VA examination correspond to Level V hearing for both ears under Table VI, which, in turn, corresponds to the current 20 percent evaluation under Table VII. Consequently, the record does not reflect the Veteran meets or nearly approximates the schedular criteria for a rating in excess of 20 percent for his service-connected hearing loss. The Board is cognizant of the fact that the Court held in Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007), that, when conducting such examinations, in addition to dictating objective test results, the VA audiologist must also fully describe the functional effects caused by a hearing disability in his or her final report. Significantly, however, the Board points out that the Court's rationale for requiring an examiner to consider the functional effects of a Veteran's hearing loss pertained to cases where consideration of referral for an extra-schedular rating under 38 C.F.R. § 3.321(b) might be warranted. Specifically, the Court noted that, "unlike the rating schedule for hearing loss, § 3.321(b) does not rely exclusively on objective test results to determine whether a referral for an extra[-]schedular rating is warranted. The Secretary's policy [requiring VA audiologists to describe the effect of a hearing disability on a Veteran's occupational functioning and daily activities] facilitates such determinations by requiring VA audiologists to provide information in anticipation of its possible application." Id. In this case, it does not appear the April 2008 VA audiological examination accurately described the functional effects of the Veteran's hearing loss. However, the September 2010 VA audiological examination did include an opinion regarding the impact of the hearing loss on the Veteran's occupational activities, and what was noted is consistent with the other evidence of record. As such, because the examiner described the functional effects caused by the Veteran's hearing disability, the Board finds that the September 2010 VA examination fully complies with the holding in Martinak. The Board further notes that the other evidence of record, to include the Veteran's own statements and hearing testimony, provides sufficient information for the Board to evaluate the functional effects of his hearing loss and are sufficient for the Board to consider whether referral for an extra-schedular rating is warranted under 38 C.F.R. § 3.321(b), which will be discussed below. Other Considerations In evaluating the Veteran's service-connected adjustment disorder, coronary artery bypass grafting residuals, peripheral neuropathy of the lower extremities, and hearing loss, the Board notes that it took into consideration the applicability of "staged" ratings pursuant to Fenderson, supra, and Hart, supra. However, a review of the record did not disclose any distinctive periods where any of these disabilities met or nearly approximated the criteria for a rating in excess of those currently in effect. Therefore, "staged" ratings are not warranted in this case. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321(b)(1). The Court has set out a three-part test for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the rating criteria contemplate the Veteran's disability from his service-connected adjustment disorder, coronary artery bypass grafting residuals, peripheral neuropathy of the right lower extremity, and hearing loss. A review of the record reflects that the manifestations that are contemplated in the rating criteria, and that nothing indicates any of these disabilities are manifested by an exceptional or unusual disability picture as to render inadequate the regular schedular standards. The rating criteria are therefore adequate to evaluate these service-connected disabilities and referral for consideration of extraschedular rating is not warranted. ORDER New and material evidence having been received, the claim of entitlement to service connection for age-related macular degeneration is reopened. Service connection for age-related macular degeneration is granted. A rating in excess of 50 percent for adjustment disorder with mixed anxiety and depressed mood is denied. A rating in excess of 60 percent for coronary artery disease bypass grafting residuals is denied. A rating in excess of 20 percent for peripheral neuropathy of the right lower extremity is denied. A rating in excess of 20 percent for hearing loss is denied. REMAND As noted in the Introduction, the Veteran filed a timely appeal with the denial of TDIU in the March 2009 rating. The notice of disagreement was also received within one year of the April 2008 rating decision denying TDIU. The notice of the July 2011 rating decision, which ultimately awarded a schedular combined 100 percent rating from the September 30, 2008 date of claim, advised the Veteran that the TDIU claim was now moot. However, shortly after the date of that notice the Veteran's attorney argued that the Veteran is entitled to a TDIU prior to September 30, 2008. Accordingly, the TDIU issue remains on appeal, and remand for issuance of a Statement of the Case (SOC) is necessary. The Court has indicated that when a claimant submits a notice of disagreement and the RO has not issued an SOC on that issue, remand for issuance of an SOC is required. Manlincon v. West, 12. Vet. App. 238, 240-41 (1999). After the RO has issued the statement of the case, the claim should be returned to the Board only if the Veteran perfects the appeal in a timely manner. See Smallwood v. Brown, 10 Vet. App. 93, 97 (1997). 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.) The RO should undertake all actions required by 38 C.F.R. § 19.26, including issuance of a Statement of the Case, so that the Veteran may have the opportunity to complete an appeal on this issue (if he so desires) by filing a timely substantive appeal. The issue should only be returned to the Board if a timely substantive appeal is filed. The appellant has the right to submit additional evidence and argument on the matter or 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). ______________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs