Citation Nr: 1323983 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 09-46 976 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to a disability evaluation in excess of 50 percent for PTSD. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Haddock, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1968 to April 1970, with service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision by the St. Petersburg, Florida Department of Veterans Affairs (VA) Regional Office (RO). The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a complete review of the evidence. FINDINGS OF FACT 1. The Veteran's hypertension has not been shown to be causally or etiologically related to active service, and was not caused or aggravated by his service-connected PTSD. 2. The occupational and social impairment caused by the Veteran's PTSD more nearly approximates deficiencies in most areas than occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have not been met. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303. 3.310 (2012). 2. The criteria for a disability evaluation of 70 percent, but not higher, for PTSD are met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection for Hypertension The Board has reviewed all of the evidence in the claims folders. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to these claims. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). In general, service connection requires (1) 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. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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) (2012). In a claim for secondary service connection, the regulations provide that service connection shall be granted for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310. In the context of claims for secondary service connection, the evidence must demonstrate an etiological relationship between the service-connected disability or disabilities on the one hand and the condition said to be proximately due to the service-connected disability or disabilities on the other. Buckley v. West, 12 Vet. App. 76, 84 (1998). Secondary service connection may also be warranted for a non-service-connected disability when that disability is aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Also, with regard to a claim for secondary service connection, the record must contain competent evidence that the secondary disability was caused by the service-connected disability. See Wallin v. West, 11 Vet. App. 509 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Under the benefit-of-the-doubt rule embodied in 38 U.S.C.A. § 5107(b), in order for a claimant to prevail, there need not be a preponderance of the evidence in the Veteran's favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1994). The Veteran's primary contention is that his hypertension is aggravated by his service-connected PTSD. He has not alleged, nor is there evidence to suggest, that his currently diagnosed hypertension was directly caused by his active service. In this regard, the Board notes a January 2009 statement from the Veteran in which he specifically stated that his hypertension was not connected to his service, but that it was aggravated by his service-connected PTSD, in that his stress and anxiety symptoms would cause his blood pressure to elevate. In a June 2003 VA examination afforded to the Veteran in connection with a claim for an increased rating for his service-connected PTSD, he was noted to have problems with hypertension, but he reported that he took no medications at that time. On July 2008 VA examination, again afforded to the Veteran in connection with a claim for an increased rating for his PTSD, the Veteran was noted to have problems with hypertension. At that time he reported that his hypertension was not stable and that he took medication and was being followed at the VA Medical Center for the issue. In August 2009, the Veteran was afforded a VA examination for his hypertension. The Veteran reported that his hypertension began after his separation from active service. Review of the medical records showed the first documentation of hypertension in January 2008, with blood pressure findings of 160/83. The examiner diagnosed essential hypertension and opined that the Veteran's hypertension was less likely than not caused by or related to his service-connected PTSD. The examiner explained that the Veteran had an increased risk of hypertension, with a positive family history of hypertension in his mother, race factors, hyperlipidemia and mild obesity. Therefore, it was less likely than not that his hypertension was related to his service-connected PTSD, providing evidence against this claim. Also of record are VA treatment records that show the Veteran receives intermittent treatment at the VA Medical Center for a variety of disabilities, including his hypertension. These records contain no indication that the Veteran's hypertension is aggravated by his service-connected PTSD. As noted above, a claim for secondary service connection may be granted when the disability claimed is proximately due to a service-connected disability or when the disability claimed has been aggravated by a service-connected disability. Entitlement to service connection on these bases requires competent evidence that the secondary disability was caused or aggravated by the service-connected disability. See Wallin v. West, 11 Vet. App. 509 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). The only competent (medical) evidence of record that addresses this issue is the report of the August 2009 VA examiner, who found that the Veteran's hypertension was not caused by or related to his service-connected PTSD. The examiner noted that the Veteran had several risk factors for hypertension; including, family history, race factors, hyperlipidemia, and mild obesity. The finding that the condition is not related to the PTSD clearly provides highly probative evidence against a finding that the disability has been aggravated by PTSD, indicating no connection between the two problems at all, with the examiner clearly indicating the cause of the problem explicitly. As the examiner (a trained medical professional) expressed familiarity with the record, and provided an expression of rationale for her findings, the August 2009 VA examination report is probative evidence in this matter. Because there is no competent evidence to the contrary, the August 2009 VA examination report is persuasive. The Board acknowledges the Veteran's statements that his hypertension is aggravated by his service-connected PTSD. While the Board notes that the Veteran is competent to report observable symptoms, he is not competent to provide a nexus opinion regarding his hypertension and his service-connected PTSD, as he is a layperson without the specialized training necessary to address a complex question with respect hypertension, and he does not cite to any supporting medical texts or treatises. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In sum, the Board finds that the preponderance of the evidence weighs against the claim and service connection for hypertension, to include as secondary to service-connected PTSD cannot be granted. As there is a preponderance of evidence against the claim, the benefit-of-the-doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Accordingly, the Board finds that service connection is not warranted. Disability Evaluation for PTSD The Veteran contends that his service-connected PTSD is more severe than is indicated by the 50 percent disability evaluation currently assigned. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. Psychiatric disability is rated under the General Rating Formula for Mental Disorders. PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, which provides for a 50 percent evaluation is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty 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; difficult establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation 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 work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). The Global Assessment Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996). A score of 31 to 40 reflects some impairment in reality testing or communication or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood. A score of 41 to 50 is assigned where there are "[s]erious 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)." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV) 47 (4th ed. 1994). A score of 51 to 60 is appropriate where there are "[m]oderate 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)." Id. A GAF score of 61 to 70 indicates the examinee has some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functions pretty well with some meaningful interpersonal relationships. Id. at 46. While particular GAF scores are not contained in the VA schedule of ratings for mental disorders, 38 C.F.R. § 4.130, they are a useful tool in assessing a Veteran's disability and assigning disability evaluations. However, they are just one of many factors considered when determining an evaluation. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, including degree of disability, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3 The United States Court of Appeals for Veterans Claims (Court) has held that when the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). In an April 2008 letter, the Veteran's treatment provider, Mr. C.H., at the Pensacola Vet Center indicated that the Veteran was attending weekly therapy sessions. Mr. C.H. explained that during his therapy sessions, the Veteran addressed PTSD symptoms of anxiety, irritability, hyper-arousal, nightmares, intrusive thoughts, withdrawal behavior, and detachment from others. Mr. C.H. noted that these symptoms severely impacted the Veteran's ability to fully embrace life. In his letter, Mr. C.H. further detailed the Veteran's individual symptoms that had been discussed over the course of the Veteran's treatment. He explained that the Veteran's anxiety reduced and adversely affected his ability to establish and maintain meaningful levels of comfortable social interaction. Specifically, the Veteran was only able to maintain employment because his employer went to great lengths to limit the amount of interaction the Veteran had with customers and the public, and even so, maintaining this level of employment had proven difficult for him. The Veteran's hyper-arousal and nightmares caused significant interruptions to his sleep and left him lethargic and irritable during the day. He was easily startled by noises and he had intrusive thoughts of his combat experiences which were triggered daily by various sights, sounds, and situations. The Veteran spent most of his time alone, he did not have visitors or engage in social activity. He no longer attended church as he did not like to be around crowds. He spent some time with his mother and daughter, but had no meaningful contact with any others. Mr. C.H. noted that while the Veteran had been suffering from PTSD for a number of years, his symptoms had increased in severity to a degree which significantly impacted his daily functioning and overall quality of life. The Veteran was afforded a VA examination in July 2008. At that time he reported he had experienced an increase in PTSD symptoms including intrusive thoughts and flashbacks, which triggered memories of events he experienced in the Republic of Vietnam. He reported that this increase in symptoms had been triggered by a hurricane that had caused devastation and damage to his neighborhood. He reported that he received treatment at the Vet Center, but that he continued to have major problems with PTSD. He reported that he was unable to tolerate group therapy, but that he attended individual therapy on a weekly basis. He reported that he experienced nightmares that were intense and severe which occurred almost nightly. He reported that his nightmares included dead people talking to him and that he also heard voices during the day. He reported that he suffered from an erratic sleep pattern, that he had frequent awakenings and was unable to fall back to sleep because he was scared, and that he stayed tired and lethargic during the day. He reported that his lack of sleep caused him to function poorly at work and he became stressed out. He reported that he had become increasingly frustrated, that he did not want to be around people, and that in the past he would go to the storeroom and hide while at work. He reported that he worked at a local supermarket as a butcher and had worked there for approximately twelve years. He reported that he was trying to stay in his job until he was 62, so that he could retire, and that his boss was very understanding and tolerated his PTSD, but that he had been sent home on occasions when he became overly stressed. He reported that he lived alone and that he had one or two friends, but that he did not socialize. He reported his only contact was with his mother and his daughter, but that he tried to avoid them. He reported that along with hearing voices, he also saw faces and shadows at night. He reported that he drank alcohol on a daily basis in order to relax and help with his nerves. On mental status examination, the Veteran was noted to be casually attired and poorly groomed, he looked untidy and unkempt. He appeared tired and haggard. He was alert and oriented times three. He remained verbal and logical. He reported problems with depression and mood swings. He did not maintain good eye contact and he was somewhat guarded and vigilant. He denied any suicidal ideation or intent, but admitted to feeling hopeless or helpless at times. He had difficulty concentrating and remembering things. He admitted to feeling paranoid and hearing voices on and off. His insight and judgment were limited. The examiner diagnosed chronic PTSD and assigned a GAF score of 48 to 50. The examiner explained that it was her opinion that the Veteran's PTSD had seemed to be exacerbated and was worsened due to his high level of stress at work. She stated that the Veteran had not maintained or achieved any significant interepisode recovery since his last rating evaluation and he was only functioning marginally at his job. She noted that he continued to have problems with mood swings, depression, isolation, and recently paranoia and auditory hallucinations. The examiner opined that the severity of his symptoms adversely affected his ability to maintain reliability and consistency in his job and severely impacted his ability to function in social and industrial settings. The Veteran was afforded another VA examination in August 2009. At that time he reported that he was having an increase in his PTSD symptoms, specifically his nightmares. He reported that his nightmares were so severe that he would wake up to find he had been acting out what was taking place in the nightmare. He reported that on a "good night" he would only sleep for four hours, but that when he had a nightmare, he would wake up and stay awake. He reported that he experienced these symptoms almost daily. He denied any periods of remission and reported that he could not take any medication for his PTSD symptoms as the side effects impacted his ability to perform his job. He reported that he had been working as a meat cutter for the past 46 years, but that work had become difficult. He reported that changes had been made at his work that had bothered and upset him and he was now required to spend more time with the customers and that dealing with the public and with different personalities was difficult for him. He reported that he lived alone and that he was not married. He reported that he had a relationship with his mother, which he described as "fine" and that he had recently been spending time with her as she had been sick. He also reported having one adult child and one seven-year-old child and also described his relationship with them as "fine." He reported that he did not socialize. He reported that his co-workers were his friends, but that he did not see them outside of work. He reported that he watched television and fished sometimes for recreational purposes. On mental status examination, the Veteran was well groomed, friendly, and cooperative. His mood was mildly to moderately anxious with restricted affect. He was fully oriented and there was no apparent impairment of thought process of communication. He denied suicidal ideation or intent, homicidal ideation, hallucinations, and delusions. His attention, memory, and judgment all appeared to be within normal limits. Psychological testing results were consistent with moderate to severe PTSD. The examiner diagnosed chronic PTSD and assigned a GAF of 55. The examiner noted that the Veteran's PTSD symptoms caused reduced reliability and productivity, and explained that the Veteran had reported disturbances of motivation and mood as well as difficulty in establishing and maintaining effective work and social relationships. The examiner noted that the Veteran's prognosis was guarded, but that his involvement in treatment was a positive sign. After review of the evidence, the Board finds that the Veteran is entitled to a disability evaluation of 70 percent for his PTSD. In this regard, the Board notes that the April 2008 letter from the Pensacola Vet Center and the July 2008 VA examination report show that the Veteran's PTSD symptoms more closely approximate occupational and occupational and social impairment with deficiencies in most areas for the entire period on appeal rather than social impairment with reduced reliability and productivity. Specially, the Veteran was noted to have PTSD symptoms that included: daily nightmares, restricted affect, paranoia, auditory and visual hallucinations, sleep interruptions, irritability, hyper-arousal, social withdrawal and isolation, alcohol abuse, depression, mood swings, hyper-vigilance, feelings of hopelessness and helplessness, poor insight and judgment, poor grooming and hygiene, difficulty concentrating, impaired memory, difficulty establishing and maintaining social and occupational relationships, and difficulty functioning in the workplace. Additionally, the Veteran's mental health counselor at the Pensacola Vet Center clearly stated that the Veteran's PTSD significantly impacted his daily functioning and overall quality of life. 38 C.F.R. § 4.130, Diagnostic Code 9411 The Board acknowledges that the symptoms described in the April 2008 Vet Center letter and the July 2008 VA examination report do not indicate that the Veteran experiences all of the symptoms associated with a 70 percent disability evaluation for PTSD. However, the Court has held that the symptoms enumerated under the schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, a finding that there is occupational and social impairment resulting in deficiencies in most areas is sufficient to warrant a 70 percent disability evaluation for the period on appeal, even though all the specific symptoms listed for a 70 percent evaluation are not manifested. The Board notes that the August 2009 VA examination report seems to indicate that the Veteran's PTSD symptoms may have decreased in severity since his July 2008 VA examination; however, the Board finds that the August 2009 examination report is not nearly as thorough as the July 2008 examination report and does not provide as much detail with regard to the Veteran's subjective complaints. Therefore, the Board finds that the April 2008 letter from the Pensacola Vet Center and the July 2008 VA examination report portray a more accurate representation of the severity of the Veteran's PTSD symptoms and thus, the basis for the 70 percent disability evaluation. Consideration has been given to assigning a higher disability evaluation for the period on appeal. However, the Board finds that the evidence of record does not support a finding of total occupational and social impairment. In this regard, the Board notes that while the medical evidence does indicate the Veteran suffered from some hallucinations and some inability to maintain his personal hygiene, there is no evidence that he suffered from gross impairment of thought processes or communication, grossly inappropriate behavior, that he was in persistent danger of hurting himself or others, that he was disoriented to time or place, or that he suffered from significant memory loss. Most importantly, while the medical evidence of record indicated that the Veteran does have some difficulty in his employment, he is still able to maintain his full-time job as a butcher, and as such, total occupational impairment has not been shown. Therefore, a total disability evaluation is not warranted at this time. 38 C.F.R. § 4.130, Diagnostic Code 9411. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the disability warranted a higher schedular rating. Hart v. Mansfield, 21 Vet. App. 505 (2007). Therefore, as the medical evidence of record shows a worsening of the Veteran's PTSD symptoms, but that he was still able to maintain his employment, the Board finds that the Veteran's PTSD symptoms more nearly approximate a disability evaluation of 70 percent, but no higher. Extra-Schedular Consideration The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1). The Court has held that the threshold factor for extra-schedular consideration is a finding on part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disabilities at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the disability with the established criteria provided in the rating schedule for the disabilities. If the criteria reasonable describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluations are therefore adequate, and no referral for extra-schedular consideration is require. Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the evidentiary record does not show any manifestations of, or functional impairment due to, the Veteran's PTSD that are not encompassed by the schedular criteria. While the record indicates the Veteran receives weekly treatment at the Pensacola Vet Center, there is no indication from the evidence of record that the Veteran has ever received any inpatient mental health treatment or emergency treatment for his PTSD. In sum, there is no indication that the average industrial impairment from the Veteran's PTSD would be in excess of that contemplated by the disability evaluation assigned herein. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. Finally, the Court has held that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim, or, if the disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In the instant case, the Board notes that at both his July 2008 and August 2009 VA examinations, the Veteran indicated that his PTSD symptoms caused stress and difficulty at his job, but that he was still able to maintain his employment. Therefore, as the record indicates the Veteran is employed, no further discussion of this matter is necessary. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the required notice should be furnished prior to the issuance of the appealed rating decision, any initial errors of notice will not be prejudicial if: (1) corrective actions (e.g., issuance of a post-adjudication notice letter containing the required information) are taken, and (2) the appeal is re-adjudicated (e.g., in a Supplemental Statement of the Case). See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in April 20008 that fully addressed all notice elements. The letter informed the Veteran of what evidence was required to substantiate his claims and of his and VA's respective duties for obtaining evidence. The letter also informed the Veteran how disability ratings and effective dates were established. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. VA also has a duty to assist the Veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished and therefore appellate review of the claims addressed above may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained pertinent VA treatment records and the Veteran was afforded VA medical examinations in July 2008 and August 2009. The Board notes that the Veteran receives treatment at the Pensacola Vet Center for his service-connected PTSD and that records of such treatment are not associated with the claims file. However, of record is an April 2008 letter from the Veteran's treatment provider at the Pensacola Vet Center. This letter details the Veteran's PTSD symptoms that have been the focus of his treatment at the Vet Center and provides analysis by his treatment provider of the Veteran's PTSD and expected prognosis. Further, the PTSD symptoms reported in the July 2008 VA examination report are consistent with those reported in the April 2008 Vet Center letter. Therefore, as the April 2008 letter detailed the Veteran's PTSD symptoms discussed over the course of his Vet Center treatment, and these are consistent with subsequent VA examinations, there is no bar to proceeding with a final decision in this matter. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of his claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, is denied. Entitlement to a disability evaluation of 70 percent, but no higher, for PTSD is granted. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs