Citation Nr: 1319928 Decision Date: 06/20/13 Archive Date: 07/02/13 DOCKET NO. 07-35 381 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for sleep apnea, to include as secondary to service-connected diabetes mellitus and posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and PTSD. 3. Entitlement to service connection for a right ankle disability. 4. Entitlement to service connection for a left ankle disability. 5. Entitlement to service connection for a peptic ulcer with gastrointestinal bleeding. 6. Entitlement to an initial rating higher than 10 percent for PTSD prior to March 12, 2011, and a rating higher than 30 percent as of March 12, 2011. 7. Entitlement to an initial compensable rating for tinea versicolor. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARINGS ON APPEAL Appellant and Spouse ATTORNEY FOR THE BOARD T. L. Douglas, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from January 1970 to September 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions in March 2004, March 2005, June 2006, September 2007, and May 2009 by the Nashville, Tennessee, Regional Office (RO) of the Department of Veterans Affairs (VA). In September 2010, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. He and his spouse also testified before a decision review officer in April 2007. Copies of the transcripts of those hearings are of record. The Board remanded the service connection claims then on appeal and the claim for a rating higher than 10 percent for PTSD in February 2011. A subsequent July 2012 rating decision granted entitlement to service connection for tinea versicolor and granted an increased 30 percent rating for PTSD effective from March 12, 2011. However, as that grant does not represent a total grant of benefits sought on appeal, the claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The Veteran waived agency of original jurisdiction (AOJ) review of additional evidence submitted after a June 2012 supplemental statement of the case. The Veteran also submitted a notice of disagreement with the assigned rating for tinea versicolor in August 2012. Where the Board finds a notice of disagreement has been submitted regarding a matter which has not been addressed in a statement of the case, the issue should be remanded for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). The issue of entitlement to an initial compensable rating for tinea versicolor is REMANDED to the RO via the Appeals Management Center in Washington, D.C. FINDINGS OF FACT 1. Sleep apnea was not manifest during active service and is not shown to have developed as a result of an established event, injury, or disease during active service or a service-connected disability. 2. Hypertension was not manifest during active service or within one year of service discharge, is not shown to have developed as a result of an established event, injury, or disease during active service including herbicide exposure in service, and is not shown to have developed as a result of or to have been permanently aggravated by a service-connected disability. 3. A right ankle disability was not manifest during active service and is not shown to have developed as a result of an established event, injury, or disease during active service. 4. A left ankle disability was not manifest during active service and is not shown to have developed as a result of an established event, injury, or disease during active service. 5. A peptic ulcer with gastrointestinal bleeding was not manifest during active service or within one year of service discharge, is not shown to have developed as a result of an established event, injury, or disease during active service including herbicide exposure in service, and is not shown to have developed as a result of nor to have been permanently aggravated by a service-connected disability. 6. The Veteran's service-connected PTSD prior to January 8, 2010, was manifested by an occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during period of significant stress. 7. The Veteran's service-connected PTSD as of January 8, 2010, is manifested by no more than an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss. CONCLUSIONS OF LAW 1. Sleep apnea was not incurred in or aggravated by military service and is not proximately due to a service-connected disability. 38 U.S.C.A. §§ 1110, 1154, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. Hypertension was not incurred in or aggravated by military service, is not proximately due a service-connected disability, and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1116, 1154 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 3. A right ankle disability was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1154, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). 4. A left ankle disability was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1154, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). 5. A peptic ulcer with gastrointestinal bleeding was not incurred in or aggravated by military service, is not proximately due a service-connected disability, and it may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1154 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 6. The criteria for an initial rating higher than 10 percent for PTSD prior to January 8, 2010, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 7. The criteria for a 30 percent rating for PTSD, but not higher, as of January 8, 2010, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The Veteran was notified of the duties to assist and of the information and evidence necessary to substantiate his claims by correspondence dated in June 2003, October 2004, August 2005, January 2006, April 2006, December 2007, and August 2008. The notice requirements pertinent to the issues on appeal have been met and all identified and authorized records relevant to these matters have been requested or obtained. The available record includes service medical records; VA treatment and examination reports; Virtual VA electronic records; private treatment records; lay statements from the Veteran's spouse, daughter, sister-in-law, and a fellow serviceman; and the Veteran's statements and testimony in support of his claims. The Board notes that service records show the Veteran served in the Republic of Vietnam from June 1970 to May 1971 and his exposure to herbicide agents during that service is conceded. A July 2007 VA memorandum also verified a combat stressor during his service in Vietnam and he is found to be a combat veteran for VA compensation purposes. There is no evidence that any additional pertinent records exist or that any additional VA treatment records for PTSD exist which are necessary for an adequate determination. The development requested by the Board in February 2011 has been substantially completed. Further attempts to obtain additional evidence would be futile. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. The VA medical opinions obtained are adequate as they are predicated on a substantial review of the record and medical findings and consider the Veteran's complaints and symptoms. The March 2011 VA examiner is shown to have adequately considered the Veteran's statements about having sustained ankle injuries during combat service in Vietnam. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Although the Veteran asserted in correspondence dated in July 2012 that he had not denied delusions and panic attacks at his March 2011 VA PTSD examination, the Board finds he has provided no specific evidence of having had delusions or panic attacks that would require additional development. Accordingly, VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2012). The available medical evidence is sufficient for adequate determinations. There has been substantial compliance with all pertinent VA law and regulations and to adjudicate the claims would not cause any prejudice to the appellant. Service Connection Service connection may be granted for a disability resulting from injury suffered or disease contracted in line of duty or for aggravation of preexisting injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.306 (2012). Service connection may be established on a secondary basis for a disability which is proximately due to or aggravated by service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). Where a Veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of the Veteran's service as shown by the veteran's service record, the official history of each organization in which the Veteran served, the Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). In the case of a veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, VA shall accept as sufficient proof of service-connection of any disease or injury alleged to have been incurred in or aggravated by that service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service. 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(d) (2012). Service connection can be granted for certain chronic diseases, including arthritis, hypertension, and peptic ulcers, if manifest to a degree of 10 percent or more within one year of separation from active service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Certain diseases associated with herbicide exposure in service may also be presumed service connected. 38 U.S.C.A. § 1116 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). These presumptions are rebuttable by affirmative evidence to the contrary. Veterans diagnosed with an enumerated disease who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307 (2012). For presumptive service connection purposes, hypertension is not included. 38 C.F.R. § 3.309, Note 3 (2012). Even though a disease is not included on the list of presumptive diseases a nexus between the disease and service may nevertheless be established on the basis of direct service connection. Stefl v. Nicholson, 21 Vet. App. 120 (2007). When a claimed disorder is not included as a presumptive disorder, direct service connection may be established by evidence demonstrating that the disease was in fact incurred during the service. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). For the showing of chronic disease in service, there are required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). Continuity of symptomatology applies to those conditions explicitly recognized as chronic. 38 C.F.R. § 3.309(a) (2012); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In order to prevail on the issue of service connection on the merits, there must be medical evidence of (1) a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). A veteran seeking disability benefits must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Medical evidence is required to demonstrate a relationship between a current disability and the continuity of symptomatology demonstrated if the condition is not one where a lay person's observations would be competent. Clyburn v. West, 12 Vet. App. 296 (1999). Whether lay evidence is competent and sufficient in a particular case is an issue of fact and lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Lay evidence presented by a Veteran concerning his continuity of symptoms after service may be considered credible, and ultimately competent, regardless of a lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (2006). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102 (2012). The pertinent evidence of record shows the Veteran complained of right ankle pain in April 1971. The examiner noted swelling and that an X-ray study was negative. No diagnosis was provided. In an August 1971 report of medical history, the Veteran noted he injured his right ankle in Vietnam, but he denied having had high or low blood pressure or stomach trouble. His August 1971 separation examination revealed normal clinical evaluations of the heart, abdomen and viscera, and lower extremities. A sitting blood pressure reading of 116/76 was provided. VA treatment records show a February 1982 Agent Orange examination revealed no evidence for acute or chronic "Agent Orange" toxicity. No complaints or diagnoses pertinent to sleep apnea, hypertension, ankle disabilities, or peptic ulcer disease were provided. Private medical records dated in March 2001 show the Veteran had a history of gastroesophageal reflux disease that had been quiet recently, but no history of chronic disease or abdominal pain. It was noted that approximately five days earlier he experienced diarrhea with dark, black, watery stools and that he had been admitted to the emergency room with profound anemia. An endoscopy revealed several evidences of ulcerative disease in the duodenal bulb. The discharge diagnoses included peptic ulcer disease with hemorrhage and acute anemia secondary to gastrointestinal blood loss. VA treatment records show that on Agent Orange examination in November 2001 the Veteran reported treatment for peptic ulcer disease in 2001 and intermittent abdominal pain since 1970, secondary to a mortar explosion. He complained of occasional abdominal cramping pain and ankle pain that was secondary to numerous ankle sprains he sustained during service in Vietnam. The examiner noted there was no history of hypertension, but that blood pressure readings were elevated. There was full range of motion of all extremities. The diagnoses included degenerative joint disease and peptic ulcer disease with gastrointestinal bleed. No opinions as to etiology were provided. An April 2003 X-ray study of the bilateral ankles revealed an unremarkable left ankle. There was a suggestion of a benign process with an approximate one centimeter defect in the lateral aspect of the dome of the talus. In his May 2003 application for VA compensation benefits the Veteran reported he had right ankle and stomach disabilities that began in 1970. He noted he began receiving treatment for peptic ulcer disease in 2001. In correspondence dated in September 2004, he requested service connection for pre-diabetes, ankle pain, and hypertension. In subsequent statements he stated he had injured his ankle during service in Vietnam and was on crutches for two weeks. He reported he had been told his blood pressure was stimulated by his diabetes. VA diabetes mellitus examination in February 2005 included a diagnosis of type II diabetes mellitus. It was noted that a diagnosis of hypertension was provided prior to his diagnosis of diabetes mellitus in 2002. In correspondence dated in June 2005, he reported that he did not have ulcers or any problems until he came home from Vietnam and that his private physician told him his ulcer was an old bleeding ulcer. He stated he also had ankle pain. In a statement dated in July 2005, he reported he developed ulcers in Vietnam and that he had been treated for stomach pain while serving in Vietnam. He stated he had injured both ankle during service in Vietnam and that he had been on crutches for about six weeks. He asserted that he had arthritis in the ankles as a result of five or six servicemen having jumped on him in a hole during an attack. A February 2006 VA diabetes mellitus examination found the Veteran's hypertension was not a complication of his diabetes mellitus because it was diagnosed prior to his diabetes mellitus. It was also noted that it was not worsened or increased by his diabetes. In correspondence dated in March 2006 the Veteran asserted that he did not have hypertension before he began having problems with diabetes. He also stated his belief that he had early stage diabetes for some time before it was detected by blood work. In a July 2006 statement A.R.L. reported he had severed with the Veteran in Vietnam. He recalled that he had some injuries as a result of hostile action, but that he did not recollect any specific injury. At an April 2007 hearing before a decision review officer the Veteran and his spouse testified that he had self-treated ankle problems for many years with ointments, heat, ice, and elastic bandages. The Veteran stated that testing had revealed chips in one of his ankle like it was an old wound. He stated he had been treated for stomach problems in service and that after service he had taken antacids. In a May 2008 statement the Veteran's spouse reported that he was receiving treatment, including for high blood pressure, and that he had recently started using a sleep apnea machine. He stated he had continued to have problems sleeping unless he took medication. In a July 2008 statement the Veteran requested entitlement to service connection for sleep apnea and hypertension as secondary to his service-connected diabetes mellitus. He also asserted that his hypertension was related to his PTSD. In a March 2010 statement he reported his sleep apnea was due to his PTSD. The Veteran reiterated his claims for service connection at a Board videoconference hearing in September 2010. He described having injured his ankles in Vietnam and having had stomach pain after a mortar attack. A March 2011 VA examination found that the Veteran had hypertension that began about 2003 and that he began seeing mental health professionals for symptoms of PTSD in about 2006. Diabetes, it was noted, did not cause hypertension in the absence or renal disease. A diagnosis of essential hypertension was provided. It was the examiner's opinion that it was less likely his essential hypertension was caused by, a result of, or permanently aggravated by PTSD, diabetes, or military service. The examiner noted the Veteran's obstructive sleep apnea was onset in 2006 and that it was an anatomic problem that was not caused by, a result of, or permanently aggravated by PTSD, diabetes, or military service. The examiner also found that a review of the Veteran's service medical records revealed no evidence of peptic ulcer disease and that records revealed he did not develop peptic ulcer disease for many years after leaving service. His peptic ulcer disease, status post gastrointestinal bleed, was less likely caused by mental stress during active service. Upon evaluation of the ankles the examiner noted the Veteran described injuries to the ankle during active service in Vietnam in 1970 with pain since then that had progressively worsened. There were no constitutional symptoms of arthritis and no evidence of inflammatory arthritis on physical examination. X-ray studies revealed normal joint spaces to the right and left ankles. There was a benign ossicle at the medial malleolus and lateral soft tissue swelling to the right ankle. The examiner noted a review of the evidence revealed one episode of ankle pain and swelling during service, but that there was no evidence of arthritis in subsequent records. The Veteran's right ankle injury in service, based upon findings upon separation examination in August 1976, was a mild injury and was not expected to cause early onset arthritis or further joint problems. It was the examiner's opinion that bilateral ankle strains were less likely caused by or a result of active service. In correspondence dated in July 2012 the Veteran asserted that his sleep apnea was secondary to his diabetes. He also claimed that his hypertension was incurred as a result of service in Vietnam because he had provided a blood pressure test after a traffic stop in 1984 which was high. He reported that he had experienced ankle pain since his injuries in Vietnam and that he had been told there was nothing that could be done for it. He stated he had been told that his hospitalization for duodenal ulcer disease was due to an old scar that flared up with stress from his PTSD. Based upon the evidence of record, the Board finds that sleep apnea, hypertension, a right ankle disability, a left ankle disability, and peptic ulcer disease with gastrointestinal bleeding were not manifest during active service and are not shown to have developed as a result of an established event, injury, or disease during active service or a service-connected disability. The persuasive medical evidence demonstrates that the Veteran's ankle injuries in service were not chronic, that there is no present evidence of ankle arthritis, that his hypertension and peptic ulcer disease was not manifest within one year of service, and that his sleep apnea, hypertension, and peptic ulcer disease were neither caused or permanently aggravated as a result of a service-connected disability. The March 2011 VA medical opinions in this case are persuasive and based upon adequate rationale. They are shown to have been based upon thorough examinations, a thorough review of the evidence of record, and adequate consideration of the Veteran's statements including injuries sustained during combat. While the Veteran is competent to provide evidence as to observations and some medical matters, his statements are, at most, conclusory assertions of a nexus between his post-service diagnoses and service. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (2006). As questions of a present medical diagnosis and any relationship an incident during service are complex etiological questions akin to the type of medical matters which courts have found laypersons are not competent to provide, his statements are insufficient to establish service connection. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (Board must determine whether the claimed disability is a type of disability for which a lay person is competent to provide etiology or nexus evidence). The Veteran is not found to be competent to state that any symptoms he experienced during service were related to a present disability nor that a present disability was either caused or aggravated by a service-connected disability or herbicide exposure. His statements as to having sustained ankle and ulcer disorders in service that continued after service are found to be not credible due to inconsistency with his report of medical history in August 1971. The Board finds the preponderance of the evidence in this case is against the claims for entitlement to service connection. The competent medical opinions in this case show that the Veteran's sleep apnea, hypertension, right ankle disability, left ankle disability, and peptic ulcer disease with gastrointestinal bleeding were not manifest during or for many years after active service, did not develop as a result of active service, and were not caused or aggravated by a service-connected disability. Therefore, the claims must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability rating are determined by the application of VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. For the application of the schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Over a period of many years, a Veteran's disability claim may require re-ratings in accordance with changes in laws, medical knowledge and his or her physical or mental condition. It is thus essential, both in the examination and in the rating of disability, that each disability be viewed in relation to its history. 38 U.S.C.A. § 1155(West 2002); 38 C.F.R. § 4.1 (2012). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately compensate the elements of disability present. 38 C.F.R. § 4.2 (2012). Whether lay evidence is competent and sufficient in a particular case is an issue of fact and that lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). Rating of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses is prohibited. 38 C.F.R. § 4.14 (2012). Disabilities may be rated separately without violating the prohibition against pyramiding unless the disorder constitutes the same disability or symptom manifestations. Esteban v. Brown, 6 Vet. App. 259, 261 (1994). When rating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and a veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating 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. When rating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). Diagnostic Code 9411 governs ratings for PTSD. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2012). PTSD, like most mental disorders, is rated pursuant to the Schedule for Rating Formula for Mental Disorders. 38 C.F.R. § 4.130 (2012). A 10 percent rating is warranted when the symptoms exhibited include occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during period of significant stress, or; when the symptoms are controlled by continuous medication. A 30 percent rating is warranted when the symptoms exhibited include 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, and 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 maintaining 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; intermittently illogical, obscure, or irrelevant speech; 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 when 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. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2012). The psychiatric symptoms listed in the rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In the context of a 70 percent rating, the rating criteria require not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas and that the regulation requires an ultimate factual conclusion as to the level of impairment in most areas. Vazquez-Claudio v. Shinseki, ___F.3d.___, 2013 WL 1395804 (Fed. Cir. Apr. 8, 2013). Global Assessment of Functioning (GAF) scores, which indicate the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health, are also useful indicators of the severity of a mental disorder. Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). GAF scores ranging between 61 to 70 indicate 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 indicate that the individual is functioning pretty well, and has some meaningful interpersonal relationships. Scores between 51 to 60 indicate 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). GAF scores between 41 to 50 indicate 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). Scores between 31 to 40 indicate some 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). The pertinent evidence of record shows that in August 2006 the Veteran sought treatment at a VA medical facility due to nightmares about combat in Vietnam. The examiner noted he was well developed, well nourished, and oriented to person, place, and time. No psychomotor agitation was noted. He was appropriately dressed and groomed. Speech was normal in rate, rhythm, and volume. His mood was depressed and anxious and his affect was restricted without acute distress. Thought process was logical and content was nondelusional. Cognition was intact. He denied suicidal and homicidal ideation. His insight was good and his judgment was intact. A diagnosis of chronic PTSD was provided with a GAF score of 60. The treatment plan included medication. A September 2006 report noted the Veteran reported he had experienced difficulty falling or staying asleep. He stated he felt irritable and had outbursts of anger, but that he was better since he began taking medication. He reported having depressed mood from time to time and denied suicidal ideation. The examiner noted he had moderate grooming and hygiene. Speech was normal in rate, rhythm, and volume. His mood was depressed and anxious and his affect was mood congruent. Thought process was logical and goal directed and his thought content was about getting better. He denied suicidal and homicidal ideation. His insight and judgment were good. The diagnoses included depression, anxiety, and rule out PTSD. A GAF score of 65-70 was provided. At his personal hearing before a decision review officer in April 2007, the Veteran reported he was receiving treatment for PTSD and taking medication. He stated he was concerned about taking anxiety medication because it was habit forming. He stated he sometimes took a vacation day from work when he felt he need to be off, but that he did not usually take sick leave. He reported having had poor communication with his spouse. VA treatment records dated in May 2007 show the Veteran reported increased anxiety after having discussed his war experiences at his personal hearing. He stated he was taking his anxiety medication more frequently. The examiner noted he had good personal hygiene and grooming. There was no evidence of psychomotor disturbance, abnormal movements, or apraxia. He was alert and oriented to time, place, and person. His thoughts were organized and goal directed. His mood was slightly depressed and his affect was appropriate. His speech was normal, his memory was intact, and his judgment and insight were not impaired. There were no suicidal or homicidal thoughts at that time. The diagnosis was chronic PTSD with a GAF score of 60. On VA PTSD examination in August 2007, the Veteran reported he had noticed improvement in his psychiatric symptoms since starting psychotropic medications in August 2006. The examiner noted he was neatly groomed and appropriately dressed. Psychomotor activity and speech were unremarkable. His affect was normal and his mood was anxious. His attention was easily distracted with a short attention span. He was intact to person, place, and time. His thought process and content were unremarkable. He understood the outcome of behavior and understood he had a problem. He reported he usually got five to six hours sleep in a 24-hour period, but that he woke up approximately two times per week due to "shock" or combat-related nightmares. He also stated that he had difficulty relaxing and falling to sleep. There was no evidence of obsessive/ritualistic behavior, panic attacks, homicidal thoughts, suicidal thoughts, episodes of violence, inability to maintain minimal personal hygiene, or problems with activities of daily living. His impulse control was good and remote and recent memory were normal. His immediate memory was noted to be mildly impaired, and was likely impaired due to anxiety related to the examination. It was noted he reported he took approximately three days off every three months due to mental health reasons. A diagnosis of chronic PTSD was provided with a GAF score of 62. His PTSD signs and symptoms were found to be transient or mild with decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress. VA treatment records dated in December 2007 show the Veteran reported he had not done well since his May 2007 visit. He complained of continued daytime anxiety issues and nightmares. He stated he startled easily and slept three hours per night on average. He asserted his daytime anxiety was starting to affect his work. The examiner noted the Veteran was casually dressed and alert and oriented to person, place, time, and purpose. Mood was described as anxious. His affect was mood congruent. His thought process was organized and goal directed. Suicidal and homicidal ideations were denied. Speech was normal and insight and judgment were good. His impulse control was good. The diagnosis was chronic PTSD. An April 2008 report noted the Veteran complained of increased irritability and being easily frustrated. The Veteran's spouse provided a statement in support of his claim in May 2008 and described worsening problems with his forgetfulness. She stated he experienced depressed mood at times and had anxiety attacks often. She reported he was very suspicious, had panic attacks, and had problems sleeping at night. She noted he seemed to become angry when he could not remember names of his close relatives and friends. In a May 2008 statement, the Veteran's daughter reported he never wanted to go anywhere and that he liked to stay home in his room or in his garden. She stated he was forgetful and withdrawn at times. In another May 2008 statement, the Veteran's sister-in-law reported he had been withdrawn, but that he seemed happy when he attended church. VA treatment records dated in March 2009 show the Veteran was casually dressed with good grooming and hygiene. There was no abnormal movements or psychomotor agitation. His mood was described as feeling fine and his affect was appropriate. Suicidal and homicidal ideations were denied and no perceptual disturbance was noted. Insight and judgment were not impaired and impulse control was good. A diagnosis of chronic PTSD was provided with a GAF score of 65. In June 2009, the Veteran reported he was sleeping adequately about six to seven hours per night. He denied depressive or anxiety symptoms. A January 8, 2010, report shows the Veteran complained of more depression recently associated with the death of two of his friends. He complained of increasing stress at work and an increased daily commute due to his job being relocated. The examiner noted he had good personal hygiene and grooming and that his memory was grossly intact. His mood was sad and his affect was mood congruent. His insight, judgment, impulse control, and reliability were fair. A diagnosis of chronic PTSD was provided with a GAF score of 55. In August 2010, he reported he was feeling irritable, sad, and stressed out and that he was having relationship problems with his spouse. He also reported feeling paranoid and that someone was observing him. The examiner noted he had fair personal hygiene and grooming. There was no evidence of psychomotor agitation or abnormal movements. His speech was clear with normal rate and volume. Speech rhythm was fluid. His mood was sad and his affect was dysphoric. His thought process was logical and his thought content was appropriate. His memory was intact and his judgment and insight were fair. There was no suicidal or homicidal ideation. The diagnosis was chronic PTSD with a GAF score of 51-55. At his Board videoconference hearing in September 2010, the Veteran asserted that a higher rating was warranted for his PTSD because his treatment providers had given him higher and higher doses of medication. He stated taking that the medication was a problem for his commute and safety at work. He reported that due to his PTSD he had difficulty being around others and liked to isolate himself. VA treatment records dated in September 2010 show the Veteran reported feeling irritable, sad, and stressed out. He stated his relationship with his spouse was improving. The examiner noted his speech was clear, with normal rate and volume. Speech rhythm was fluid. His mood was okay and his affect was mood congruent. His thought process was logical and his thought content was appropriate. There was no suicidal or homicidal ideation. His memory was intact and his judgment and insight were fair. A diagnosis of chronic PTSD was provided with a GAF score of 55-65. In November 2010, he reported he was doing well with no problems at work and his relationship with his spouse was improving. The examiner noted his personal hygiene and grooming were good. His speech was clear with normal rate and volume. Speech rhythm was fluid. His mood was fairly well and his affect was mood congruent. His thought process was logical and his thought content was appropriate. There was no suicidal or homicidal ideation. His memory was intact and his judgment and insight were fair. A diagnosis of chronic PTSD was provided with a GAF score of 55-65. On VA PTSD examination in March 2011 the Veteran reported that overall he had good relationships with his family and his spouse of 37 years. He denied having any close friends he could talk with about personal issues. He stated that he isolated at home when not at work. He stated he had stopped coaching baseball because of anxiety being around other people. The examiner noted he was clean, neatly groomed, and appropriately dressed. His psychomotor activity was lethargic. Speech was unremarkable. His affect was normal and his mood was anxious. His thought process was rambling and his thought content was unremarkable. He understood the outcome of behavior and understood he had a problem. He reported he had a sleep impairment when he did not take medication. There was evidence of obsessive/ritualistic behavior, but no evidence of panic attacks, homicidal thoughts, suicidal thoughts, episodes of violence, or inability to maintain minimal personal hygiene. Activities of daily living included moderate problems with traveling, driving, and other recreational activities. His impulse control was good and remote and immediate memory were mildly impaired. Recent memory was moderately impaired. It was noted he was employed fulltime driving heavy equipment at a warehouse and that he had only lost one week from work over the past 12 months due to a back injury. His decreased concentration was noted to be a problem related to occupational functioning. A diagnosis of chronic PTSD was provided with a GAF score of 51. The examiner noted that signs and symptoms of PTSD resulted in deficiencies in judgment, thinking, family relations, and work. It was noted that those deficiencies were based upon his reports that he made decisions when angry that he regretted, that problems with concentration impacted his ability to stay on task, that his irritability and anger led to tension and distance in his relationship with his spouse, and that he had problems with concentration at work due to controlling his irritability and anger with some detachment from coworkers. In correspondence dated in July 2012, the Veteran reported that he continued to struggle at work and that he was having more panic attacks and needed to be home due to his medication. He stated he almost had two accidents at work due to his medication and had almost wrecked three times commuting home from work due to his medication. He reported that he had not denied delusions and panic attacks at his last VA examination. He also stated that he did not think he could handle the daily pressures of dealing with clogged traffic and the people at his job. Based upon the evidence of record, the Board finds that prior to January 8, 2010, the Veteran's service-connected PTSD was manifested by an occupational and social impairment due to mild or transient symptoms which decreased work efficiency and an ability to perform occupational tasks only during period of significant stress. His symptoms are shown to have been controlled by continuous medication. GAF scores, while not definitive, were consistently above 60 prior to January 8, 2010. The Board finds that the evidence does not show occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to psychiatric symptoms prior to January 8, 2010. Therefore, a initial rating in excess of 10 percent for PTSD prior to January 8, 2010, must be denied. The Board finds that evidence of records shows that the Veteran's service-connected PTSD was increased in severity on January 8, 2010, and after that date was manifested by no more than an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss. The January 8, 2010, VA treatment report noted the Veteran complained of more depression recently associated with the death of two of his friends and increased stress at work. A GAF score of 55 was provided which is indicative of moderate difficulty in social and occupational functioning. Subsequent treatment reports indicate some improvement in functioning in September and November 2010, but that improvement was not shown to have been maintained through examination in March 2011. A GAF score of 51 was provided at that examination. It is significant to note that upon VA examination in March 2011 the Veteran reported that he did not have any close friends he could talk with about personal issues, but that overall he had good relationships with his family and his spouse of 37 years. He was noted to have an anxious mood at that time, a sleep impairment when he did not take medication, and evidence of obsessive/ritualistic behavior. However, the examiner noted his speech was unremarkable, his affect was normal, and there was no evidence of panic attacks, homicidal thoughts, suicidal thoughts, episodes of violence, or inability to maintain minimal personal hygiene. There were moderate problems with traveling, driving, and other recreational activities without any other impairment in activities of daily living. His impulse control was noted to be good and his remote and immediate memory were only mildly impaired. His recent memory was moderately impaired. He was employed fulltime and report no lost time from work as a result of his PTSD in the previous 12 months, but decreased concentration was noted to be a problem with occupational functioning. Although the March 2011 examiner noted that signs and symptoms of PTSD resulted in deficiencies in judgment, thinking, family relations, and work which is terminology included in the criteria for a 70 percent rating, the Board finds the assigned GAF score of 51 and the described symptoms are not shown to have caused occupational and social impairment in most of the referenced areas as to warrant a 70 percent rating for PTSD. Vazquez-Claudio v. Shinseki, ___F.3d.___, 2013 WL 1395804 (Fed. Cir. Apr. 8, 2013). In fact, the GAF score of 51 and the noted deficiencies of decisions when angry he regretted, problems with concentration, and irritability and anger which led to tension and distance in his relationship with his spouse and some detachment from coworkers are more consistent with the criteria for a 30 percent rating. The Board finds that the evidence of record does not show occupational and social impairment with reduced reliability and productivity due to PTSD symptoms at any time during the period on appeal. VA regulations require consideration of the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and a veteran's capacity for adjustment during periods of remission, but that the must be assigned based on all the evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (2012). The overall evidence in this case demonstrates symptoms of PTSD after January 8, 2010, that were no more than 30 percent disabling. The statements of the Veteran and his spouse as to symptoms of PTSD appear to assert a more severe disability. However, to the extent they are inconsistent with the reported medical evidence, such as memory loss for names of close relatives and friends and delusions and panic attacks, those claims are found to be not credible because those claims were advanced in furtherance of a claim for benefits and are not supported by the medical evidence of record. There is no persuasive evidence of symptoms due to PTSD of 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships; 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; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Therefore, an increased 30 percent rating, but no higher, is warranted for PTSD effective from January 8, 2010. The Board further finds there is no evidence of any unusual or exceptional circumstances related to the service-connected disabilities that would take the Veteran's case outside the norm so as to warrant referral for consideration of an extraschedular rating. There is a three-step inquiry for determining whether a Veteran is entitled to extraschedular rating consideration. First, VA must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. Second, if the schedular rating does not contemplate the level of disability and symptomatology and is found to be inadequate, then VA must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as governing norms. Third, if the rating schedule is inadequate to rate a Veteran's disability picture and that picture has related factors, such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. 38 C.F.R. § 3.321(b)(1) (2012); Thun v. Peake, 22 Vet. App. 111 (2008). The Board finds the Veteran's service-connected PTSD is adequately rated under the available schedular criteria and that the objective findings of impairment are well documented. There is no credible evidence of disability more severe than the assigned schedular rating and the opinion of the March 2011 VA examiner is persuasive that the disability has not resulted in a marked interference with employment. Therefore, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. Bagwell v. Brown, 9 Vet. App. 337 (1996). ORDER Entitlement to service connection for sleep apnea, to include as secondary to service-connected diabetes mellitus and PTSD, is denied. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and PTSD, is denied. Entitlement to service connection for a right ankle disability is denied. Entitlement to service connection for a left ankle disability is denied. Entitlement to service connection for a peptic ulcer with gastrointestinal bleeding is denied. Entitlement to an initial rating higher than 10 percent for PTSD prior to January 8, 2010, is denied. Entitlement to a 30 percent rating, but nto higher, for PTSD effective January 8, 2010, is granted. REMAND A review of the record shows that service connection was established for tinea versicolor in a July 2012 rating decision and that in August 2012 the Veteran submitted a notice of disagreement as to the assigned rating in that decision. Therefore, this matter must be remanded for the issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: Issue a statement of the case as to the issue of entitlement to an initial compensable rating for tinea versicolor. The Veteran and his representative should be apprised that a substantive appeal must be submitted to perfect an appeal. 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 or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs