Citation Nr: 1326404 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 08-01 028 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an initial increased rating for gastroesophageal acid/reflux disorder, currently rated 10 percent disabling. 2. Entitlement to an initial increased rating for posttraumatic stress disorder (PTSD), rated 30 percent disabling prior to July 13, 2009. 3. Entitlement to an initial increased rating for PTSD, rated 50 percent disabling from July 13, 2009. 4. Entitlement to a total disability rating due to individual unemployability (TDIU) due to service-connected disabilities, for the period prior to July 13, 2009. REPRESENTATION Veteran represented by: John S. Berry, Attorney-at-Law ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel INTRODUCTION The Veteran served on active duty from February 1951 to January 1953. These matters come to the Board of Veterans' Appeals (Board) from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In a March 2007 rating decision, the RO, in pertinent part, granted entitlement to service connection for PTSD, assigning a 30 percent rating, effective May 6, 2005, and granted entitlement to service connection for hearing loss, assigning a 30 percent rating, also effective May 6, 2005. A notice of disagreement was filed in April 2007 with regard to the disability ratings assigned and a statement of the case was issued in November 2007. In January 2008, the Veteran filed a substantive appeal with regard to the PTSD issue. In an October 2009 rating decision, the RO assigned a 50 percent rating for PTSD, effective July 13, 2009. Although an increased rating has been granted, the issue remains in appellate status, as the maximum schedular rating has not been assigned. AB v. Brown, 6 Vet. App. 35 (1993). In a December 2010 rating decision, the RO granted entitlement to service connection for gastroesophageal acid/reflux disorder, assigning a 10 percent rating, effective May 6, 2005. In March 2011, the Veteran filed a notice of disagreement with the disability rating assigned. A statement of the case was issued in April 2012 and a substantive appeal was received in May 2012. In February 2012, the RO denied entitlement to a TDIU. A notice of disagreement was filed in June 2012. In September 2012, the RO granted entitlement to a TDIU, effective July 13, 2009. In November 2012, a notice of disagreement was received with regard to the effective date assigned to the grant of a TDIU. A statement of the case was issued in January 2013 and a substantive appeal was received in January 2013. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to a rating in excess of 50 percent for PTSD from July 13, 2009, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the VA St. Louis RO. VA will notify the Veteran if any further action is required on his part. FINDINGS OF FACT 1. The evidence of record does not show the Veteran's service-connected gastroesophageal acid/reflux disorder to be productive of persistently recurrent epigastric distress with dysphagia, pyrosis , and regurgitation, accompanied by substernal or arm or shoulder pain, and is not productive of considerable impairment of health. 2. For the period prior to July 13, 2009, the Veteran's service-connected PTSD is manifested by depressed mood, anxiety, panic attacks, and irritability. However, difficulty in establishing and maintaining effective work and social relationships has not been shown. CONCLUSIONS OF LAW 1. The criteria for the assignment of a disability rating in excess of 10 percent for gastroesophageal acid/reflux disorder have not been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.114, Diagnostic Code 7346 (2012). 2. For the period prior to July 13, 2009, the criteria for a disability rating in excess of 30 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), 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). Proper notice from VA must inform the claimant of any information and medical or lay 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. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's claims arise from an appeal of the initial evaluations following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment 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 also finds that VA has complied with all assistance provisions of VCAA. His private treatment records have been obtained. The Board does not have notice of any additional relevant evidence that is available but has not been obtained. The Veteran was afforded VA examinations in conjunction with his gastroesophageal acid/reflux disorder and PTSD, which will be discussed below. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claims for an increased ratings for gastroesophageal acid/reflux disorder, and PTSD, for the period prior to July 13, 2009. 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). Criteria & Analysis Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Gastroesophageal acid/reflux disorder Disabilities involving the digestive system are evaluated under the regulatory criteria found at 38 C.F.R. §§ 4.110- 4.114. The Veteran's service-connected gastroesophageal acid/reflux disorder has been rated by the RO as 10 percent disabling under the provisions of 38 C.F.R. § 4.114, Diagnostic Code 7346. Under Diagnostic Code 7346, a 60 percent evaluation is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent evaluation is assigned when there is evidence of persistently recurrent epigastric distress with dysphasia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent evaluation is assigned when there is evidence of two or more of the symptoms for the 30 percent evaluation of less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346. The record includes private treatment records and lay statements from the Veteran. (ADD) A December 2006 VA examination report reflects complaints of post-service abdominal problems, which were treated with over-the-counter medicines. He has experienced episodes of gastric burning, regurgitation, occasional bloating, and cramping throughout his lifetime. He had an increase of abdominal symptoms when anxious or stressed. He took medication for anxiety which helps. He did not seek medical evaluation until 2004 when he was recommended to take Prilosec for gastroesophageal reflux disease (GERD). He reported that he received good control of his symptoms with use of the medication and he has not had recurrence of GERD since starting the medication. There is no history of esophageal neoplasm, nausea, vomiting, or dysphagia. He experiences esophageal distress, heartburn or pyrosis, and less than weekly regurgitation. The contents of esophageal regurgitation consist of partially digested food. There was no history of hematemesis or melena or esophageal dilation. On physical examination, there were no signs of significant weight loss or malnutrition. He was obese, with a soft, non-tender abdomen. There were no masses or organomegally. His bowel sounds were positive times 4 quads. He underwent an esophagus barium in January 2007 which showed no evidence of esophageal mucosal irregularity or gastroesophageal reflux. In May 2010, the Veteran underwent another VA examination. He reported that since 2004 he had been on medication that had largely controlled his symptoms. Despite this, he still had to avoid eating late and slept with his head elevated. He took Omeprazole 40 milligrams per day. There was no history of trauma to the esophagus, esophageal neoplasm, nausea, vomiting, dysphagia, esophageal distress, heartburn or pyrosis, regurgitation, hematemsis or melena, or esophageal dilation. He had a history of nausea, epigastric distress, heartburn and reflux since the 1950's but these symptoms were mostly controlled with Prilosec. The examiner noted that the examination template was not well structured to reflect this. There were no signs of anemia or no signs of significant weight loss or malnutrition. A June 2012 VA examination noted that the Veteran took Prilosec 40 milligrams daily. He reported infrequent episodes of epigastric distress, pyrosis (heartburn), reflux, regurgitation, substernal arm or shoulder pain, and sleep disturbance caused by esophageal reflux. The examiner noted that the symptoms recur once per year less than once a day. He did not have esophageal stricture, spasm of esophagus or an acquired diverticulum of the esophagus. His abdomen was soft and bowel sounds were present. There was diffuse tenderness in the upper quadrants, moderate tenderness epigastric region, and no spasm. The examiner diagnosed GERD. Private treatment records throughout the rating period on appeal reflect a diagnosis of GERD. These records also reflect that his symptoms were controlled by Prilosec. The objective findings noted in such records are consistent with those found at the above VA examinations- no findings indicate a disability picture more severe than that described in the VA examinations. Based on the subjective complaints, and objective findings in the record, the Board has determined that a disability rating in excess of 10 percent is not warranted for the Veteran's gastroesophageal acid/reflux disorder. Initially, the Board notes that the VA examination reports and private treatment records reflect that the Veteran's gastroesophageal acid/reflux disorder is mostly controlled by prescription medication, specifically Prilosec. In fact, the private treatment providers have repeatedly indicated that his reflux esophagitis is controlled on medication. As reflected in the May 2010 VA examination report, while he initially experienced nausea, epigastric distress, heartburn and reflux associated with his disorder, these symptoms have been largely controlled by Prilosec. As detailed above, the June 2012 VA examination report reflects that the Veteran experiences infrequent episodes of epigastric distress, pyrosis (heartburn), reflux, regurgitation, substernal arm or shoulder pain, and sleep disturbance caused by esophageal reflux. Thus, the evidence of record does not support a finding that the Veteran has two or more of the symptoms described under the 30 percent rating criteria. There is no showing of persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Again, while he has experienced pyrosis and regurgitation, these symptoms are well controlled with medication, and he is not shown to be in persistent recurrent epigastric distress due to his gastroesophageal acid/reflux disorder. Moreover, the Veteran has specifically denied any vomiting, dysphagia, hematemesis, or melena, and moderate anemia or weight loss was not shown. There is otherwise no other diagnostic code which could provide for a higher disability rating. The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board finds the severity of the Veteran's service-connected gastroesophageal acid/reflux disorder is fully contemplated by the rating criteria. There is nothing exceptional about the Veteran's service-connected disability. The degree of disability exhibited is contemplated by the rating schedule. Thus, the Board finds that the threshold test is not met for referral for extraschedular consideration. 38 C.F.R. § 4.16(b); Thun v. Peake, 22 Vet. App. 111 (2008). PTSD Pursuant to the applicable rating criteria, a 30 percent evaluation will be assigned with evidence of 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation will be assigned with evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent evaluation will be awarded with evidence of 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; speech intermittently illogical, obscure, or irrelevant; 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 rating is assigned when there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather 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). In addition, in Mittleider v. West, 11 Vet. App. 181 (1998), the Court held that VA regulations require that when the symptoms and/or degree of impairment due to a veteran's service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. Also relevant in evaluating psychiatric claims, the DSM-IV provides for a global assessment of functioning (GAF), a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the DSM-IV). The GAF score is not conclusive of the degree of impairment for VA purposes but, rather, must be considered together with all evidence of record. See 38 C.F.R. § 4.126; see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). A GAF score of 61 to 70 is reflective of 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 generally functioning pretty well with some meaningful interpersonal relationships. A GAF score of 51 to 60 is illustrative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 41 to 50 is reflective of 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). In the present case, the Veteran contends that the symptomatology associated with his service-connected PTSD is severe, and includes panic attacks, mood swings, insomnia, social isolation, and depression, avoidance of large crowds, outbursts of anger, nightmares, suicidal ideation, and hyperventilation, His symptoms require medication. The statements concerning the Veteran's service-connected psychiatric pathology involve matters capable of lay observation, and are deemed to be competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Such descriptions must, however, be considered in conjunction with the clinical evidence of record and the pertinent rating criteria. The record includes VA examination reports, private treatment records, and lay statements from the Veteran. All of these records have been reviewed by the Board, although they will not all be discussed in assessing the rating assigned to the Veteran's PTSD. Initially, the Board notes that a 30 percent rating is assigned to PTSD for the period May 6, 2005, to July 13, 2009. A determination will be made as to whether a higher rating is warranted for any period from May 6, 2005, to July 13, 2009; however, the period from July 13, 2009 is addressed in the Remand below. The medical evidence of record shows that on VA examination in January 2007, the Veteran was diagnosed with PTSD, chronic, moderate; and, alcohol dependence, chronic, moderate. The examiner assigned a GAF score of 51. The examiner noted that the GAF score was the same for his PTSD and alcohol abuse, as he uses alcohol in an attempt to reduce his anxiety. While he took medication, this did not help sufficiently to allow him to be free of alcohol. During the examination, the Veteran reported nightmares, low energy, anxiety, nervousness, panic attacks, anger problems, relationship problems, sexual problems, and alcohol use. He reported a "pretty good" relationship with his spouse of 20 years, good relationships with his adult children and grandchildren, being friendly with neighbors, and raising cattle as his primary hobby. He reported excessive anxiety since service and drinking heavily for the 10 years following service. He continued to drink a case of beer per week, averaging 2 to 5 per day. He did not see alcohol use as a problem or having a negative effect on his relationships. He reported experiencing intrusive thoughts on a weekly basis and disturbing dreams concerning in-service events occurring twice a month. He denied any flashbacks and did not report any intense psychological distress when experiencing any unexpected loud noise. He did avoid roadside accidents as a truck driver due to his fear of seeing wounded or dismembered people again. He tried to keep busy and talk with fellow farmers about cattle but he feels extremely uncomfortable in crowds of people and that this has limited his social activities. He had difficulty sleeping, and chronic irritability resulting in verbal fits of outrage but no physical aggression. He had exaggerated startle response and his chronic hypervigilance is beginning to "pass now." On mental status examination, he was appropriately oriented and groomed although his affect was restricted. His mood was good with friends but anxious when alone. Symptoms of mania were denied. He feels anxious and has panic attacks at least twice a month, including increased heart rate, sweating, nausea, hot flashes, and feeling that he is losing control. He reported suicidal ideation during his first divorce but not since and he denied homicidal ideation. He reported concentration and memory problems due to age. Private treatment records dated from 2002 through 2008 reflect varying reports of bouts of depression and anxiety, but he took Celexa for his symptoms and he had no problems with the medication. For example, a June 2005 treatment record reflects that he was "feeling good" and had no side effects from taking Celexa. An April 2006 treatment record reflects that while he became agitated easily, he felt better with Celexa and had no side effects. His daughter's perception was that while he was better, his anxiety and mood were still a problem from the standpoint of the family. A July 2006 treatment record reflects that he was sleeping "fine" and that he "feels good." His daughter and wife reported that he still felt anxious and stressed, which may play a role in excessive eating. An April 2007 private treatment record reflects that he was "doing well" on Celexa and an August 2007 private treatment record reflects that on medication his mood "has been quite good" and he denied any depression or significant anxiety. A June 2008 private treatment record reflects that Celexa was helpful. Again, a 30 percent disability rating has been awarded for the period May 6, 2005 to July 13, 2009. Based on review of the evidence detailed hereinabove and review of the entirety of the record, the Board finds a 50 percent disability rating is not warranted for any period prior to July 13, 2009. As described previously, the GAF score assigned in January 2007 denotes moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social or occupational functioning (e.g., few friends, conflicts with peers or co-workers). Richard, 9 Vet. App. at 267. The GAF score also contemplated his alcohol abuse, with the examiner noting that he took medication but also self-treats his anxiety with alcohol. The symptoms reported by the Veteran and the observations of the VA examiner, coupled with the private treatment records, do not warrant a 50 percent rating for the period prior to July 13, 2009. Indeed, he has reported experiencing panic attacks twice a month, but not amounting to more than once a week. He did have a restricted affect while being interviewed but was otherwise polite and his speech was normal with organized and goal-directed thoughts. There was no indication of circumstantial, circumlocutory or stereotyped speech, and there was also no indication that he had difficulty in understanding complex commands, impairment of short and long-term memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. In sum, despite the Veteran's anxiety and irritability, he has maintained relationships with family members and neighbors. He also occupies his time raising cattle. It is also helpful to note that the 50 percent rating assigned effective July 13, 2009, was based in part on a VA examination conducted that same date. Such examination report reflects that the VA examiner assigned a GAF score of 45 denoting serious symptoms, and the examiner commented that his symptoms had worsened since the prior examination. The private treatment records on file prior to July 13, 2009, however, do not support symptomatology associated with PTSD to support a disability rating in excess of 30 percent. Based on the foregoing, the next higher rating of 50 percent for the Veteran's service-connected PTSD is not warranted for the period prior to July 13, 2009. 38 C.F.R. § 4.130, Diagnostic Code 9411. Moreover, it stands to reason that if a higher rating of 50 percent is not warranted, then neither is a higher rating of 70 or 100 percent warranted in this instance. The Board has also considered whether this case should be referred for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1) for the Veteran's PTSD. However, the rating schedule contemplates the totality of his PTSD symptomatology. Thus, the Board finds that the threshold test is not met for referral for extraschedular consideration. 38 C.F.R. § 4.16(b); Thun v. Peake, 22 Vet. App. 111 (2008). In conclusion, the Board finds that for the period prior to July 13, 2009, a disability rating in excess of 30 percent is not warranted. ORDER Entitlement to a disability rating in excess of 10 percent for gastroesophageal acid/reflux disorder is denied. For the period prior to July 13, 2009, entitlement to a disability rating in excess of 30 percent for PTSD is denied. REMAND Initial increased rating for PTSD for the period from July 13, 2009 Correspondence dated in February 2013 from the Veteran's private physician, Dr. G.L.A. of the Mayo Clinic reflects that he has treated the Veteran for a number of years and that the Veteran has had depression and anxiety since 2001. During that time, he has also had issues with anger management. The Board notes that the evidence of record contains treatment records from the Mayo Clinic through November 10, 2010, but not thereafter. Such treatment records reflect continuous evaluation and notations regarding anxiety and depression. As it is clear that there may be outstanding treatment records pertaining to the PTSD issue in appellate status, remand is necessary to obtain the records. 38 C.F.R. § 3.159(c)(1). TDIU for the period prior to July 13, 2009 Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 4.16(a). If, however, there is only one such disability, it shall be ratable at 60 percent or more, and, if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Under 38 C.F.R. § 4.16(b), all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Therefore, rating boards should submit to the Director, Compensation and Pension service, for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in § 4.16(a). Before a finding may be made that entitlement to submission of the Veteran's claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service for extraschedular consideration is warranted, there must be a showing of marked interference with employment, or an inability to secure or follow a substantially gainful occupation by reason of service-connected disability. Entitlement to a TDIU was awarded, effective July 13, 2009, which corresponds to the date PTSD is rated 50 percent disabling and in which the Veteran's combined evaluation is 70 percent. His combined evaluation is 80 percent, effective September 5, 2012, which corresponds to the 40 percent rating assigned for hearing loss. Effective May 6, 2005 and for the period prior to July 13, 2009, the Veteran's PTSD is rated 30 percent disabling, his hearing loss is rated 30 percent disabling, his tinnitus is rated 10 percent disabling, his gastroesophageal acid/reflux disorder is rated 10 percent disabling, and his sexual dysfunction is rated noncompensably disabling. Thus, for the period prior to July 13, 2009, his service-connected disabilities do not meet the percentage standards per § 4.16(a). The evidence of record reflects that the Veteran worked as a truck driver for many years and retired in 1991, thus prior to service connection being established for any disability. Following his retirement, the Veteran has raised cattle and farmed for many years; however, it is not clear whether this constitutes a hobby or gainful employment. The Veteran asserts that he is unable to maintain gainful employment due to his service-connected disabilities, and that he was not able to do any of the farming activities involved in raising cattle for the period from 2005. See March 2013 Statement from Veteran. Initially, the Board finds that the Veteran should be requested to complete VA Form 21-8940s, Applications for Increased Compensation Based on Unemployability, for the period May 6, 2005 to July 12, 2009. Then, a VA examiner should review the record to assess whether PTSD, hearing loss, tinnitus, gastroesophageal reflux/acid disorder, and sexual dysfunction together precluded the Veteran from following a substantially gainful occupation for any period from May 6, 2005 to July 12, 2009. Finally, a determination should be made to whether the Veteran's claim should be submitted to the Director, Compensation and Pension Service, for extraschedular consideration per § 4.16(b). Appropriate action to develop the record in this regard is necessary. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Upon obtaining an appropriate release from the Veteran, request treatment records from the Mayo Clinic, specifically Dr. G.L.A., for the period from November 11, 2010. If such efforts prove unsuccessful, documentation to that effect should be added to the claims folder. 2. Contact the Veteran and request that he complete VA Form 21-8940s, Applications for Increased Compensation Based on Unemployability, for the period from May 6, 2005 to July 12, 2009. 3. Thereafter, the Veteran's claims files should be reviewed by appropriate VA examiners for an assessment as to whether the Veteran's service-connected PTSD (rated 30 percent disabling), hearing loss (rated 30 percent disabling), tinnitus (rated 10 percent disabling), gastroesophageal reflux/acid disorder (rated 10 percent disabling), and sexual dysfunction (rated 0 percent disabling) precluded the Veteran from working for any period between May 6, 2005 and July 12, 2009. The examiner should provide supporting rationale for this opinion. If the examiner feels that it is necessary, an examination should be scheduled. 4. The RO/AMC should then determine whether the Veteran's claim should be submitted to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for extraschedular consideration as to whether his service-connected disabilities precluded the Veteran from participating in gainful employment for any period between May 6, 2005 and July 12, 2009. 5. After completion of the above, the RO should readjudicate the issues of entitlement to a disability rating in excess of 50 percent for the period from July 13, 2009, and entitlement to a TDIU per § 4.16(b) for the period prior to July 13, 2009. If either of the benefits sought are not granted in full, the Veteran and his attorney should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The Veteran and his attorney have 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). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs