Citation Nr: 1325259 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 10-12 910 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to an initial disability evaluation in excess of 30 percent for service connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: William J. Overby ATTORNEY FOR THE BOARD E. D. Anderson, Counsel INTRODUCTION The Veteran served on active duty from July 1965 to July 1968. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina which granted service connection for PTSD and assigned an initial 30 percent rating, effective January 2008. FINDINGS OF FACT 1. Prior to September 29, 2011, the Veteran's service-connected PTSD was productive of a depressed mood, anxiety, irritability, flashbacks, chronic sleep impairment and intrusive thoughts. 2. As of September 29, 2011, the Veteran's service connected PTSD increased in severity and was productive of: multiple panic attacks per week, chronic sleep impairment, disturbances of motivation and mood, GAF scores ranging from the 40s to the 50, and difficulty establishing and maintaining effective work and social relationships. CONCLUSIONS OF LAW 1. Prior to September 29, 2011, the criteria for an initial disability evaluation in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). 2. As of September 29, 2011, the criteria for a 50 percent disability evaluation, but no greater, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the claims folder. 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. 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). The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2010); 38 C.F.R., Part 4 (2012). Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding the veteran's increased evaluation claim, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 22 Vet. App. 505 (2007), and whether the veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the U.S. Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126. Hart appears to extend Fenderson to all increased rating claims. The Veteran is seeking entitlement to an initial disability evaluation in excess of 30 percent for his service connected PTSD. The Veteran was granted service connection for PTSD in a March 2009 RO decision and assigned an initial 30 percent rating, effective January 2008. The Veteran's PTSD is rated under the General Rating Formula for Mental Disorders, found at 38 C.F.R. § 4.130 (2012). A 30 percent evaluation is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss(such as forgetting names, directions, recent events). A 50 percent 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. It is further noted that the nomenclature employed in the portion of VA's Schedule for Rating Disabilities ("the Schedule") that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "the DSM-IV"). 38 C.F.R. § 4.130 (2012). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but the individual is functioning pretty well and has some meaningful interpersonal relationships. American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th. ed., 1994). GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. GAF scores ranging between 41 and 50 are assigned when there are 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). Id. GAF scores ranging between 31 and 40 are assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). Id. GAF Scores between 21 and 30 are assigned when behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). Id. Symptoms listed in VA's general rating formula for 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 rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a) (2012). In addition, the evaluation must be 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. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2012). In August 2008, the Veteran was afforded a VA psychiatric examination. The Veteran complained of symptoms of insomnia, poor concentration, sadness, anhedonia, irritability, hypervigilance, and nightmare three or four time a week. He stated that he goes shopping late at night to avoid crowds. He also drinks rather heavily to help him sleep. While the Veteran was retired at the time of the examination due to his age and length of employment, he reported that the last few years on the job, he was irritable and edgy and had difficulty getting along with others. However, his supervisor convinced him to continue working for an extra year. The Veteran also reported a positive relationship with his children and grandchildren, and was married to his late wife for thirty one years. He also reported that he has a couple of friends that he can talk to and enjoys playing golf. During the examination, the Veteran was cooperative, but had a constricted affect and appeared tense. He was easily distracted, but well oriented, with no impairment of thought processes, thought content, or memory. Judgment and insight were intact. The Veteran denied hallucinations, delusions, panic attacks, suicidal or homicidal ideations, and inappropriate or violent behavior. He was capable of maintaining minimal personal hygiene and performing most activities of daily living without any problems, with the exception of shopping and exercise. The Veteran was diagnosed with PTSD and assigned a GAF score of 59. Of record are VA treatment records, which show that the Veteran has participated in both individual and group therapy during the period on appeal. While outpatient treatment records reflect complaints of sadness, anxiety, insomnia, intrusive thoughts, nightmares, and alcohol abuse, they also show that the Veteran has a strong relationship with family and friends, is able to engage in social activities, and has a number of hobbies. See, e.g., VA SATP Note (August 4, 2011) (Veteran hosted a birthday party for his brother with the help of his children and girlfriend);VA SATP Note (May 10, 2011) (Veteran has lunch with his grandson); VA Mental Health Group Counseling Note (July 23, 2010) (Veteran attended sporting event with his son); VA SATP Note (May 19, 2008) (Veteran joined family and friends for a picnic, enjoys golfing with buddies two or three times a week); VA Mental Health Consult (April 14, 2008) (Veteran keeps busy by watching television, playing computer games, golfing). From January 2008 through September 2011, the Veteran's GAF score ranged between 50 and 59, indicating a generally moderate disability. However, on September 29, 2011, the Veteran presented for VA treatment and reported experiencing a stressful couple of months, due to the recent deaths of both his mother and brother. He was assigned a GAF score of 45. In December 2011, the Veteran reported that he was drinking more, becoming more depressed, and isolating himself. He was assigned a GAF score of 40. In December 2011, the Veteran also sought private counseling and substance abuse treatment at North Raleigh Family Clinic. He complained of flashbacks, nightmares, sadness, irritability, hypervigilance, and alcohol dependence. He reported poor relationships with family and friends, as well as avoidance of social and family obligations. He admitted to suicidal ideations, but denied intent. He was diagnosed with PTSD, panic disorder with acrophobia, and major depression without psychotic features. A GAF score of 45 was assigned. In January 2012, the Veteran was afforded another VA examination of his service connected PTSD. The Veteran complained of symptoms of nightmares, flashbacks, depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideation. He reported that when he was much younger, he got into frequent altercations and was arrested several times, but never spent time in jail. The Veteran reported alcohol abuse of up to a pint of liquor daily, a habit he has engaged in for fifteen to twenty years. He asserted that alcohol is the only thing that gives him relief from his PTSD symptoms. While the Veteran acknowledged that his drinking is problematic, he indicated that he preferred to drink heavily rather than constantly suffer the full repercussions of his mental illness. He denied drinking and driving or any other legal repercussions from his drinking. The Veteran reported a good relationship with his two children and his siblings. He was also very close to wife of thirty one years prior to her death and to his parents before their deaths. The Veteran has been retired since 2007, but before that, he worked as the Director of Utilities for a town for eighteen years. He denied ever being fired from a job, although as he was nearing retirement, others noticed that he was becoming argumentative. He reported that he enjoys fishing, plays golf, and occasionally attends church, but prefers solitary activities and avoids noise and crowds. The Veteran was diagnosed with PTSD and Alcohol Dependence. A GAF score of 60 was assigned. The examiner concluded that the Veteran's PTSD symptoms would cause occupational and social impairment with occasional decreases in work efficiency and intermittent period of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. In May 2012, the Veteran admitted he had started using marijuana again, after abstaining for many years. His GAF score was 45. Based on all the above evidence, the Board finds that prior to September 29, 2011, an initial disability evaluation in excess of 30 percent for the Veteran's PTSD cannot be granted. During this period on appeal, the Veteran consistently described symptom of depression, anxiety, irritability, chronic sleep impairment, nightmares, and intrusive thoughts. He also reported using alcohol to self-medicate. However, overall his symptoms resulted in only occasional impairment of social functioning and intermittent periods of inability to perform daily tasks. Despite his disability, the Veteran has reported having a close relationship with his children, grandchildren, and siblings, as well as having several close friends, and the record reflects that the Veteran regularly participated in social activities with these individuals. The Veteran has also reported engaging in a number of recreational activities, including fishing, golfing, playing video games, and watching television. He is capable of taking care of himself and can perform most activities of daily living without impairment. The only exception to this is shopping, which causes the Veteran stress because of the crowds and noise, so he shops late at night when the stores are less crowded or asks his children for assistance. Between January 2008 and September 28, 2011, his GAF scores ranged between 50 and 59, suggesting symptoms/impairment of moderate severity. A 50 percent disability rating is assigned for disabilities that result in a generally continuous impairment of social and occupational, as well as impaired judgment, cognition, or thought processes, as evidenced by symptoms such, for example, circumstantial, circumlocutory, or stereotyped speech; difficulty understanding complex commands; or impairment of short and long-term memory. Here, the Board finds that the Veteran's PTSD does not result in that severity of impairment for the period in question and entitlement to an initial disability evaluation in excess of 30 percent must be denied prior to September 29, 2011. However, beginning on September 29, 2011, the Veteran began reporting a worsening in his PTSD symptoms, coinciding with the deaths of several close family members. He complained of increasing depression, isolation, and alcohol abuse. In May 2012, he reported that he was using marijuana again. GAF scores assigned by the Veteran's VA treatment providers were lower than previously assigned scores, with the lowest score of 40 being assigned in December 2011. In December 2011, the Veteran sought private counseling and substance abuse treatment at the North Raleigh Family Clinic and was assigned a GAF score of 45 by the clinical social worker evaluating him. Specifically, the psycho-social assessment demonstrates that the Veteran reported poor relationships with his family and friends, whom he avoids out of fear of having unprovoked angry outbursts. He said he was having difficulty sleeping and depended on alcohol to manage his PTSD symptoms. He reported frequently experiencing flashbacks and nightmares, as well as feelings of sadness. He related he had thoughts of harming himself and others, although he denied any plans of carrying them out. There was no history of suicide attempts but he had been in altercations with others. He admitted having difficulty maintaining a normal life, as well as feeling cheated. On examination, it was noted he was oriented but had difficulty providing additional information. He required continuous redirecting to the topic being discussed and at times dissociated. There was no indication of exaggeration. In fact, he appeared to diminish his symptoms. While the January 2012 VA examiner assigned a GAF score of 60 and characterized the degree of impairment from the Veteran's PTSD as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, the preponderance of the evidence, including VA and private treatment records, indicates an overall worsening of the Veteran's disability in September 2011. In particular, his ongoing treatment at the North Raleigh Family Clinic (to include in January 2012) demonstrates that his condition has not improved since apparently worsening in September 2011. Additionally, in May 2012, the Veteran informed his VA psychiatrist that he had begun using marijuana again after a long period of non-use. His GAF score at this appointment was only 45. Accordingly, entitlement to a disability rating of 50 percent for the Veteran's service connected PTSD is granted from September 2011. However, the Board finds that entitlement to a disability rating in excess of 50 percent is not warranted for any period on appeal. The Veteran's PTSD is not characterized by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as, for example, 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; and inability to establish and maintain effective relationships. Despite the worsening in his symptoms, the Veteran continues to be capable of maintaining minimal personal hygiene and performing activities of daily living independently. He is able to communicate clearly and lucidly with other and manage his finances competently. His disability has not caused any legal problems. There is no evidence of impaired judgment or thought processes. In sum, his PTSD does not cause the severe, near total impairment contemplated by the criteria for a 70 percent disability. Finally, the Board has also considered whether the Veteran's disability warrants referral for extraschedular consideration. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2012). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, it does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for that service-connected disability are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is not required. See Thun, supra. In conclusion, prior to September 2011, entitlement to an initial 30 percent disability rating for PTSD is denied. After September 30, a 50 percent disability rating, but no greater, is granted. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2011). The Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the Veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess, the Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. VA also has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records, as well as VA treatment records. The Veteran has submitted private treatment records. The appellant was also afforded VA medical examinations in August 2008 and January 2012. These examinations are based upon review of the claims folder, and thoroughly discuss the nature and severity of the Veteran's disability as well as the functional impairments resulting therefrom. The examination reports are adequate for rating purposes. See 38 C.F.R. § 4.2; see also 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). Significantly, neither the appellant 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 appellant is required to fulfill VA's duty to assist the appellant in the development of the 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 an initial 30 percent disability rating for PTSD is denied prior to September 29, 2011. As of September 29, 2011, entitlement to a 50 percent disability rating for PTSD is granted. ____________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs