Citation Nr: 1324263 Decision Date: 07/31/13 Archive Date: 08/07/13 DOCKET NO. 06-13 423 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to a compensable evaluation for headaches prior to August 5, 2011. 3. Entitlement to an evaluation in excess of 30 percent for headaches from August 5, 2011. 4. Entitlement to an evaluation in excess of 10 percent for bronchitis prior to August 5, 2011. 5. Entitlement to an evaluation in excess of 30 percent for bronchitis from August 5, 2011. 6. Entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Marenna, Associate Counsel INTRODUCTION The appellant had active service from September 1958 to September 1978. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 2005 and April 2007 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. In March 2013, a Travel Board hearing was held before the undersigned Veterans Law Judge and a transcript of that hearing is of record. The Board notes that the appellant also appealed several other issues. In a July 2012 statement, the appellant withdrew his claim for service connection for hypertension. In an August 2012 statement, the appellant withdrew many issues on appeal, except for the claims noted above. At the March 2013 hearing, the appellant stated that he wished to withdraw the issue of entitlement to an earlier effective date for the grant of service connection for tinnitus. In January 2013 and March 2013, the Board received additional medical records and information. The Board notes that VA regulations require that pertinent evidence submitted by the appellant must be referred to the agency of original jurisdiction for review and preparation of a supplemental statement of the case (SSOC) unless this procedural right is waived in writing by the appellant or representative. 38 C.F.R. §§ 19.37, 20.1304 (2012). In written statements dated in January 2013 and March 2013, the appellant waived RO consideration of the new evidence. Thus, the Board finds no prejudice to the appellant in proceeding to adjudicate this appeal. The issues of entitlement to an acquired psychiatric disability, to include PTSD and major depressive disorder, entitlement to an evaluation in excess of 30 percent for bronchitis from August 5, 2011, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A February 1996 rating decision denied the appellant's claim of entitlement to service connection for PTSD on the basis of no diagnosis; no appeal was taken from that determination. 2. Evidence submitted subsequent to the February 1996 rating decision is not cumulative or redundant, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim. 3. Throughout the period on appeal, the appellant's headaches were manifested by prostrating attacks two to three times a week. 4. Prior to April 21, 2011, the appellant's bronchitis was manifested by FEV-1 of no less than 71 percent predicted, FEV-1/FVC of no less than 71 percent or predicted, and DLCO of no less than 66 percent of predicted, and no right ventricular hypertrophy, pulmonary hypertension, episodes of acute respiratory failure or outpatient oxygen therapy. 5. From April 21 to August 5, 2011, the appellant had a DLCO result of between 56 to 65 percent of predicted, and no right ventricular hypertrophy, pulmonary hypertension, episodes of acute respiratory failure or outpatient oxygen therapy. CONCLUSIONS OF LAW 1. The February 1996 rating decision is final as to the claim of entitlement to service connection for PTSD. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.302, 20.1103 (2012). 2. New and material evidence has been received since the February 1996 to reopen the claim of entitlement to service connection for PTSD. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). 3. Throughout the rating period on appeal, the criteria for a rating of 50 percent for service-connected headaches have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1-4.14, 4.124a, Diagnostic Code 8100 (2012). 4. Prior to April 21, 2011, the criteria for a rating in excess of 10 percent for bronchitis were not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.97, Diagnostic Code 6600 (2012). 5. From April 21 to August 5, 2011, the criteria for a 30 percent rating for bronchitis were met. Id. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the appellant's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Notice and Assistance As to the petition to reopen the previously disallowed claim for service connection, his petition has been granted, as discussed below. As such, the Board finds that any error related to notice and assistance on that petition to reopen is moot. See 38 U.S.C. §§ 5103, 5103A (West 2002 & Supp. 2005); 38 C.F.R. § 3.159 (2009); Mayfield v. Nicholson, 19 Vet. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Kent v. Nicholson, 20 Vet. App. 1 (2006). Accordingly, the Board may proceed with a decision on the appellant's petition to reopen. In regard to the appellant's increased rating claims, VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). More specific notice is required in claims for increased compensation. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VA has met all statutory and regulatory notice and duty to assist provisions as to the appellant's increased rating claims. Appropriate notice was provided in a March 2004 letter. In a July 2008 letter, notice of how VA determines the disability rating and effective date was provided to the appellant. The claim was subsequently readjudicated, most recently in a September 2012 supplemental statement of the case. Mayfield, 444 F.3d at 1333; See Prickett v. Nicholson, 20 Vet. App. 370 (2006). VA's duty to assist has been satisfied. The appellant's service treatment records and VA medical records are in the file. Private medical records identified by the appellant have been obtained, to the extent possible. The appellant's Social Security Administration records have been associated with the file. The appellant has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the appellant. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the appellant's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the appellant with an appropriate VA examination for his headaches in August 2011. The RO provided the appellant with appropriate VA examinations for his bronchitis in April 2004, August 2008 and August 2011. The examinations are adequate because they are based on a thorough examination, a description of the Veteran's pertinent medical history and appropriate diagnostic tests. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). The appellant has not reported receiving any recent treatment specifically for his headaches, and there are no records suggesting an increase in his headache disability has occurred as compared to the prior VA examination findings. As discussed below, the Board is remanding the issue of entitlement to a higher rating for bronchitis from August 5, 2011. There is no objective evidence indicating that there has been a material change in the severity of the appellant's service-connected headaches since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. The VA examination reports are thorough and provided findings pertinent to the rating criteria. The examination in this case is adequate upon which to base a decision. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). II. PTSD Legal Criteria In general, rating decisions that are not timely appealed are final. See 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. If new and material evidence is presented or secured with respect to a claim that has been finally disallowed, the claim shall be reopened and reviewed. See 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. The question of whether new and material evidence has been received to reopen each claim must be addressed in the first instance by the Board because the issue goes to the Board's jurisdiction to reach the underlying claim and adjudicate it on a de novo basis. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); see also Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996), aff'g 8 Vet. App. 1 (1995). If the Board finds that no such evidence has been offered, this is where the Board's analysis must end; hence, what the RO may have determined in this regard is irrelevant. Jackson, 265 F.3d at 1369; Barnett, 83 F.3d at 1383. "New" evidence is defined as evidence not previously submitted to agency decision-makers. "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. In Shade v. Shinseki, 24 Vet. App. 110, 120 (2010), the United States Court of Appeals for Veterans Claims (Court) interpreted the phrase 'raises a reasonable possibility of substantiating the claim' as "enabling rather than precluding reopening." The Court held that 38 C.F.R. § 3.159(c)(4)(iii) does not require new and material evidence as to each previously unproven element of a claim. See Shade, 24 Vet. App. at 120. Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet.App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Pursuant to 38 C.F.R. § 3.303(b), a claimant may establish the second and third elements by demonstrating continuity of symptomatology. See Barr v. Nicholson, 21 Vet.App. 303 (2007). Continuity of symptomatology can be demonstrated by showing (1) that a condition was "noted" during service; (2) evidence of continuous symptoms after service; and (3) medical, or in certain circumstances, lay evidence of a nexus between the current disability and the postservice symptoms. Savage v. Gober, 10 Vet.App. 488 (1997). Certain chronic disabilities, such as psychosis, if manifest to a degree of 10 percent or more within one year after separation from active duty, may be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Analysis In a February 1996 rating decision, the RO denied entitlement to service connection for PTSD because there was no confirmed diagnosis of PTSD or of any psychiatric condition. The appellant did not appeal the rating decision and consequently, it became final. 38 U.S.C.A. § 7105. The evidence of record at the time of the previous final denial, in February 1996 included the appellant's service treatment records and August 1995 and December 1995 VA examinations. The December 1995 VA examiner found that the appellant did not have an Axis I diagnosis of any psychiatric disorder. The VA examiner specifically stated that although the appellant reported some PTSD symptoms, he did not meet the criteria for PTSD. The evidence added to the record since the previous final denial includes statements from the appellant, private treatment records, VA treatment records and an August 2012 VA examination. The August 2012 VA examination report reflects that the appellant had Axis I diagnoses of PTSD and major depressive disorder with psychotic features. A claim for service connection requires evidence of a current disability. The RO denied the appellant's claim for service connection for PTSD in February 1996 because he did not have a diagnosis of PTSD or any psychiatric disorder. The Board finds that since the February 1996 rating decision, new and material evidence has been received to reopen the claim for service connection for a psychiatric disorder. The August 2012 VA examination report indicates the appellant had diagnoses of PTSD and major depressive disorder. This evidence had not been submitted before to agency decision-makers. Thus, it is new. As the evidence shows that the appellant has acquired psychiatric disabilities, specifically PTSD and major depressive disorder, it relates to an unestablised fact necessary to substantiate the claim. Thus, the August 2012 VA examination report is new and material. New and material evidence is not required as to each previously unproven element of a claim. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Furthermore, consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. See Shade, 24 Vet. App. at 120. As the August 2012 VA examination report indicates that the appellant has diagnoses of PTSD and major depressive disorder with psychotic features, this evidence is new and material, goes to the basis of the prior final denial, and raises a reasonable possibility of substantiating the claim. Accordingly, the claim for service connection for PTSD is reopened. II. Increased Rating Claims Legal Criteria Disability evaluations are determined by comparing a veteran's present symptomatology with the criteria set forth in the Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 4.1 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the appellant. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. 38 C.F.R. § 4.1. Nevertheless, where, as here, the appellant is appealing the rating for an already established service-connected condition, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The appellant's claims for a increase ratings were received on January 29, 2004. Headaches The appellant's headaches are currently rated under Diagnostic Code 8100. This diagnostic code provides for a 10 percent evaluation for migraines with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent evaluation is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months, and a maximum scheduler evaluation of 50 percent for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. A September 2005 VA treatment record notes that the appellant reported pain on the right side of his face down the right side of his tongue. He stated that the pain was now constant on the left side of his face. He was taking Mirapex for nerve pain. An April 2008 private treatment record noted that the appellant reported having constant headaches for several months. An October 2008 private treatment record noted that the appellant had ongoing/chronic headaches. A July 2010 private treatment record reflects that the appellant had a CT scan of the head following weakness and a severe headache for two days. The scan showed mild brain atrophy. At an August 2011 VA examination, the appellant reported that he had chronic, daily moderate to severe headaches which were constant. The headaches were non-throbbing and bilateral in the temporal/frontal and occipital. They were associated with nausea and there was no visual aura. The course since onset was stable. He stated that he had prostrating attacks of migraine headaches 2 to 3 times a week lasting two to three hours. The diagnosis was mixed tension and migraine headaches. The headaches slowed him down and reduced his motivation for doing anything. He could do activities of daily living and did not drive much anymore. At the March 2013 hearing, the appellant reported that he had one to three headaches a week. He stated that when he gets his headaches he has to lay down. He stated that he laid down for about 14 hours due to his most recent headache. Board Hearing Transcript (Tr.) at p. 10. He stated that he maintained a pain level five headache all the time, and he had gotten to the point where he kept a lot of Aspirin around. Id. As noted above, the appellant's headaches are currently evaluated as noncompensable prior to August 5, 2011, and as 30 percent from August 5, 2011. Lay statements may be competent to support a claim for service connection where the events or the presence of disability, or symptoms of a disability are subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Thus, the appellant is competent to report symptoms capable of lay observation, such as headaches. In weighing the evidence of record, the Board finds that, with resolution of doubt in the appellant's favor, an evaluation of 50 percent for the appellant's migraine headaches is warranted throughout the rating period on appeal. The Board finds the appellant's statements regarding his headaches to be credible. The August 2011 VA examination reflects that the appellant reported having prostrating attacks of migraine headaches two to three times a week lasting 2 to 3 hours. The appellant stated that his headache symptoms had been constant since their onset, indicating his symptoms were the same throughout the period on appeal. The October 2008 private treatment record noted that the appellant had ongoing/chronic headaches. The appellant's March 2013 testimony that he had headaches one to three times a week, and had to lay down for about 14 hours due to his most recent headache, also supports a higher rating of 50 percent. The Board finds that the evidence supports a finding that the appellant had very frequent completing prostrating and prolonged attacks productive of severe economic inadaptability. This is the maximum evaluation that may be assigned under Diagnostic Code 8100. The Board has also considered the applicability of an alternative diagnostic code for evaluating the appellant's tension and migraine headaches, but finds that no other diagnostic code is more appropriate for rating the appellant's headache disability. The Board has considered whether extraschedular consideration is warranted based on the evidence of functional, including occupational, impairment secondary to the service-connected headaches. See Barringer v. Peake, 22 Vet. App. 242 (2008). The discussion above reflects that the symptoms of the appellant's headaches are contemplated by the applicable rating criteria. The competent medical evidence of record shows that the headache disability is primarily manifested by pain and prostrating attacks. The applicable diagnostic codes used to rate the appellant's disability provide for ratings based the effect of pain and functional impairment have been taken into account and are considered in applying the relevant criteria in the rating schedule. The effects of the appellant's disability have been fully considered and are contemplated in the rating schedule. Consideration of whether the appellant's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). In sum, the Board finds that a higher rating of 50 percent, but no higher, for headaches is warranted throughout the rating period on appeal. Bronchitis- Prior to August 5, 2011 The appellant's bronchitis is evaluated under Diagnostic Code 6600. Under this Diagnostic Code, a 10 percent rating is warranted if the Forced Expiratory Volume in one second (FEV-1) is 71 to 80 percent of predicted value, the ratio FEV-1/ Forced Vital Capacity (FVC) is 71 to 80 percent, or Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO(SB)) is 66 to 80 percent predicted. A 30 percent rating is warranted if FEV-1 is 56 to 70 percent of predicted value, or FEV-1/FVC is 56 to 70 percent, or if DLCO (SB) is 56 to 65 percent predicted. A 60 percent rating is warranted if FEV-1 is 40 to 55 percent of predicted value, FEV-1/FVC is 40 to 55 percent, DLCO (SB) is 40 to 55 percent predicted, or if maximum oxygen consumption is 15 to 20 ml/kg/min (with cardiorespiratory limit). FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy, is rated 100 percent disabling. 38 C.F.R. § 4.97. An April 2004 pulmonary function test reflects that the appellant had results of FEV-1 of 91 percent of predicted, FEV-1/FVC of 83 percent of predicted, and DLCO of 77 percent of predicted. The appellant was afforded a VA examination in April 2004. The VA examination report reflects that the appellant stated that he got some dyspnea and wheezing on a regular basis and used Albuterol frequently throughout the day. He did not use any other inhalers. He stated that he had had courses of prednisone in the past, but not in the last year. The VA examiner noted that the appellant did not have any appearance of any dyspnea at rest or with minimal exertion of undressing for the exam and dressing again, although he reported dyspnea on exertion. A pulmonary function test showed mild restrictive disease without improvement from bronchodilators. FEV-1/FVCA was 80 percent predicted. A June 2004 private treatment record indicates the appellant was using an Albuterol inhaler for chronic obstructive pulmonary disease (COPD). A June 2004 exercise stress test produced no signs or symptoms. The results were normal on stress and rest. An August 2005 private echocardiographic report reflects that there was an enlarged right ventricle with normal right ventricular systolic function. There was no evidence of pulmonary hypertension An April 2008 private chest X-ray report indicated there was no evidence of a pulmonary embolism, but there were low lung volumes. An April 2008 private treatment record noted that the appellant had bronchitis which was resolving, status post antibiotic therapy. A May 2008 private treatment record noted that a spirometry performed was normal. The appellant had symmetric chest expansion with good air entry, and no wheezes, crackles or rhonci. The impression was a chronic cough in a previous smoker with normal chest imaging. A differential diagnoses included chronic bronchitis. The physician stated that the appellant could safely discontinue bronchodilators. The private May 2008 test results reflect that the appellant had FEV-1 results of 96 percent of predicted. An August 2008 private pulmonary function test reflects that the appellant had FEV-1 that was 101 percent of predicted, post-bronchodilator. Fev-1/FVC that was 109 percent of predicted and DLCO that was 82 percent of predicted. The appellant was afforded a VA examination in August 2008. The appellant reported dyspnea on exertion at approximately 20 to 30 feet before he has to stop because of shortness of breath. He had a chronic thick phlegm production with chronic cough. He had a generalized chronic shortness of breath and wheezed four to six times a day. He stated that he was on three types of inhalers of unknown type for his breathing when his pulmonologist discontinued them. The appellant did not use oxygen and had not been on Prednisone since the mid-1990s. At that time he was not receiving any treatment for his breathing. The appellant did not report any periods of incapacitation or hospitalization due to shortness of breath. On examination, the lungs were clear to auscultation without wheezes or crackles. The VA examiner noted that the Aug 20, 2008 pulmonary function test showed no airflow obstruction. There was no suggestion of restriction, normal diffusion capacity and no bronchodilator change. The VA examiner stated that the appellant's pulmonary function tests were normal. A November 2009 chest x-ray was done due to an increasing productive cough. The report found no acute cardiopulmonary process. A November 2009 private echocardiographic report reflects that the right heart chambers and valves were grossly unremarkable. Physiologic trace pulmonic insufficiency. Pulmonary pressure could not be estimated. The appellant had borderline left ventricular hypertrophy. A February 2010 VA treatment record noted that the appellant's complaints included shortness of breath. On examination, the chest was clear and there were no rales or wheezing. A July 2010 chest X-ray reflects that appellant had shortness of breath. The lungs were mildly hypoinflated. An April 2011 private pulmonary report reflects that the appellant had a pulmonary function test on April 21, 2011. The pulmonary function test showed the appellant had results of FEV-1 of 83 percent of predicted, FEV-1/FVC of 83 percent of predicted, and Diffusion capacity (DLCO) of 63 percent of predicted. Under Diagnostic Code 6601, a rating of 30 percent is warranted for DLCO of between 56 to 65 percent. As the appellant's DLCO was 63 percent, the Board finds that a higher rating of 30 percent is warranted from April 21, 2011. At an August 2011 VA examination, the examiner noted the appellant did not have a history of respiratory failure, cor pulmonales, right ventricular hypertrophy, pulmonary hypertension, chronic pulmonary mycosis, spontaneous pneumothorax, asthma, or bronchiectasis. Based on the above evidence, the Board finds that a higher rating is warranted from April 21, 2011, the date of the pulmonary function test noted above, but not prior to April 21, 2011. The evidence of record prior to the date demonstrates the appellant had normal pulmonary function test results and tests within the range warranting a 10 percent rating under Diagnostic Code 6600. The August 2008 and August 2011 VA examination reports reflect that the appellant did not have pulmonary hypertension. The August 2011 VA examiner noted the appellant did not have a history of cor pulmonale, right ventricular hypertension. At the March 2013 Board hearing, the appellant stated that he had not been prescribed oxygen therapy. See Board Hearing Transcript (Tr.) at p. 8. The Board has considered whether the appellant would be entitled to a higher rating under another Diagnostic Code, but finds no other Diagnostic Code which would warrant a higher rating. The August 2011 VA examiner specifically noted that the appellant did not have a history of asthma, or bronchiectasis. Thus, a higher rating is not warranted under those diagnostic odes. The evidence does not reflect the appellant had any other symptoms due to his chronic bronchitis that would warrant separate evaluation, prior to August 5, 2011. The Board has considered whether extraschedular consideration is warranted based on the evidence of functional, including occupational, impairment secondary to the service-connected bronchitis. See Barringer v. Peake, 22 Vet. App. 242 (2008). The discussion above reflects that the symptoms of the appellant's bronchitis are contemplated by the applicable rating criteria. The competent medical evidence of record shows that the bronchitis is primarily manifested by shortness of breath. The August 2011 VA examination report noted that the appellant was able to do activities of daily living, but could not do much physical activity. The applicable diagnostic codes used to rate the appellant's disability provide for ratings based the effect of pain and functional impairment have been taken into account and are considered in applying the relevant criteria in the rating schedule. The effects of the appellant's disability have been fully considered and are contemplated in the rating schedule. Consideration of whether the appellant's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). In sum, the Board finds that a preponderance of the evidence supports a higher rating of 30 percent for bronchitis from April 21, 2011, the date of the pulmonary function test cited in the August 2011 VA examination, which indicates the appellant had a DLCO result between 56 to 65 percent predicted. However, the Board finds that a higher rating is not warranted prior April 21, 2011, because the appellant's symptoms did not meet the criteria for a higher rating prior to the date. Accordingly, the Board finds that the preponderance of the evidence is against the appellant's claim. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER New and material evidence having been received, the claim for entitlement to service connection for PTSD is reopened. Entitlement to an evaluation of 50 percent is warranted for headaches prior to and from August 5, 2011. A rating of 30 percent, but no higher, is granted for bronchitis from April 21 to August 5, 2011. REMAND While further delay is regrettable, the Board finds that further development is required prior to adjudicating the appellant's claims for entitlement to service connection for PTSD, entitlement to a higher rating for bronchitis, from August 5, 2011, and entitlement to a TDIU. See 38 C.F.R. § 19.9 (2012). The August 2012 VA examiner found that the appellant had a diagnosis of PTSD. However, the VA examiner noted that the appellant's claimed stressor of plane crashes could be part of his psychotic symptoms. The Board finds that further development is necessary to verify whether there were any plane crashes while the appellant was stationed at Kodiak, Alaska, and at the U.S. Naval Air Station at the Patuxent River, Maryland, when the appellant was stationed there. Further, the appellant stated that he heard tapes of plane crashes as part of his training for his work on radar units. See 2008 statement. The VA examiner did not address whether this was an adequate stressor for his PTSD. Thus, a new VA opinion is necessary. The August 2012 VA examiner also found that the appellant had a diagnosis of major depressive disorder with psychotic features. The VA examiner stated that based on the available information, the origin and casual factors of his depression cannot be determined without resorting to speculation. The examiner noted that private medical records noted his depression but there were not records describing the depression or its etiology. However, the VA examiner did not address the appellant's in-service psychiatric symptoms, including symptoms of depression. A March 1973 service treatment record reflects that the appellant was hospitalized for reactive depression. The appellant also had a diagnosis of passive dependent personality. The appellant's final diagnosis was marital maladjustment. The in-service psychiatric symptoms are relevant to the appellant's claim and should be addressed by a VA examiner. As the VA examiner's rationale does not indicate that she reviewed the appellant's service treatment records regarding the diagnosis of reactive depression in service, the Board finds that a new VA opinion is necessary. The service treatment records note that the appellant was hospitalized at the Naval Hospital in Oakland, California in April 1973 with a diagnosis of passive dependent personality. A Medical Board report of the hospitalization was incorporated into his service treatment records. However, no attempt has been made to obtain the complete records of his hospitalization at the Naval Hospital. Thus, on remand, an attempt should be made to obtain these records. The Board finds that the appellant's testimony at the March 2013 Board hearing indicates the appellant's bronchitis may have worsened since the last VA examination of record, in August 2011, which used pulmonary function test results from April 2011, more than two years ago. The appellant stated that his bronchitis was not getting any better. He stated that he coughed up gobs of grayish stuff out of his lungs that had blood in it. He also said it had degenerated into lung cancer into pulmonary effusion. See Tr. at p. 9. The appellant's statements indicate that the condition has worsened since the previous VA examination two years ago. Thus, the Board finds that the August 2011 VA examination is not sufficiently contemporaneous for purposes of evaluating the nature and severity of the appellant's bronchitis. The appellant is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination. Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Therefore, the Board finds that a VA examination is necessary prior to appellate adjudication of this issue. At the March 2013 hearing, the appellant stated that he had a nuclear stress tests in July 2012 and September 2013 when he had heart attacks. See Tr. at p. 8. The record was held open for 90 days, but no evidence was received. The most recent Yakima Heart Center records in the claims file date to August 31, 3012, prior to the appellant's reported heart attack in September 2013. As the records are relevant to the claim, on remand the appellant should be requested to provide the appropriate release form to obtain the records. Finally, the VA treatment records in the file only date to April 2012. Consequently, the Board requests the appellant's complete VA treatment records from April 2012 to present. The appellant's claim for entitlement to TDIU is inextricably intertwined with the issues being remanded. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Thus, the issue of entitlement to TDIU must also be remanded. Accordingly, the case is REMANDED for the following action: 1. After obtaining any authorization necessary, request the appellant's private treatment records from the hospital September 2012 to present, including any pulmonary function tests and stress tests. If no records are available, the claims file must indicate this fact. 2. Obtain all of the appellant's VA treatment records from April 2012 to present. If no records are available, the claims folder must indicate this fact. 3. Obtain the appellant's service treatment records from his hospitalization at the Naval Hospital in Oakland, California in April 1973. If no records are available, the claims file must indicate this fact. 4. Contact the JSRRC or any other relevant source to verify the stressor of plane crashes during the appellant's service while stationed at Kodiak, Alaska, and at the U.S. Naval Air Station at the Patuxent River, Maryland. All steps taken to verify the stressors should be noted in the claims file. 5. After completion of the above and after any records obtained have been associated with the claims file, schedule the appellant for VA psychological examination to determine the following: (a) Identify all current acquired psychiatric disabilities, to include PTSD and depression. (b) Provide an opinion as to whether it is at least as likely as not that the appellant's PTSD is at least as likely as not (50 percent probability) related to any verified stressors, including listening to tapes of plane crashes as part of his training. (c) Provide an opinion as to whether the appellant's major depressive disorder with psychotic features is at least as likely as not related to service, to include his in-service psychiatric symptoms. Forward the claims file to the examiner for review. The VA clinician is requested to provide a thorough rationale for any opinion provided. If the clinician is unable to provide an opinion without resorting to speculation, the clinician should explain why a definitive opinion cannot be provided. 6. After completion of steps 1 and 2 above, schedule the appellant for a VA examination to determine the current symptoms of his service-connected bronchitis. All necessary tests should be completed, to include pulmonary function tests. All findings should be reported in detail. The pulmonary function test should contain the full range of results necessary to rate the disability under the Diagnostic Code (FEV-1, FVC, DLCO, FEV-1/FEV). The presence or absence of right ventricular hypertrophy, cor pulmonale, pulmonary hypertension, episodes of acute respiratory failure, or the use of outpatient oxygen therapy should also be documented. The VA examiner should address the impact of the appellant's service-connected bronchitis on his ability to work. Forward the claims file to the examiner for review. The VA clinician is requested to provide a thorough rationale for any opinion provided. If the clinician is unable to provide an opinion without resorting to speculation, the clinician should explain why a definitive opinion cannot be provided. 7. Thereafter, readjudicate the issues on appeal. If any benefit sought is not granted, issue a supplemental statement of the case and afford the appellant an appropriate opportunity to respond. The case should then be returned to the Board, as warranted. 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs