Citation Nr: 1320718 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 10-00 645 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Portland, Oregon THE ISSUES 1. Whether new and material evidence has been received to reopen service connection for post-operative left knee internal derangement residuals and, if so, whether service connection is warranted. 2. Entitlement to service connection for headaches to include migraine. 3. Entitlement to service connection for tinnitus. 4. Entitlement to service connection for right ear hearing loss. 5. Entitlement to service connection for left ear hearing loss. 6. Entitlement to service connection for sleep apnea. 7. Entitlement to a higher initial disability rating for posttraumatic stress disorder (PTSD), in excess of 50 percent for the period prior to January 16, 2010, and in excess of 70 percent for the period on and after January 16, 2010. 8. Entitlement to a total disability rating for based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD J. T. Hutcheson, Counsel INTRODUCTION The Veteran is the appellant in the instant appeal. He had active service from April 1970 to December 1971. The appellant served in the Republic of Vietnam. He was awarded the Combat Infantryman Badge, the Air Medal, and the Bronze Star. This matter came before the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision of the Portland, Oregon, Regional Office (RO) which, in pertinent part, determined that new and material evidence had not been received to reopen service connection for post-operative left knee internal derangement residuals and denied service connection for PTSD, Type II diabetes mellitus, headaches, tinnitus, hearing loss, and sleep apnea. In November 2009, the RO, in pertinent part, granted service connection for PTSD and assigned a 50 percent initial rating for that disability from January 9, 2007; reopened service connection for post-operative left knee internal derangement residuals; and denied the claim on the merits. In November 2010, the RO granted service connection for Type II diabetes mellitus; assigned a 10 percent initial rating for the period from May 20, 2010 to August 25, 2010 and a 20 percent rating for the period on and after August 26, 2010 for that disability; and increased the rating for PTSD for 50 to 70 percent for the period from January 16, 2010. In June 2011, the RO denied a TDIU. In February 2013, the Board requested an opinion from a Veterans Health Administration (VHA) medical expert in neurology. In March 2013, the requested VHA opinion was incorporated into the record. In April 2013, the appellant was provided with a copy of the VHA opinion. The appellant did not subsequently submit additional evidence or argument. The Board has reviewed both the physical claims files and the "Virtual VA" file so as to insure a total review of the evidence. As to the issue of whether new and material evidence has been received to reopen service connection for post-operative left knee internal derangement residuals, the Board is required to consider the question of whether new and material evidence has been received to reopen the claim without regard to the RO's determination in order to establish the Board's jurisdiction to address the underlying claim and to adjudicate the claim on a de novo basis. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). The Board has reframed the issues of service connection for headaches and bilateral hearing loss as entitlement to service connection for headaches to include migraine, right ear hearing loss to include sensorineural hearing loss, and left ear hearing loss to include sensorineural hearing loss in accordance with the United States Court of Appeals for Veterans Claims' (Court) decision in Clemons v. Shinseki, 23 Vet. App. 1 (2009) (finding that a claim for benefits for one psychiatric disability also encompassed benefits based on other psychiatric diagnoses and should be considered by the Board to be within the scope of the filed claim). The Board observes that the appellant has appealed from the initial rating assigned for the service-connected PTSD. In Fenderson v. West, 12 Vet. App. 119 (1999), the Court addressed a similar appeal and directed that it was specifically not a claim for an increased disability rating. The Court also directed that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. The Board has therefore framed the issue as entitlement to a higher disability rating for PTSD in excess of 50 percent for the period prior to January 16, 2010, and in excess of 70 percent for the period on and after January 16, 2010. The appellant is not prejudiced by such action. The Board has not dismissed any issue and the law and regulations governing the rating of disabilities are the same regardless of how the issue is styled. In April 2010, the RO denied service connection for both traumatic brain injury (TBI) residuals and Meniere's disease. The appellant has not submitted a notice of disagreement (NOD) with the denial of service connection for both TBI residuals and Meniere's disease; therefore, these service connection issues are not on appeal, and will not be addressed below. The issues of service connection for both a left knee disorder and sleep apnea and entitlement to a TDIU are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. In February 1972, the RO denied service connection for post-operative left knee internal derangement residuals. The appellant was informed in writing of the adverse decision and his appellate rights in March 1972. The appellant did not submit a NOD with the decision. 2. The additional documentation submitted since the February 1972 rating decision is new, relates to an unestablished fact, and raises a reasonable possibility of substantiating the claim for service connection for post-operative left knee internal derangement residuals. 3. Service connection is currently in effect for right knee internal derangement, PTSD, Type II diabetes mellitus, hypertension, and erectile dysfunction. 4. Headaches and migraine were not shown during active service or for many years thereafter. 5. Migraine is etiologically related to the service-connected PTSD. 6. The appellant sustained combat-related acoustical trauma (loud noise exposure) while in the Republic of Vietnam. 7. Tinnitus originated during active service. 8. Symptoms of right ear hearing loss were not continuous since service separation; did not manifest to a compensable degree within one year of service separation; and were first objectively manifested some 38 years after service in February 2010. 9. The appellant has current disability of Meniere's disease with associated right ear sensorineural hearing loss. Service connection has been denied for Meniere's disease. 10. Right ear sensorineural hearing loss did not begin during service and is not related to active service. 11. Left ear hearing loss does not meet the criteria of disability for VA purposes under 38 C.F.R. § 3.385 (2012). 12. For the initial rating period from January 9, 2007 to January 16, 2010, PTSD was productive of occupational and social impairment with reduced reliability and productivity due to symptoms such as recurrent Vietnam-related thoughts; occasional nightmares; avoidance of crowds; hypervigilance; episodic road rage; a sensitivity to loud noises; anxiety; an appropriate affect; a euthymic mood; impaired concentration and judgment; intact abstraction and reasoning abilities; intact memory; understandable speech; and no history or evidence of psychosis, hallucinations, or delusions. 13. For the rating period on and after January 16, 2010, PTSD is productive of occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as a neutral, congruent, and appropriate affect; a congruent and appropriate mood; appropriate communication; coherent and logical thought processes; intact memory; fair concentration and attention; and no suicidal or homicidal ideation. CONCLUSIONS OF LAW 1. The February 1972 rating decision denying service connection for post-operative left knee internal derangement residuals became final; new and material evidence sufficient to reopen service connection for post-operative left knee internal derangement residuals has been received. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5108, 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.326(a), 20.1105 (2012). 2. Resolving reasonable doubt in the appellant's favor, migraine was incurred proximately due to or as the result of the service-connected PTSD. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310(a), 3.326(a) (2012). 3. Resolving reasonable doubt in the appellant's favor, tinnitus was incurred in active service. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.326(a) (2012). 4. Right ear hearing loss was not incurred in or aggravated during active service and sensorineural hearing loss may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137, 1154(b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310(a), 3.326(a), 3.385 (2012). 5. The criteria for service connection for left ear hearing loss have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137, 1154(b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310(a), 3.326(a), 3.385 (2012). 6. The criteria for a rating in excess of 50 percent for PTSD for the period from January 9, 2007 to January 16, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 7. The criteria for a rating in excess of 70 percent for PTSD for the rating period on and after January 16, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and to Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473(2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this decision, the Board reopens and remands the issue of service connection for post-operative left knee internal derangement residuals and grants service connection for both migraine and tinnitus; therefore, no further discussion of VA's duties to notify and to assist is necessary as to those issues. In addressing the issues of service connection for hearing loss and the initial rating of PTSD, VA has issued several VCAA notices to the appellant including a September 2007 notice which informed him of the evidence generally needed to support a claim of service connection and the assignment of a rating and effective date for an initial award of service connection; what actions he needed to undertake; and how VA would assist him in developing his claim. The March 2007 VCAA notice was issued to the appellant prior to the November 2007 rating decision from which the instant appeal arises. The issues were readjudicated in the November 2009 statement of the case (SOC) and the multiple supplemental statements of the case (SSOC); therefore, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Moreover, because this appeal arises in part from the appellant's disagreement with initial rating following the grant of service connection for PTSD, no additional notice is required regarding this downstream element of the service connection claim for PTSD. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Court have similarly held that regarding the downstream element of the initial rating that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (noting that, once an initial VA decision awarding service connection and assigning a disability rating and effective date has been made, 38 U.S.C.A. § 5103(a) notice is no longer required); 38 C.F.R. § 3.159(b)(3) (no VCAA notice required because of filing of NOD). Regarding the duty to assist in this case, VA has secured or attempted to secure all relevant documentation required by the VCAA. The appellant was afforded multiple VA examinations. The examination reports are of record. All identified and available relevant documentation has been secured and all relevant facts have been developed. There remains no question as to the substantial completeness of the claims. 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). For these reasons, the Board finds that the VCAA duties to notify and to assist have been met. Reopening Service Connection for Left Knee Disorder Generally, absent the filing of a NOD within one year of the date of mailing of the notification of the initial review and determination of an appellant's claim and the subsequent filing of a timely substantive appeal, a rating determination is final and is not subject to revision upon the same factual basis except upon a finding of clear and unmistakable error. 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. §§ 20.200, 20.300, 20.1103. The provisions of 38 C.F.R. § 3.156 direct, in pertinent part, that: (a) General. A claimant may reopen a finally adjudicated claim by submitting new and material evidence. 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. (b) Pending claim. New and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed (including evidence received prior to an appellate decision and referred to the agency of original jurisdiction by the Board of Veterans Appeals without consideration in that decision in accordance with the provisions of § 20.1304(b)(1) of this chapter), will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. The provisions of 38 C.F.R. § 3.156(a) creates a low threshold, with the phrase "raises a reasonable possibility of substantiating the claim" enabling rather than precluding reopening and not constituting a third requirement that must be met before the claim is reopened. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court has elaborated on what constitutes "new and material evidence." New evidence is not that which is cumulative of other evidence already present in the record. In determining whether new and material evidence has been submitted, the Board must consider the specific reasons for the prior denial. Evans v. Brown, 9 Vet. App 273, 283 (1996). See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). In making the determination of materiality, "the Board is precluded from considering the credibility of the newly submitted evidence; strictly for purposes of determining whether new and material evidence has been presented, the Board must presume that the newly submitted evidence is credible." Duran v. Brown, 7 Vet. App. 216, 220 (1994) (citing Justus v. Principi, 3 Vet. App. 510, 513 (1992)). In applying 38 C.F.R. § 3.156(b), the Court has clarified that: When a claim is filed and the RO renders an adverse decision, the claimant has the right to disagree with that decision by filing an NOD within one year from the date of mailing of notice of the decision. 38 U.S.C. § 7105(b)(1). However, "[n]ew and material evidence received prior to the expiration of the appeal period ... will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period." Muehl v. West, 13 Vet. App. 159, 161 (1999); see also Bond v. Shinseki, 659 F.3d 1362, 1368-69 (Fed.Cir.2011). Where documents are within VA's control and could reasonably be expected to be a part of the record, such documents are, in contemplation of law, before VA and should be included in the record. Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). In February 1972, the RO denied service connection for post-operative left knee internal derangement residuals as the disability "was not incurred in or aggravated by service." The appellant was informed in writing of the adverse decision and his appellate rights in March 1972. A NOD with the decision was not subsequently received. The evidence upon which the RO formulated its February 1972 decision may be briefly summarized. A pre-service February 1969 treatment record from G. Casebolt, M.D., states that the appellant had undergone removal of a left knee patellar chip fracture fragment. The report of the April 1970 physical examination for service entrance notes the appellant's pre-service history of a patellar fracture and removal of a portion of the patella. The appellant reported that his knee "bothers him [with] squatting." On physical evaluation, the examiner observed "knee-patellar fairly tight - cannot displace;" identified no left lower extremity abnormalities; and found the appellant to be qualified for induction. The appellant's service treatment records indicate that he was seen for left knee complaints. A May 1970 treatment entry notes that the appellant complained "of left knee coming out." He exhibited a swollen left knee and was issued an Ace bandage and crutches. A May 1971 treatment record states that the appellant complained of bilateral knee pain of five years' duration. An impression of a left partial patellectomy by history was advanced. At the November 1971 physical examination for service separation, the appellant reported that he had "bad knees." On physical evaluation, the appellant was reported to have normal lower extremities. The report of a February 1972 VA examination for compensation purposes states that the appellant was diagnosed with post-operative left knee internal derangement. New and material evidence pertaining to the issues of service connection for post-operative left knee internal derangement residuals was not received by VA or constructively in its possession within one year of written notice to the appellant of the February 1972 rating decision; therefore, that decision became final. 38 C.F.R. § 3.156(b). The additional documentation received since the February 1972 rating decision consists of service personnel records, photocopies of service treatment records, VA examination and clinical documentation, private clinical documentation, Internet medical articles, a written statement from the appellant's former employer, and written statements from the appellant. In an August 2008 written statement, the appellant conveyed that he had reinjured his left knee in Vietnam and his left lower extremity had been subsequently placed in a cast in Phu Bai, Republic of Vietnam. The report of a May 2011 VA general medical examination states that the appellant presented a history of having injured his left knee while jumping from a helicopter in the Republic of Vietnam. No left knee diagnosis was advanced. The appellant's August 2008 written statement and the May 2011 VA examination report convey that the appellant presented a history of a left knee injury sustained while jumping from a helicopter in the Republic of Vietnam. When such a history is presumed to be credible for the limited purpose of reopening a claim and considered with the previously evidence of record, the Board finds that the additional documentation is of such significance that it raises a reasonable possibility of substantiating a claim of service connection for a left knee disorder. New and material evidence has been received to reopen service connection for post-operative left knee internal derangement residuals is reopened. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. (The issue of service connection for a left knee disorder is further addressed in the Remand section below.) Service Connection for Headaches to Include Migraine The appellant asserts that service connection for headaches is warranted as the claimed disability was incurred as the result of a combat-related TBI/concussive force trauma sustained in combat during service while in the Republic of Vietnam. Service connection may be granted for disability arising from disease or injury incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110; 38 C.F.R § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of 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 current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The claimed disorder is not a "chronic disease" enumerated under 38 C.F.R. § 3.309(a); therefore, the provisions of 38 C.F.R. § 3.303(b) are not for application. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). The Court has clarified that service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service-connected disorder has aggravated a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection is currently in effect for right knee internal derangement, PTSD, Type II diabetes mellitus, hypertension, and erectile dysfunction. In the case of any 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, campaign, or expedition, the Secretary shall accept as sufficient proof of service connection of any disease or injury alleged to have been incurred in or aggravated by such 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, and, to that end, shall resolve every reasonable doubt in favor of the veteran. Service connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. The reasons for granting or denying service-connection in each case shall be recorded in full. 38 U.S.C.A. § 1154(b). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1154(a) (West 2002); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Federal Circuit has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The service treatment records do not refer to headaches, migraine, or head trauma. The service personnel records do convey that the appellant participated in significant combat activities while in the Republic of Vietnam and experienced some explosions and other rigors associated with such wartime service. The appellant was awarded the Combat Infantryman Badge, the Air Medal, and the Bronze Star. A September 2000 neurological consultation summary from J. Boggs, M.D., states that the Veteran presented a history of "recurrent headaches since childhood that over time have become more frequent and severe in nature." An impression of "chronic daily headaches with superimposed episodic severe migraine" was advanced. Clinical documentation from Dr. Boggs dated between June 2002 and May 2007 shows assessments of refractory headaches and chronic headaches. In his January 2007 Veteran's Application for Compensation or Pension (VA Form 21-526), the Veteran stated that his "headaches started in the military service - nothing confirmed as why they exist - first headache was in boot camp." At a January 2010 VA TBI examination, the Veteran presented a history of headaches since discharge from the service diagnosed as migraine. Assessments of "TBI, mild, Grade 1 concussion due to military service" and "TBIs, non-service related, probable Grade II-III concussions due to civilian 'on-job' and football injuries not a result of active military service" were advanced. The examiner commented that "as his headaches did not occur until after discharge, I would think that that they would be more likely due to his Grade 3 concussion sustained on a civilian work injury than the Grade 1 concussion which occurred during service." The March 2013 VHA neurological opinion relates that the clinical record had been thoroughly reviewed. The physician opined that: "the patient's headache disorder was most likely migraine;" "the chronic migraine cannot be linked through documentation to the period of military service"; "while PTSD is not proven to aggravate headache, it appears to be a viable hypothesis that deserves further study"; and "I feel that it is as likely as not that PTSD has permanently increased the veteran's severity beyond its natural progression." The Board finds by the weight of the evidence that headaches and/or migraine were not shown during active service or for many years thereafter. No competent medical professional has attributed the appellant's migraine to active service including his significant combat experiences in the Republic of Vietnam. However, the March 2013 VHA neurological opinion concluded that "it is as likely as not that PTSD has permanently increased the veteran's severity beyond its natural progression." The Board finds that the VHA opinion is persuasive and supported by the record. For these reasons and upon resolving all reasonable doubt in the appellant's favor, the Board concludes that service connection for migraine secondary to the service-connected PTSD is now warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 3.310. Service Connection for Tinnitus The appellant asserts that service connection for tinnitus is warranted as he initially experienced ringing of the ears during service following his combat-related noise exposure while in the Republic of Vietnam. In his May 2008 NOD, the appellant conveyed that he had been routinely exposed to noise associated with jet engines, medium and small arms fire, and demolitions during active service. He asserts that he experienced tinnitus during active service due to his extensive in-service combat noise exposure which has persisted to the present time. Tinnitus is not a "chronic disease" enumerated under 38 C.F.R. § 3.309(a). Therefore, the provisions of 38 C.F.R. § 3.303(b) are not for application. Walker, 708 F.3d 1331 (Fed. Cir. 2013). After a review of all the evidence, lay and medical, the Board finds that the evidence of record is in relative equipoise as to whether tinnitus originated during active service. As noted above, the service personnel records establish that the appellant participated in extensive combat in the Republic of Vietnam, and the evidence shows acoustic trauma during service, including due to noise during combat. The evidence weighing against the claim includes that the service treatment records make no reference to tinnitus. The evidence against the claim also includes medical evidence relating the tinnitus to non-service-related Meniere's disease. At a September 2007 VA diabetes mellitus examination, the Veteran reported that he had episodic tinnitus and a familial history of Meniere's disease. At a June 2008 Ear Disease VA examination, the appellant complained of intermittent right ear ringing of five years' duration. The appellant was diagnosed with right ear Meniere's disease. The examiner opined that the appellant's symptoms were attributable to his Meniere's disease. At a January 2010 VA TBI examination, the appellant was reported to have come under artillery fire during combat and to have experienced tinnitus associated with Meniere's disease for approximately nine years. Assessments of "TBI, mild, Grade 1 concussion due to military service" and "TBIs, non-service related, probable Grade II-III concussions due to civilian 'on-job' and football injuries not a result of active military service" were advanced. Clinical documentation from J. Yun, M.D., dated between February 2010 and November 2011 notes that the appellant experienced tinnitus and was being treated for Meniere's disease. The favorable evidence includes a June 2008 VA audiological evaluation report, which reflects that the appellant complained of tinnitus and includes a favorable opinion relating the current tinnitus to the in-service noise exposure. A diagnosis of tinnitus was advanced. The examiner opined that "suspect tinnitus is as likely as not related to military noise as occup[ational] noise (and/or possible suspected inner ear problems)." The favorable evidence also includes the Veteran's more recent statements that tinnitus began in service following the loud noise exposure. In his January 2007 Veteran's Application for Compensation or Pension (VA Form 21-526), the appellant indicated that his tinnitus had begun secondary to his in-service acoustical trauma. In an August 2011 written statement, the appellant asserted that he had not previously understood that tinnitus denoted ringing of the ears. He advanced that he had experienced constant tinnitus since active service. The appellant is competent to describe his experience of ringing in the ears during and after service. See Charles v. Principi, 16 Vet. App. 370 (2002) (providing that ringing in the ears is capable of lay observation). The appellant's ringing of the ears has been diagnosed as tinnitus by competent VA and private audiological professionals. The appellant has reported that he experienced ringing in his ears after being exposed to combat-related explosions and other noise which continued thereafter. His statements are competent, credible and probative. While he presented an apparently conflicting history as to ringing of the ears during active service, the appellant clarified that such inconsistencies were the result of his lack of knowledge as to the meaning of the term "tinnitus." The Board accepts this explanation as to the inconsistency in the subjective history presented by the appellant. The positive evidence reflects that the appellant sustained significant combat-related acoustical trauma/noise exposure and has been diagnosed with tinnitus as the result of such exposure. The negative evidence consists of post-service diagnoses of non-service-connected Meniere's disease manifested in part by tinnitus. Regarding the medical opinion evidence, while the June 2008 and January 2010 VA evaluations concluded that the appellant's tinnitus was secondary to his nonservice-connected Meniere's disease and, therefore, not related to active service, the June 2008 VA audiological examination report determined that his tinnitus was consistent with his reported in-service acoustic trauma. The Board finds, and applying the provisions of 38 U.S.C.A. § 1154(b), resolving reasonable doubt in the appellant's favor, the Board concludes that service connection is now warranted for tinnitus. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Bilateral Hearing Loss The Veteran contends that he incurred chronic bilateral hearing loss as the result of in-service combat-related acoustic trauma. In his January 2007 Veteran's Application for Compensation or Pension (VA Form 21-526), the appellant indicated that his hearing loss had begun due to his combat-related acoustical trauma. In his May 2008 NOD, the appellant conveyed that he had been routinely exposed to noise associated with jet engines, medium and small arms fire, and demolitions during active service. He asserted that his "discharge physical does not provide exit audio gram." Service connection for impaired hearing for VA purposes shall be established when the thresholds for any of the frequencies of 500, 1000, 2000, 3000 and 4000 Hertz are 40 decibels or more; or the thresholds for at least three of these frequencies are 26 decibels; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Regarding the element of current disability for hearing loss, the Court has held that the provisions of 38 C.F.R. § 3.385 prohibit the award of service connection for hearing loss where audiometric test scores are within the established limits. Hensley v. Brown, 5 Vet. App. 155, 158 (1993) citing Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The Board notes that the provisions of 38 C.F.R. § 3.303(b) are for application in this case as organic disease of the nervous system, including sensorineural hearing loss, is a "chronic disease" within the meaning of 38 C.F.R. § 3.309(a). See Walker. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Where a veteran served ninety days or more during a period of war or during peacetime service after December 31, 1946, and an organic disease of the nervous system including sensorineural hearing loss becomes manifest to a degree of ten percent within one year of termination of such service, such disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). After reviewing all the evidence, the Board finds that the Veteran was exposed to loud noise (acoustic trauma) during service, including during combat in service. See 38 U.S.C.A. § 1154(b). The evidence shows that the Veteran has right ear hearing loss disability that meets the regulatory criteria at 38 C.F.R. § 3.385, but does not have a current hearing loss disability in the left ear that meets this criteria. The weight of the evidence demonstrates that the symptoms of right ear hearing loss to include sensorineural hearing loss were not chronic in service or continuous since service separation; did not manifest to a compensable degree within one year of service separation; and were first objectively manifested in February 2010, some 38 years after service. With regard to in-service symptoms, service treatment records make no reference to hearing loss or impaired auditory acuity. At the November 1971 physical examination for service separation, the appellant exhibited pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 - 0 LEFT 0 0 0 - 0 The Board concludes further that left ear hearing loss disability for VA purposes (38 C.F.R. § 3.385) has not been shown at any time prior to or during the current claim period. An October 2007 VA treatment record states that the appellant complained of impaired hearing. He presented a history of Meniere's disease. At the June 2008 VA audiological evaluation, the appellant exhibited pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 35 20 15 20 25 LEFT 25 15 15 15 15 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 98 percent in the left ear. The appellant was diagnosed with right ear sensorineural hearing loss. The examiner observed that the left ear was "essentially [within normal limits]." At the June 2008 VA Ear Disease examination, the Veteran complained of impaired hearing. He was diagnosed with right ear Meniere's disease. The examiner commented that "it is my opinion that more likely than not the patient's current symptoms, which sounds like Meniere's disease are not related to the time he was in the service." A February 2010 audiological evaluation from S. Bryant, Au.D., conveys that the appellant exhibited pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 70 65 60 55 60 LEFT 30 20 15 15 10 Speech audiometry revealed speech recognition ability of 64 percent in the right ear and of 90 percent in the left ear. The appellant was diagnosed with bilateral sensorineural hearing loss. A November 2011 audiological evaluation from S. Anderson, Au.D., conveys that the appellant exhibited pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 60 55 50 55 65 LEFT 25 20 10 10 10 Speech audiometry revealed speech recognition ability of 60 percent in the right ear and of 100 percent in the left ear. No audiological diagnosis was advanced. Clinical documentation from Dr. Yun dated between February 2010 and November 2011 indicates that the Veteran was diagnosed with Meniere's disease and sensorineural hearing loss. The evidence demonstrates that left ear hearing loss disability for VA purposes (i.e., hearing loss manifested by either thresholds for any of the frequencies of 500, 1000, 2000, 3000 and 4000 Hertz of 40 decibels or more; where at least three of these frequencies are 26 decibels; or speech recognition scores using the Maryland CNC Test are less than 94 percent) was not shown at any time during or soon prior to this claim period. For these reasons, a preponderance of the evidence is against the claim for service connection for left ear hearing loss, and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. With regard to the issue of service connection for right ear hearing loss, the Board first finds that the weight of the evidence demonstrates that, while the appellant sustained in-service noise exposure/acoustical trauma during combat in the Republic of Vietnam, no chronic symptoms of right ear hearing loss were manifested during active service. All in-service audiometric findings were found to be within normal limits. To the extent that the appellant asserts that he was not afforded an audiological evaluation at service separation, the Board observes that such a statement is belied by the report of the November 1971 physical examination for service separation which encompassed audiometric findings reflecting bilateral hearing loss acuity essentially within normal limits. The Board next finds that symptoms of right ear sensorineural hearing loss were not continuous since service separation, did not become manifest to a compensable degree within one year of service separation, and were first objectively manifested in February 2010, some 38 years after service. The appellant has a currently diagnosed disability of Meniere's disease with associated right ear sensorineural hearing loss. Service connection has been denied for Meniere's disease. The appellant did not submit a NOD with that decision. No competent medical professional has attributed the onset of the appellant's right ear sensorineural hearing loss to active service. Indeed, treating VA and private physicians have consistently related the right ear hearing loss to the appellant's non-service-connected Meniere's disease. The appellant asserts that his hearing loss is related to his combat-related noise exposure while in the Republic of Vietnam. The Board acknowledges that the appellant was exposed to significant combat-related noise. His statements as to such noise exposure are competent, credible, and consistent with the circumstances, conditions, and hardships of his service during the Vietnam War; therefore, the provisions of 38 U.S.C.A. § 1154(b) are for application. However, the statute does not eliminate the need for medical nexus evidence. It merely reduces the evidentiary burden on combat veterans as to the submission of evidence of incurrence or aggravation of an injury or disease in service. Clyburn v. West, 12 Vet. App. 296, 303 (1999); Libertine v. Brown, 9 Vet. App. 521, 523-24 (1996). The Board finds that the appellant was exposed to significant in-service noise during combat; however, the appellant's lay statements that his hearing loss was precipitated by such in-service noise exposure do not constitute competent evidence as to either the existence of left ear hearing loss for VA purposes or etiology of hearing loss of either ear and the disabilities' relationship to active service. The appellant is not competent to offer an opinion concerning either the etiology of his right ear sensorineural hearing loss, which encompasses the nervous system and acoustical trauma to the nerves or the existence of left ear hearing loss for VA purposes as the determinations require both objective audiometric and speech recognition testing, which the Veteran cannot perform on himself. The appellant is not an audiologist, and has not offered any form of medical qualification. The question of the etiology of such a disability is not amenable to observation alone and is too complex to be addressed by a layperson. Such a relationship is the subject of extensive training and research by medical and audiological professionals. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Right ear sensorineural hearing loss for VA purposes has not been shown to be related to the Veteran's significant combat noise exposure or to have otherwise originated during active service. It was not manifested to a compensable degree within one year of service separation and may not be presumed to have been incurred in service. It has been consistently related by medical professionals to non-service-connected Meniere's disease. Left ear hearing loss for VA purposes was not shown during active service or at any time thereafter. Therefore, service connection for both right ear hearing loss and left ear hearing loss is not warranted. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. PTSD Initial Rating In November 2009, the RO granted service connection for PTSD, assigned an initial 50 percent rating for that disability, and effectuated the award as of January 9, 2007. The evidence at that time included a report of a July 2008 VA PTSD examination for compensation purposes that states that the appellant was diagnosed with PTSD secondary to his Vietnam combat experiences. The examiner advanced a Global Assessment of Functioning (GAF) score of 55. The appellant disagreed with the initial rating. During the appeal for a higher initial rating, in November 2010, the RO assigned a 70 percent "staged" initial rating for the period beginning January 16, 2010, thus effectuating a "staged" initial rating for PTSD. The appellant contends that his PTSD is manifested by significant occupational and social impairment which was productive of severe impairment relieved only through the assistance of an understanding employer and his wife. Disability ratings are determined by comparing a veteran's current symptomatology with the criteria set forth in the Schedule For Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. A 50 percent rating is warranted for PTSD which is productive of occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks occurring 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 or forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such 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 work-like setting); and an inability to establish and maintain effective relationships. A 100 percent rating requires total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting herself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). Initial Rating from January 9, 2007 to January 16, 2010 After reviewing all the evidence, the Board finds that, for the initial rating period from January 9, 2007 to January 16, 2010, PTSD was productive of occupational and social impairment with reduced reliability and productivity due to symptoms such as recurrent Vietnam-related thoughts; occasional nightmares; avoidance of crowds; hypervigilance; episodic road rage; a sensitivity to loud noises; anxiety; an appropriate affect; a euthymic mood; impaired concentration and judgment; intact abstraction and reasoning abilities; intact memory; understandable speech; and no history or evidence of psychosis, hallucinations, or delusions, which more nearly approximates the criteria for a 50 percent disability rating. The criteria for a rating in excess of 50 percent for PTSD for the period from January 9, 2007 to January 16, 2010 have not been met or more nearly approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326(a), 4.3, 4.7, 4.130, Diagnostic Code 9411. At the July 2008 VA PTSD examination for compensation purposes, the appellant complained of constant Vietnam-related thoughts and occasional nightmares; having to avoid crowds; hypervigilance; episodes of road rage; and a sensitivity to loud noises and especially to helicopters. He denied having received any prior mental health treatment. The appellant reported that he was currently employed as a city public works employee and had been married to the same woman since 1972, had three children, and was close to his family. The appellant was observed to be anxious; cooperative; and oriented to person, place, and time. On mental status examination, the appellant exhibited impaired concentration; impaired judgment; intact abstraction and reasoning abilities; intact memory; understandable speech; and no history or evidence of psychosis, hallucinations, or delusions. A GAF score of 55 over the preceding year was advanced. The examiner commented that while the appellant had no social life, he was able to both work and to take care of his own activities of daily living. In his December 2009 NOD, the appellant advanced that a 70 percent rating was warranted for PTSD notwithstanding the fact that he was able to maintain both his longstanding employment and his marriage. He believed that he was able to function at such a level solely due to the patience of both his employer and his wife. A January 15, 2010 VA psychological evaluation notes that the appellant complained of intrusive PTSD symptoms and impaired sleep. He reported that he had been retired since July 2009. The appellant was noted to be "always oriented x4;" groomed; casually dressed; and responsive. On mental status examination, the appellant exhibited an appropriate affect which was "broad in range;" a euthymic mood; "extremely poor" memory "for anything involving social stimuli;" reduced attention and social interaction; and normal judgment. The examiner noted that the appellant's "PTSD has become more severe" since his retirement. A GAF score of 48 was advanced. A March 2011 Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21- 4192) states that the appellant had retired from his position as a public work maintenance supervisor in June 2009. For the initial rating period prior to January 16, 2010, PTSD was productive of occupational and social impairment with reduced reliability and productivity due to recurrent Vietnam-related thoughts; occasional nightmares; avoidance of crowds; hypervigilance; episodic road rage; a sensitivity to loud noises; anxiety; an appropriate affect; a euthymic mood; impaired concentration and judgment; intact abstraction and reasoning abilities and memory; understandable speech; and no history or evidence of psychosis, hallucinations, or delusions. The appellant's impairment was found to be represented by GAF scores of 48 and 55. The GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994). A GAF score of between 41 and 50 denotes 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. A score of between 51 to 60 reflects moderate difficulty in social, occupational, or school functioning. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996). The appellant reported being able to maintain both longstanding employment with a local municipality and good relationships with his wife and family, albeit with the patience and cooperation of his employer and his family during the relevant time period. The PTSD symptomatology has been shown to be productive of significant occupational and social impairment most closely approximating the criteria for a 50 percent rating for the period from January 9, 2007 to January 16, 2010. The record does not establish and the appellant has not advanced that his PTSD disability picture encompassed symptoms such as suicidal ideation; obsessional rituals; illogical, obscure, or irrelevant speech; panic or depression affecting his ability to function; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or an inability to establish and maintain effective relationships which would be indicative of occupational and social impairment with deficiencies in most areas such as work, school, family relations. Given these findings, the Board concludes that the appellant's service-connected psychiatric disability picture prior to January 16, 2010 most closely approximates the criteria for a 50 percent rating. 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. Initial Rating on and after January 16, 2010 For the initial rating period on and after January 16, 2010, PTSD is productive of occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as a neutral, congruent, and appropriate affect; a congruent and appropriate mood; appropriate communication; coherent and logical thought processes; intact memory; fair concentration and attention; and no suicidal or homicidal ideation. The criteria for a rating in excess of 70 percent for PTSD for the rating period on and after January 16, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326(a), 4.3, 47, 4.130, Diagnostic Code 9411. At a March 2011 VA PTSD examination for compensation purposes, the appellant reported that he remained married; was close to his family; socialized; and had been retired from his long term employment since July 2009. He clarified that his PTSD symptoms had improved since his retirement. The appellant was observed to be well-groomed; cooperative; and fully oriented to person, place, time, and purpose. On mental status examination, the appellant exhibited a neutral, congruent, and appropriate affect; a congruent and appropriate mood; appropriate communication; coherent and logical thought processes; intact memory; fair concentration and attention; and no suicidal or homicidal ideation. A diagnosis of severe PTSD and a GAF score of 57 were advanced. The examiner commented that "the veteran's PTSD signs and symptoms are generally somewhat better than they were at the time of the last examination." He opined further that "it is this examiner's opinion that this veteran is experiencing PTSD signs and symptoms that result in deficiencies in most of the following areas: work, school, family relations, judgment, thinking, and mood." In an August 2011 NOD with the denial of a TDIU, the appellant advanced that his PTSD in the past had caused significant social and occupational impairment which he was able to overcome through striving to be both a good employee and a good spouse. It is not evident what time period the appellant was describing or whether it was after the award of service connection for PTSD. On and after January 16, 2010, PTSD has been shown to be productive of occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as a neutral, congruent, and appropriate affect; a congruent and appropriate mood; appropriate communication; coherent and logical thought processes; intact memory; fair concentration and attention; no suicidal or homicidal ideation; and a GAF score of 57. That GAF score reflects moderate difficulty in social, occupational, or school functioning. A VA examiner observed that the appellant's "PTSD signs and symptoms" were found to be "generally somewhat better." Given the documented improvement in the appellant's PTSD disability picture as manifested by the improved GAF score and the absence of objective evidence of symptoms of total occupational and social impairment such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting himself or others, an intermittent inability to perform activities of daily living, disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name, the Board finds that the current 70 percent rating adequately reflects the appellant's PTSD symptomatology for the period on and after January 16, 2010 and the criteria for a 100 percent rating are neither met nor more nearly approximated. 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has also evaluated whether the appellant's claim should be referred for consideration of an extra-schedular rating for PTSD under 38 C.F.R. § 3.321(b)(1). The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extra-schedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. Second, if the schedular rating does not contemplate the appellant's level of disability and symptomatology and is found inadequate, the Board must determine whether the appellant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a appellant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the appellant's disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet App 111 (2008). With respect to the first prong of Thun, the evidence in this instant appeal does not establish such an exceptional disability picture as to render the schedular rating is inadequate. A comparison between the level of severity and symptomatology of the appellant's PTSD with the established criteria found in 38 C.F.R. § 4.130, Diagnostic Code 9411, reflects that the diagnostic criteria reasonably describes the Veteran's disability level and symptomatology. The diagnostic criteria convey that compensable ratings will be assigned for PTSD which is manifested by various levels of occupational and social impairment. The appellant's disability picture has been shown to encompass significant occupational and social impairment and symptoms which falls squarely within the diagnostic criteria for a 50 percent rating for the period prior to January 16, 2010 and a 70 percent rating for the period on and after January 16, 2010. The VA Secretary, acting within his authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C.A. § 1155; see 38 U.S.C.A. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 psychiatric disorders, there can be no doubt that the VA Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128(1997). See Mauerhan v. Principi, 16 Vet. App. 436, 442 (1992). The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The Federal Circuit has embraced the Mauerhan interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326(Fed. Cir. 2004). For the initial rating period from January 9, 2007 to January 16, 2010, PTSD was productive of occupational and social impairment with reduced reliability and productivity due to symptoms such as recurrent Vietnam-related thoughts; occasional nightmares; avoidance of crowds; hypervigilance; episodic road rage; a sensitivity to loud noises; anxiety; an appropriate affect; a euthymic mood; impaired concentration and judgment; intact abstraction and reasoning abilities; intact memory; understandable speech; and no history or evidence of psychosis, hallucinations, or delusions. For the rating period on and after January 16, 2010, PTSD is productive of occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as a neutral, congruent, and appropriate affect; a congruent and appropriate mood; appropriate communication; coherent and logical thought processes; intact memory; fair concentration and attention; and no suicidal or homicidal ideation. All the impairment and symptoms are either explicitly part of the schedular rating criteria or like or similar to examples or symptoms in the schedular rating criteria. In addition, the GAF score, which is incorporated into the schedular rating criteria as part of the DSM-IV, assesses the degree of overall occupational and social impairment. For these reasons, the PTSD has not been shown to be productive of an exceptional disability picture; therefore, the Board determines that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not merited. ORDER Reopening service connection for post-operative left knee internal derangement is granted. Service connection for migraine is granted. Service connection for tinnitus is granted. Service connection for right ear hearing loss is denied. Service connection for left ear hearing loss is denied. A higher initial rating for PTSD, in excess of 50 percent for the period prior to January 16, 2010, and in excess of 70 percent for PTSD for the prior on and after January 16, 2010, is denied. REMAND Service Connection for Left Knee Disorder In light of its reopening above, the appellant's claim for service connection for a left knee disorder is to be adjudicated on the merits following a de novo review of the entire record. The appellant asserts that he sustained a left knee injury while jumping from a helicopter in the Republic of Vietnam. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. The Board finds that a VA examination is necessary to assist in determining the nature and etiology of any current left knee disorder. VA must afford the appellant a medical examination and/or obtain a medical opinion when it is necessary to make a decision on his claim. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the Court provided further guidance directing that VA must provide a medical examination when there is: (1) competent evidence of a current disability or persistent recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the appellant's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. With respect to the need for an indication that the current disability or persistent or recurrent symptoms of a disability may be associated with service or with another service-connected disability, the Court stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and an appellant's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology to include symptoms capable of lay observation. McLendon, 20 Vet. App. at 83. The appellant has reported experiencing a combat-related left knee injury. His statements are competent, credible, and consistent with his combat experiences. The pre-service February 1969 treatment record from Dr. Casebolt states that the appellant had undergone removal of a left knee patellar chip fracture fragment. The report of the April 1970 physical examination for service entrance notes the appellant's pre-service history of a patellar fracture and removal of a portion of the patella. The appellant's service treatment records indicate that he was seen for left knee complaints including "left knee coming out," a swollen left knee, bilateral knee pain, and "bad knees." The report of a February 1972 VA examination for compensation purposes states that the appellant was diagnosed with post-operative left knee internal derangement. As the appellant has been diagnosed with a left knee disorder, the Board finds that the record contains sufficient evidence to warrant a VA examination and medical opinion under the low threshold of McLendon. Given the Court's direction and the provisions of 38 C.F.R. § 1154(b) as to combat veterans' statements, the Board finds that further VA orthopedic evaluation would be helpful in resolving the issues raised by the instant appeal. VA should obtain all relevant VA and private clinical documentation which could potentially be helpful in resolving the appellant's claims. Murphy v. Derwinski, 1 Vet. App. 78, 81-82 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). Clinical documentation after August 2012 is not of record. Service Connection for Sleep Apnea A June 2010 VA sleep study states that the appellant was diagnosed with obstructive sleep apnea. The report of a March 2011 VA examination for compensation purposes states that the appellant was diagnosed with sleep apnea. The examiner commented that: Although PTSD has been shown to be associated with sleep-disordered breathing, this veteran has a confounding condition: veteran is obese, with BMI of 38.15. The veteran's obesity is by far his greatest risk factor for sleep apnea - it would not be reasonable to say that PTSD is the major cause of this veteran's sleep apnea while he continues to have this degree of obesity ... The Board is unable to discern whether the VA examiner concluded that sleep apnea was related to the appellant's service-connected PTSD albeit while constituting neither the "greatest risk factor" nor "the major cause" for the disability. Further, it is not evident whether the appellant's diagnosed obesity is associated with any of his service-connected disabilities. Therefore, the Board finds that an additional VA evaluation is needed to resolve the issues raised by the instant appeal. McLendon, 20 Vet. App. 79. TDIU A determination as to entitlement to a TDIU requires an accurate assessment of the functional impairment associated with all of the appellant's service-connected disabilities. Given the award of service connection above for additional disabilities of migraine and tinnitus, the issue of a TDIU should be readjudicated. Accordingly, the issues of service connection for both a left knee disorder and sleep apnea and entitlement to a TDIU are REMANDED for the following action: 1. Identify health care providers and request treatment records. Contact the appellant and request that he provide information as to all treatment of his left knee and sleep apnea, including the names and addresses of all health care providers whose records have not already been provided to VA. Upon receipt of the requested information and the appropriate releases, the RO should contact all identified health care providers and request that they forward copies of all available clinical documentation pertaining to treatment of the appellant, not already of record, for incorporation into the record. If identified records are not ultimately obtained, the appellant should be notified pursuant to 38 C.F.R. § 3.159(e). 2. VA treatment records. Associate with the record any VA clinical documentation pertaining to the treatment of the Veteran not already of record, including that provided after August 2012. 3. Schedule the appellant for a VA orthopedic examination for compensation purposes in order to assist in determining the current nature and etiology of his left knee disabilities. All indicated tests and studies should be accomplished and the findings then reported in detail. The examiner should advance the following opinions: A) Is it as likely as not (i.e., probability of 50 percent or more) that any identified left knee disorder: (i) had its onset during active service? (a) In offering the opinion, address any relationship between the in-service left knee complaints and current left knee disability. (b) In offering the opinion, address any relationship between the combat experiences in the Republic of Vietnam including jumping from helicopters. (ii) was caused by the service-connected disabilities? (iii) was permanently increased in severity beyond its natural progression due to the service-connected disabilities? (B) Did the pre-existing existed patellar chip fracture excision residuals permanently increase in severity beyond its natural progression during active service? If so, describe the nature and extent of the worsening during service. The service-connected disabilities are right knee internal derangement, PTSD, Type II diabetes mellitus, headaches, hypertension, erectile dysfunction, migraine, and tinnitus. The examiner is to specifically comment whether the appellant's current left knee disability or disabilities are related to his pre-service patellar chip fracture excision residuals. All relevant medical records, including those in the claims folders, should be made available to the examiner for review of pertinent documents therein. The examination report should specifically state that such a review was conducted. A rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. However, if the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 4. Schedule the appellant for a VA examination for compensation purposes in order to assist in determining the current nature and etiology of his sleep apnea. All indicated tests and studies should be accomplished and the findings then reported in detail. The examiner should advance the following opinions: Is it as likely as not (i.e., probability of 50 percent or more) that the sleep apnea: (A) had its onset during active service? (B) is caused by the service-connected disabilities? (D) was permanently increased in severity beyond its natural progression due to the service-connected disabilities? The service-connected disabilities are right knee internal derangement, PTSD, Type II diabetes mellitus, headaches, hypertension, erectile dysfunction, migraine, and tinnitus. All relevant medical records, including those in the claims folders, should be made available to the examiner for review of pertinent documents therein. The examination report should specifically state that such a review was conducted. A rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. However, if the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 5. Adjudicate the appellant's claim for service connection for a left knee disorder on a de novo basis and readjudicate the remaining claims on appeal. If any benefits sought on appeal remains denied, the appellant and representative should be provided a SSOC. An appropriate period of time should be allowed for response before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The appellant is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of this claim. See 38 C.F.R. § 3.655 (2012). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs