Citation Nr: 1328216 Decision Date: 09/04/13 Archive Date: 09/10/13 DOCKET NO. 10-13 052 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to an initial disability evaluation in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD E. D. Anderson, Counsel INTRODUCTION The Veteran served on active duty from January 1968 to January 1972. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Togus, Maine which granted service connection for PTSD and assigned a 30 percent disability rating, effective from May 15, 2008. Subsequently, in a January 2010 rating decision of the RO in Detroit, Michigan, an increased 50 percent rating was assigned the Veteran's service-connected PTSD, effective from May 15, 2008. Jurisdiction is currently with the RO in Detroit, Michigan In September 2012, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, D.C. for additional development, to include obtaining additional records and affording the Veteran a VA examination. The action specified in the September 2012 Remand completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). In October 2012, the RO denied a claim for a total disability rating based on individual unemployability (TDIU). As the Veteran has not perfected an appeal of this issue, the Board does not have jurisdiction over it at this time and the issue of entitlement to TDIU will not be further addressed. FINDING OF FACT Throughout the period on appeal, the Veteran's PTSD was characterized by occupational and social impairment with reduced reliability and productivity due to such symptoms as, restlessness, irritability, depression, hypervigilance, mood disregulation, and suspiciousness of others. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 50 percent for service-connected 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). REASONS AND BASES FOR FINDING AND CONCLUSION 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 United States Court of Appeals for the Federal Circuit (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 ensure 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 50 percent for his service-connected PTSD. The Veteran was granted service connection for PTSD in an April 2009 RO decision and assigned an initial 30 percent rating, effective May 2008. In a January 2010 decision, the Veteran's original disability rating was increased to 50 percent, effective May 15, 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). The Veteran was seen in May 2008 by a VA contracted psychologist for an intake evaluation. At that time, the Veteran complained of symptoms of restlessness, irritability, depression, feelings of persecution, hypervigilance, exaggerated startle response, difficulty trusting others, and mood disregulation. He reported that the war in Iraq reminded him of Vietnam and triggered feelings of anger and distrust for the government. The Veteran also reported a history of drug and alcohol abuse, including methamphetamine use as recently as January 2008. He reported that he lost his job in July 2007. Prior to that time, he had been employed for more than thirty years by the state of Michigan as a master electrician, although his period of employment was interrupted by a prior termination after which he ran his own contracting business for a number of years. The Veteran attributed both of his terminations to conflicts with his supervisor. The Veteran reported spending his free time with his spouse, children, and grandchildren. He indicated that he attended his grandchildren's activities, such as sporting events. The Veteran also identified an interest in motorcycles, shooting pool, and working on his house. He was a member of a local motorcycle club. The Veteran's appearance at this interview was described as unkempt and his manner was anxious, suspicious, and defensive. His speech was rapid and his affect labile. He appeared agitated and restless. However, he was oriented to person, place, and time and had normal memory function. He was diagnosed with PTSD, alcohol dependence, and amphetamine dependence. A GAF score of 50 was assigned. The Veteran was afforded a VA examination in February 2009. The Veteran reported suspiciousness of others and hypervigilance, telling the examiner that he was not comfortable unless he had a loaded gun around him. Nevertheless, he reported that when he went out in public, he kept his gun in a gun safe. He also described sleep disturbances and restlessness. He reported irritability and outbursts of anger, noting that at times he had abruptly screamed at someone. However, he denied any episodes of violence. He related poorly to authority. Although the Veteran reported three prior marriages, he described a positive relationship with his current spouse, as well as a good relationship with his children. He had been unemployed for approximately a year, reporting that he was discharged when he began using drugs and alcohol again, and became insubordinate. He stated that he spent his time exercising and looking to do odd jobs. He also reported being very active in a local motorcycle club, of which he was the president; collecting Native American and Harley-Davidson memorabilia; and shooting his gun. The Veteran was observed to be somewhat disheveled. His attitude was cooperative and attentive. His affect was normal and his mood good. The Veteran was unable to do serial 7s, but attention was otherwise intact. His memory function was also normal, although the Veteran did report having some difficulty remembering names. The Veteran was oriented to person, time, and place. Thought processes and content were unremarkable, with no evidence of delusions, hallucinations, or obsessive or ritualistic behavior. The Veteran denied suicidal or homicidal ideations. The Veteran's judgment and insight were normal. He was judged capable of maintaining minimal personal hygiene and competent to manage his affairs. He was diagnosed with PTSD, alcohol dependence in partial remission, amphetamine dependence in partial remission, and a personality disorder not otherwise specified with antisocial features. A GAF score of 55 was assigned. The examiner opined that the Veteran's disability most closely approximated the criteria for a 50 percent disability rating with reduced reliability and productivity due to PTSD symptoms, including hypervigilance, suspiciousness, agitation, restlessness, irritability, problems with authority, and easily provoked anger and aggression. In September 2009, the Veteran was afforded a psychiatric evaluation as part of his claim for benefits from the Social Security Administration (SSA). At that time, the Veteran reported problems with authority. He also described sleep difficulties, appetite loss with weight gain, fatigue, poor concentration, panic attacks in crowds, hypervigilance, irritability, an exaggerated startle response, distrust of others, a feeling of detachment and estrangement from others, and substance abuse. He denied depression; feelings of hopelessness, worthlessness, or guilt; suicidal ideation or attempts; obsessions; compulsions; hallucinations; or delusions. He reported that he had been prescribed Elavil, but did not like it, so he rarely took it. He reported a good relationship with his current spouse and good friendships with people in his biker club. He also stated that he watched television, listened to music, read the newspaper and books, surfed the internet, and played computer games for pleasure. He indicated that he did the shopping with his spouse, the laundry, the cooking, and managed his family's finances. The Veteran was described as cooperative, verbal, friendly, and engaged in the assessment process, although he did appear anxious. Although he dressed in stereotypical biker clothes and had long, uncombed hair, his clothing was clean and his grooming and hygiene were characterized as fair. The Veteran appeared to have good contact with reality. He was oriented to time, place, and person. His motor activity was normal. Memory and other cognitive processes were within normal limits. The Veteran was diagnosed with PTSD, Specific Phobia (being in crowds or around groups or strangers), amphetamine dependence in early partial remission, alcohol dependence in sustained partial remission, and nicotine dependence. A current GAF score of 53 was assigned. The examiner stated: I believe that [the Veteran] would have considerable difficulty working in any environment where he had to be around many strangers. If he was able to be in an environment where he could work by himself, I believe he could understand and follow simple instructions and perform simple routine tasks. He would have difficulty handling work pressure and stress. He would have difficulty effectively communicating with coworkers, customers, and especially supervisors. He has had a history of dependence with methamphetamines and alcohol. He reports using very little of either substance in the last year. I believed him, but ongoing urine testing would be required to confirm his abstinence from methamphetamines. He continues to have problems with his PTSD and anxiety even during his period of abstinence. SSA found the Veteran entitled to disability benefits on the basis of his PTSD effective July 2007 with consideration, however, of other factors including not only the severity of symptoms related to PTSD but also age, education, work experience and residual functional impairment. With all of these considerations, SSA found that there were no jobs that existed in significant numbers in the national economy that the Veteran could perform. SSA discounted the September 2009 state agency medical opinion because it found another opinion more consistent with the record as a whole; that evidence received at the hearing level showed that the Veteran was more limited than that determined by the state agency consultant; that the consultant did not adequately consider the Veteran's subjective complaints or combined effect of the Veteran's impairments; that the Veteran's residual functional impairment was extremely limited due to his mental state; and the Veteran was of advanced age. While the Board has considered the SSA evidence it, including the state agency consultant report, is but one factor for consideration in this case. In September 2012, the Veteran was afforded another VA examination. The Veteran continued to report restlessness and difficulty sleeping. He described occasional panic attacks in a crowded situations or following high stress events. Although he had problems with anger and irritability, he denied any violent behavior. To address his symptoms, the Veteran reported that he went for a motorcycle ride, exercised, or walked his dog. He continued to report a positive relationship with his spouse, and stated that he was close to his children, who he described as "the joys of my life." He also reported spending as much time as possible with his grandchildren. He reported that his social group was limited to fellow veterans and members of his motorcycle club. He reported difficulty getting along with strangers and people in authority. He admitted a period of increased substance abuse prior to a heart attack in 2011, but had reportedly been abstinent of all substances since. At the time of the evaluation, the Veteran was casually dressed and adequately groomed. He was cooperative and pleasant. He was alert and fully oriented, displaying no gross memory impairments, although he did have some mild difficulties with concentration. His mood and affect were subdued, but appropriate to content. He had some moderate psychomotor agitation. The Veteran's speech was normal in rate and tone, spontaneous, and goal directed. His thought processes were organized, with no evidence of formal thought disorder, hallucinations, delusions, mania, or obsessive compulsive features. The Veteran appeared to be of low-average intelligence, was capable of abstract thinking, and displayed fair insight into his PTSD symptoms. He denied suicidal or homicidal ideations. He had no problems performing activities of daily living. The examiner again characterized the severity of the Veteran's disability as most closely approximating a 50 percent disability rating due to "moderate" symptoms and assigned a GAF score of 50. The examiner noted that the Veteran's PTSD symptoms ...result in moderate to severe impairment of his functioning, with the Veteran having great difficulty tolerating many interactions, largely due to his difficulty with authority and limited frustration tolerance. However, the Veteran has a long history of employment success working in positions requiring minimal direct supervision, particularly night-shift work, and has no overtly aggressive or violent behavior in the workplace. He was last employed five years ago, with the position ending due to the Veteran's difficulties with a particular supervisor and a position in which he reportedly had a great deal of downtime resulting in increased anxiety and agitation. At the time of his last full time employment, the Veteran was also actively abusing methamphetamines, which could have contributed to his coping difficulties. The Veteran is now abstinent from all substances, but would still be best suited for an environment that allows him the autonomy to complete his work without the requirement of significant social interaction. In an October 2012 addendum, the examiner opined that the Veteran's alcohol dependence was more likely than not secondary to the Veteran's PTSD, with the Veteran using alcohol to self-medicate his symptoms of anxiety and insomnia. However, he also concluded that the Veteran's methamphetamine abuse is less likely than not secondary to the Veteran's PTSD. The examiner did note, however, that the Veteran's methamphetamine use "one episode of which reportedly coincided with his job loss, likely contributed greatly to his difficulties with agitation, frustration tolerance, and impulse control, given the highly stimulating properties of this substance." The examiner further noted that the Veteran is higher functioning and better able to manage his emotions and behaviors when not abusing methamphetamines. The examiner stated further that the extent of the Veteran's functional impairment attributable to his PTSD and as outlined at the September 2012 examination (consistent with a GAF of 50 and "occupational and social impairment with reduced reliability and productivity") were similar to those provided by his examiner at the 2008 examination with minimal change in overall functioning noted in the intervening years. The examiner noted further, that they take into account the secondary alcohol dependence and characterological impairment (i.e., antisocial traits) stemming from the Veteran's PTSD. The examiner noted that the Veteran's anxiety and depression symptoms impacted his ability to cope with major changes or significant downtime, and that the Veteran worked best in small groups or independently, and had difficulty tolerating certain work dynamics (e.g., working for a supervisor who is perceived to be unqualified). The examiner stated that while at times the Veteran struggled to manage his emotions, he displayed no propensity for violence or aggressive behavior in the workplace. The Veteran had maintained stable employment with the state for over 20 years, reported that he left in 1995 to run his own business, not due to conflicts or firing as a result of behavior issues. He returned to work with the state from 2003-2007 but reportedly had difficulty adapting to the change from nights to days, leading to the incident (i.e., leaving work in government vehicle to go to clubhouse) that led to his quitting/being fired from his job. The examiner concluded that while the Veteran's mood and behavioral impairment posed significant challenges with regard to employability, the Veteran did not demonstrate severe disability due to PTSD that would prevent employment in a setting similar to those in which he had been successful in the past. Finally, the Board has reviewed a series of quarterly summary reports on the Veteran's progress received from his Veteran Center psychologist ranging from July 2008 through September 2012. These records show that the Veteran has made progress in managing his disability, with a more stable affect, decreased anger, and a diminished tendency to rant. After receiving benefits from the Social Security Administration, the Veteran and his family were able to pay off their debts. The Veteran and his family also moved out of their low-income apartment to a house in a safer area, which reportedly helped decrease the Veteran's overall stress and provided him with an improved sense of security. The Veteran also purchased a dog for companionship. Based on the above evidence, 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, 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. Throughout the period on appeal, the Veteran's GAF scores have ranged from 50 to 55, indicating a generally moderate disability. Despite his PTSD symptoms, the Veteran continues to be capable of maintaining at least minimal personal hygiene and performing activities of daily living independently. He is able to communicate clearly and lucidly with others and manage his finances competently. His disability has not caused any recent legal problems. There is no evidence of impaired judgment or thought processes. Although he has some minor problems with attention and concentration, he has no serious memory or cognitive impairment. He has not reported suicidal or homicidal ideations and despite his anger and irritability, there is no evidence that he has become overtly aggressive or violent during the period on appeal. Additionally, the Veteran describes a close, positive relationship with his family, participation in social activities, engagement in a number of hobbies, and positive means of coping with his PTSD symptoms. Finally, although the Veteran's disability impairs his ability to get along with others, particularly authority figures, he was able to maintain gainful employment for more than thirty years and his termination coincided with a period of non-service related methamphetamine abuse that according to the medical evidence of record more likely than not exacerbated his agitation, irritability, and limited frustration tolerance and contributed to his termination. In sum, the Veteran's PTSD does not cause the severe, near total impairment contemplated by the criteria for a 70 percent disability. In light of the Veteran's assertions that his disability is not adequately compensated, the Board has also considered whether the Veteran's disability warrants referral for extraschedular consideration. To accord justice in an exceptional case where the schedular 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 PTSD 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, entitlement to an initial rating in excess of 50 for PTSD is denied. 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 (2012). The Duty to Notify and Assist 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). 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 Court 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 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 and records from the Social Security Administration. The Veteran has submitted private treatment records. VA examinations and/or opinions were obtained in February 2009, September 2012, and October 2012. These examinations/opinions 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 disability rating in excess of 50 percent for service-connected PTSD is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs