Citation Nr: 1329313 Decision Date: 09/12/13 Archive Date: 09/20/13 DOCKET NO. 04-36 064 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for postoperative coarctation of the aorta. 2. Entitlement to an evaluation in excess of 50 percent, prior to February 10, 2012, for posttraumatic stress disorder. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities, prior to February 10, 2012. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD W. Yates, Counsel INTRODUCTION The Veteran served on active duty from March 1969 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2004, January 2005, and September 2006 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In January 2009, the Board issued a decision which denied entitlement to an evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD), and remanded the other issues remaining on appeal for additional evidentiary development. The Veteran subsequently appealed the Board's decision concerning his PTSD to the United States Court of Appeals for Veterans Claims (Court). In September 2009, the Court granted a Joint Motion for Remand, remanding the case to back to the Board. In August 2010, the Board remanded this matter for additional evidentiary development. In a February 2012 rating decision, the RO awarded a 100 percent evaluation for the Veteran's PTSD, effective February 10, 2012. As the Veteran has been awarded the maximum benefit sought for his PTSD as of February 10, 2012, the Board will only consider whether the Veteran is entitled to an increased evaluation for his PTSD prior to that date. In addition, because a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is only available when "the schedular rating is less than total," the Board will only consider TDIU prior to the award of a 100 percent evaluation for PTSD, effective February 10, 2012. See 38 C.F.R. § 4.16(a) (2012). The issue of TDIU prior to February 10, 2012, is remanded to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. Prior to December 16, 2009, the Veteran's postoperative coarctation of the aorta was manifested by a estimated capability of 7 to 10 metabolic equivalents (METs), x-ray examination of the chest showing a normal cardiac silhouette, and no evidence of cardiac hypertrophy or dilation. 2. Beginning on December 16, 2009, the Veteran's postoperative coarctation of the aorta has been manifested by exercise stress test findings of 5.2 METs, echocardiogram findings of mild concentric left ventricular hypertrophy, and an ejection fraction greater than 55 percent. 3. Prior to February 10, 2012, the Veteran's service- connected PTSD was manifested by no more than occupational and social impairment with reduced reliability and productivity due to such symptoms as sleep disturbance, nightmares, intrusive memories, irritability, nervousness, anger, hypervigilance, exaggerated startle response, depressed affect, anxiety, depression, social isolation, avoidance of trauma-related stimuli, and poor concentration. The evidence of record also shows that the Veteran was alert and fully oriented, had fair to good grooming and hygiene, normal speech, clear and logical thought processes, and no homicidal ideation. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 10 percent for postoperative coarctation of the aorta, prior to December 16, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2012). 2. The criteria for an evaluation of 30 percent, but no more, for postoperative coarctation of the aorta, beginning on December 16, 2009, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2012). 3. The criteria for an evaluation in excess of 50 percent for PTSD, prior to February 10, 2012, 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 FINDINGS AND CONCLUSIONS With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. 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, 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This 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). The Veteran's regarding the evaluation for his postoperative coarctation of the aorta arises from his disagreement with the initial evaluation assigned to this disorder following the grant of service connection. Once service connection is granted, the claim is substantiated, additional notice is not required, and 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). As for his claim seeking an increased PTSD evaluation, the RO's November 2004, February 2006, and May 2008 letters advised him of VA's notice requirements. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (finding that the issuance of a fully compliant notification followed by readjudication of the claim, such as an statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). Specifically, the RO's letters informed the Veteran of what evidence was required to substantiate his claim for an increased evaluation for PTSD; and of his and VA's respective duties for obtaining evidence. The Veteran was also asked to submit evidence or information in his possession to the RO. Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims, including the opportunity to present pertinent evidence. Thus, the Board finds that the content requirements of the notice VA is to provide have been met. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's available service treatment records, as well as his identified VA and private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran was afforded VA examinations to ascertain the current severity of his service-connected postoperative coarctation of the aorta and PTSD. Most recently, in February 2012, the Veteran was scheduled for a VA examinations for heart disability and for PTSD. These examinations were performed by physicians that had reviewed the Veteran's claims file, treatment records, examined the Veteran, and included rationales for the conclusions reached therein. The Board therefore concludes that these examinations are adequate for evaluation purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Moreover, the Veteran has not claimed that either of these examinations was inadequate. In addition, prior VA examinations for the heart were conducted in November 2009, March 2009, July 2008, December 2004 and December 2003; and VA examinations for PTSD were conducted in March 2009, July 2008, and December 2004. Finally, there is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). In January 2009, August 2010 and September 2012, the Board remanded this matter for additional evidentiary development, including obtaining additional medical treatment records, scheduling the Veteran for a VA examination to ascertain the current severity of his service-connected postoperative coarctation of the aorta and PTSD, and clarifying whether the Veteran desired representation in this matter. A review of the claims files reveals that additional treatment records identified by the Veteran have been obtained, that the requested VA examinations were conducted, and that the Veteran provided with notice as to how to appoint a representative in this case. Accordingly, the directives of the Board's prior remands have been accomplished. See Stegall v. West, 11 Vet. App. 268 (1998). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). I. Increased Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). A. Postoperative Coarctation of the Aorta In September 2004, the RO issued a rating decision which granted service connection at a 10 percent disabling rating for postoperative coarctation of the aorta, under the provisions of 38 C.F.R. § 4.104, Diagnostic Code 7005, effective May 7, 2003. The Veteran timely appealed this decision seeking an increased initial evaluation. A 10 percent rating contemplates manifestations of the service-connected heart disorder that result in a workload of greater than 7 METs, but not greater than 10 METs, results in dyspnea, fatigue, angina, dizziness, or syncope, or; when continuous medication is required. 38 C.F.R. § 4.104, Diagnostic Code 7005. A 30 percent evaluation is warranted when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; where there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. Id. A 60 percent rating requires more than one episode of acute congestive heart failure in the past year; or when there is a workload of greater than 3 METs but not greater than 5 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. A 100 percent rating requires chronic congestive heart failure; or when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow, that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). In December 2003, a VA examination of the heart was conducted. The VA examiner noted that the Veteran's claims file had been reviewed. The Veteran reported that his legs were weak all the time, and that he had trouble when climbing ladders. Physical examination of the heart revealed a regular rhythm, no murmurs, and no apparent enlargement. The report noted that the Veteran's coarctation had been corrected satisfactorily with surgery. X-ray examination of the heart revealed an unremarkable cardiac silhouette. The report concluded with diagnoses of arterial hypertension, being treated, not controlled. The VA examiner noted that the coarctation of the aorta was a congenital developmental defect, and estimated that the Veteran's New York Heart Association (NYHA) functional classification was Class II, and that he was apparently able to exert 8 or more METs of activity. In December 2004, a second VA examination of the heart was conducted. The examination report noted that the Veteran was not currently receiving treatment for his postoperative coarctation of the aorta. Physical examination of the heart revealed a regular sinus rhythm, without murmurs, rubs, thrills, cardiomegaly, or gallop. There was also no evidence of congestive heart failure. The report noted that there was no limitation of activity secondary to the Veteran's heart condition, and provided an estimated METs level of 7 or better. The report concluded with a diagnosis of coarctation of the aorta, status postoperative surgery without residuals. In July 2008, a VA examination of the arteries was conducted. The VA examiner noted that the Veteran's claims file had been reviewed. The examination report noted that the Veteran was not currently receiving treatment for his postoperative coarctation of the aorta. It also noted that the Veteran was currently working part-time in the construction field, and that his aorta condition would not limit his ability to perform physical or sedentary employment. In March 2009, a VA general medical examination was conducted. The report noted that the Veteran's coarctation, status post repair, was a congenital deformity which was corrected completely by surgery. Physical examination of the heart revealed heart sounds present at S1 and S2, regular rhythm, and no murmur or click. The report listed a NYHA classification of heart disease of Class 1, and noted that no limitations to the heart were identified. It also noted an estimated METS level of greater than 10. In November 2009, a VA examination general examination was conducted. The VA examiner noted the Veteran's complaints of general fatigue, indigestion like chest pain, and left shoulder and arm pain during could weather. A cardiac examination revealed regular rhythm, absent murmur, and heart sounds present at S1 and S2. X-ray examination of the chest revealed no negative heart findings. The report concluded with a diagnosis of postoperative coarctation of aorta with residual loss of left sided rib and scar. The report noted that he was able to walk around the block. The VA examiner provided an estimated METs level of 7 to 8 based on observation, and noted that there would be no specific limitation in sedentary labor, except that repetitive use of the left arm for reaching would be difficult. On December 16, 2009, the Veteran underwent a VA exercise stress test. The report of this examination revealed a METs level finding of 5.2. A VA echocardiogram, performed on the same day, revealed findings of mild concentric hypertrophy. The report concluded with findings of a normal global left ventricle (LV) systolic function, and mild concentric left ventricular hypertrophy, and an ejection fraction greater than 55 percent. In February 2012, a VA examination of the heart was conducted. The VA examiner noted that the Veteran's claims file had been reviewed. The report noted the Veteran's complaints of chest wall pain, and his history of smoking one to two packs of cigarettes daily since 1969. Physical examination of the heart revealed sounds present as S1 and S2, with no murmurs, gallops, or rubs. The report concluded with a diagnosis of coarctation of aorta, congenital disease, and no heart disorder associated with coarctation of aorta. The VA examiner further noted that there was no current heart disability except for hypertensive heart disease, that coarctation of the aorta was not a heart disability, and the Veteran's coarctation of the aorta had been treated and he only had residual scarring remaining. The examiner also noted that this disorder would not limit the Veteran's ability to perform physical and or sedentary employment. In April 2013, a VA general medical examination was conducted. A cardiovascular examination revealed no murmurs, gallops or rubs, with a normal heart rate and rhythm. The report concluded with diagnoses of hypertensive heart disease and coarctation of the aorta, surgically repaired. A May 2013 addendum to the examination noted the VA examiner's opinion that it was "more likely than not" that the Veteran's heart had been damaged by past hypertension manifested by a large left ventricle diagnostically found on VA echosonography. i. Prior to December 16, 2009 Prior to December 16, 2009, the Veteran's postoperative coarctation of the aorta was manifested by a estimated workload ranging from 7 to 10 METSs, x-ray examination showing a normal cardiac silhouette, and no evidence of cardiac hypertrophy or dilation. These findings do not support an evaluation in excess of the currently assigned 10 percent. Prior to December 16, 2009, a higher rating is not warranted under Diagnostic Code 7005 as there is no evidence of record that this disorder was manifested by a workload of less than 7 METs, nor is there evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or x-ray. Accordingly, prior to December 16, 2009, manifestations of the Veteran's service-connected postoperative coarctation of the aorta was not shown to meet the requirements for a rating in excess of 10 percent under Diagnostic Code 7005. See generally, Meeks v. West, 216 F.3d 1363 (Fed. Cir. 2000); see also Hazan v. Gober, 10 Vet. App. 511, 519 (1997). ii. Beginning December 16, 2009 Beginning on December 16, 2009, the Veteran's postoperative coarctation of the aorta has been manifested by exercise stress test findings of 5.2 METs, echocardiogram findings of mild concentric left ventricular hypertrophy, and an ejection fraction greater than 55 percent. These findings warrant an increased evaluation of 30 percent, but no more, for the Veteran's postoperative coarctation of the aorta, effective December 16, 2009. Beginning on December 16, 2009, a higher rating is not warranted under Diagnostic Code 7005 as there is no evidence of record that this disorder was manifested by any episodes of acute congestive heart failure, workload of greater than 3 METs but not greater than 5 METs, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. iii. Other Considerations Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2009). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of a Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria under the Rating Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is adequate, and no referral is required. In this case, the Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the evaluations assigned herein for his service-connected heart disorder inadequate. Prior to December 16, 2009, the Veteran's postoperative coarctation of the aorta was manifested by a estimated capability of 7 to 10 METs, x-ray examination of the chest showing a normal cardiac silhouette, and no evidence of cardiac hypertrophy or dilation. Beginning on December 16, 2009, the Veteran's postoperative coarctation of the aorta has been manifested by exercise stress test findings of 5.2 METs, echocardiogram findings of mild concentric left ventricular hypertrophy, and an ejection fraction greater than 55 percent. The Veteran's postoperative coarctation of the aorta is evaluated pursuant to Diagnostic Code 7005, the criteria of which is found by the Board to specifically contemplate the levels of disability and symptomatology exhibited by the Veteran's disability, both before and after December 16, 2009. Ratings in excess thereof are provided for certain manifestations of the service-connected heart disorder, but the medical evidence of record does not demonstrate that such manifestations were present in this case. Therefore, the currently assigned staged schedular evaluations are adequate and no referral is required. In reaching this conclusion, the Board has given full consideration to the Veteran's complaints chest pain and fatigue. Despite these complaints, the facts found throughout the course of this appeal do not warrant a higher rating than those currently assigned. Specifically, the rating criteria at issue herein requires a determination based on medical evaluation. 38 C.F.R. § 4.104. Finally, in reaching this decision the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent prior to December 16, 2009, and in excess of 30 percent since December 16, 2009, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Fenderson v. West, 12 Vet. App. 119, 126 (1999). B. PTSD By an October 2003 rating decision, the RO granted service connection for PTSD and assigned a 50 percent evaluation under 38 C.F.R. § 4.130, Diagnostic Code 9411, effective May 7, 2003. In October 2004, the Veteran filed a claim for an increased evaluation for his service-connected PTSD. By a January 2005 rating decision, the RO denied the Veteran's claim for an increased evaluation. In February 2005, the Veteran filed a notice of disagreement with regard to the January 2005 rating decision, and in December 2006, he perfected his appeal. A 50 percent evaluation for PTSD is warranted where there is 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; impaired judgment; impaired abstract thinking; disturbance 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 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; inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. 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; memory loss for names of close relatives, own occupation, or own name. Id. In December 2004, the Veteran underwent a VA examination for PTSD. The examination report noted the Veteran's complaints of sleep disturbance, nightmares up to four times per week, anxiety, panic, confusion, exaggerated startle response, hypervigilance, nervousness, trouble working with others, irritability, anger, intrusive memories, depression, significant loss of energy and interest, poor concentration, and social isolation. The Veteran reported that he was bothered by crowds and that he had no friends. He indicated that he did "odd jobs" and that his symptoms kept him from having a regular job. He reported that he was living with his wife and daughter and that his daily activities included yard work and house projects. He stated that he did not socialize or go out, that he occasionally went fishing alone, and that he was very isolated due to his anxiety and depression. Mental status examination revealed the Veteran to be neatly groomed and dressed with normal behavior. The VA examiner noted that the Veteran did not exaggerate his symptoms, and that he probably minimized some of them. The Veteran communicated well and his speech was spontaneous and logical, and was not pressured. There were no flight of ideas, loose associations, hallucinations, delusions, or paranoia. There was no suicidal or homicidal ideation. The Veteran's affect was depressed with psychomotor retardation, and he was very anxious. He was also suspicious and uncomfortable. The Veteran was alert and fully oriented, had good judgment, poor insight, and average intelligence. The diagnosis was PTSD, and a GAF score of 45 was assigned. In July 2008, the Veteran underwent another VA PTSD examination. He complained of irritability, difficulty getting along with others, difficulty sleeping, nightmares, intrusive thoughts, short temper, hypervigilance, anxiety, and exaggerated startle response. He reported that he avoided crowds. He also stated that he had been self- employed his entire life and worked in the construction and remodeling industry, but noted that he was hardly working currently. He indicated that he lived with his wife, had a few friends, liked to fish, was close to his daughter, and that he did chores around the house. Mental status examination revealed the Veteran to be alert and fully oriented, and casually and appropriately dressed. There were no loose associations or flights of ideas. There were no bizarre motor movements or tics. The Veteran's mood was tense but cooperative and friendly. His affect was appropriate, and he denied suicidal or homicidal ideation. There was no impairment of thought process or communication, and there were no delusions or hallucinations. The Veteran's memory, insight and judgment were adequate, and his intellect was average. The report listed a diagnosis of PTSD, and a GAF score of 50 was assigned. The VA examiner noted that the Veteran rarely did any work as a result of a combination of physical and psychiatric symptoms. The VA examiner concluded that the Veteran's psychiatric symptoms "result in significant impairment and would make employment, either sedentary or active, quite problematic." During his October 2008 hearing before the Board, the Veteran testified that he had difficulty sleeping, difficulty getting along with others, difficulty relating to his family, frequent panic attacks, depression, and interference with the ability to function properly. He reported neglecting his personal hygiene, violent outbursts, and thoughts of suicide. He also noted social isolation. He indicated that he had been married for 32 years and got along with his wife and daughter. His hobbies included hunting and fishing, and he occasionally went out to dinner. He reported that he did not have many friends and that he was not employed. In March 2009, a VA examination for PTSD was conducted. The VA examiner noted that the Veteran's claims file had been reviewed. The Veteran reported complaints of nervousness, sleep disturbance, nightmares three to four times per week, intrusive thoughts, anxiousness, short temper, and hypervigilance. Mental status examination revealed the Veteran to be appropriately dressed, alert, cooperative, with no loosened associations or flight of ideas, no bizarre motor movements or tics. The report described his mood as a bit tense, but cooperative and friendly. It also noted that his affect was appropriate, with complaints of nightmares and intrusive thoughts, but no homicidal or suicidal ideation or intent, no delusions or hallucinations, and no impairment of thought processes or communications. It noted that he was adequately oriented, with adequate remote and recent memory, insight, judgment, and intellectual capacity. The report concluded with a diagnosis of PTSD, and listed a GAF score of 50. The VA examiner noted that the Veteran had moderate to severe and persistent symptoms of PTSD with no remissions. The VA examiner noted that the Veteran was anxious, irritable, stayed to himself, had few friends, and limited interests. The examiner opined that the Veteran's psychiatric symptoms resulted in moderate to severe impairment of employment and social functioning, and that his psychiatric symptoms of getting along with others, anxiety and temper would result in significant impairment, and would make employment, sedentary or active, quite problematic. GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter, 8 Vet. App. at 242. The Veteran's GAF scores ranging from 45 to 50 indicate serious symptoms or any serious impairment in social, occupational, or school functioning. See DSM-IV at 46-47. While the Board has considered the degree of functioning as evidenced by this reported range of GAF scores, it is but one factor for consideration in assigning a disability rating. See Brambly v. Principi, 17 Vet. App. 20, 26 (2003). The Veteran reported depression, anxiety, hypervigilance, sleep disturbance, irritability, exaggerated startle response, social isolation, nightmares, intrusive memories, panic, irritability, hypervigilance, and concentration difficulties. He also reported avoidance of trauma-related stimuli, avoidance of crowds, and short temper. During the October 2008 Board hearing, the Veteran reported family relation problems, frequent panic attacks, neglect of his personal hygiene, violent outbursts, and thoughts of suicide. The medical evidence showed that the Veteran was regularly cooperative, alert and fully oriented, had no impairment of thought process or communication, had no memory impairment, had no flight of ideas or loose associations, had no hallucinations or delusions, had normal speech, normal eye contact, fair to good hygiene, and good judgment. The Veteran denied any homicidal or suicidal ideations. The medical evidence also showed that the Veteran was depressed and tense, had a depressed affect with psychomotor retardation, and poor insight. The Veteran was self- employed his entire life in the construction and remodeling industry, and noted difficulty getting along with others. The Veteran is married and had a good relationship with his daughter. There is no evidence of the type of symptoms associated with a higher rating of 70 percent, such as 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, or 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 the inability to establish and maintain effective relationships. While the Veteran is shown to have had difficulty in establishing and maintaining effective work and social relationships, this level of impairment is contemplated by the currently assigned rating of 50 percent prior to February 10, 2012. Although the Veteran has been inconsistent in reporting his employment history, the available evidence indicates that he was working at least part time for most of appeal period being considered. On his December 2005 TDIU claim, he reported having been self employed in construction since 1971, and that he was currently working 20 hours per week, earning $600 per month. An April 2006 VA treatment report noted that the Veteran "exercised regularly-mainly with work-construction." A July 2008 VA examination of the arteries noted that the Veteran was currently working part-time in the construction field. On a work history report filed with the Social Security Administration, he reported working 5 days a week, 8 hours a day, earning $2,000 per month, up until August 31, 2008. On his March 2009 VA examination for PTSD, he reported having given up part-time construction work in 2009. Socially, the evidence of record indicates that the Veteran has relationships with his spouse, child, and a few friends. In addition, some level of social interaction had to have taken place for to have remained self employed, even on a part time basis, throughout this appeal period. Thus, while he had difficult in establishing and maintaining work and social relationships, it did not rise to the level of an inability to establish and maintain effective relationships. While the Board acknowledges the Veteran had significant symptoms from his PTSD, prior to February 10, 2102, these symptoms are clearly contemplated by the assigned 50 percent disability rating. Consideration has been given to assigning a staged rating. While the evidence does show some fluctuations in the severity of this condition, at no time prior to February 10, 2102, is a higher rating shown to be warranted. Accordingly, the Board has concluded that a higher rating is not in order for any portion of the period on appeal. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered whether this claim should be referred to the Director of the Compensation and Pension Service for extra-schedular consideration. When comparing the disability picture of the Veteran's PTSD with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the 50 percent disability rating. Prior to February 10, 2012, the Veteran's service-connected PTSD was manifested by no more than occupational and social impairment with reduced reliability and productivity due to such symptoms as sleep disturbance, nightmares, intrusive memories, irritability, nervousness, anger, hypervigilance, exaggerated startle response, depressed affect, anxiety, depression, social isolation, avoidance of trauma-related stimuli, and poor concentration. The evidence of record also shows that the Veteran was alert and fully oriented, had fair to good grooming and hygiene, normal speech, clear and logical thought processes, and no homicidal ideation. Ratings in excess of the 50 percent currently assigned are provided for certain manifestations of the service-connected PTSD, but the evidence of record does not demonstrate that such manifestations have been present in this case. The criteria for the assigned 50 percent rating reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluation is adequate and no referral is required. With consideration of the entire record, the Board finds that the evidence does not show that the Veteran's PTSD meets the criteria for the next higher disability rating of 70 percent. 38 C.F.R. § 4.130, Diagnostic Code 9411; Mauerhan v. Principi, 16 Vet. App. 436 (2002). In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert, 1 Vet. App. at 54. ORDER An initial evaluation in excess of 10 percent for postoperative coarctation of the aorta, prior to December 16, 2009, is denied. An evaluation of 30 percent, but no more, for postoperative coarctation of the aorta, beginning on December 16, 2009, is granted, subject to the laws and regulations governing the payment of monetary benefits. An evaluation in excess of 50 percent for PTSD, prior to February 10, 2012, is denied. REMAND TDIU is warranted when a Veteran's service-connected disability or disabilities result in impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. In determining whether a TDIU is warranted, consideration may be given to a Veteran's level of education, special training and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2012). TDIU is assigned when the combined schedular rating for the service-connected disabilities is less than 100 percent and when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, this disability is ratable at 60 percent or more, or, if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16. The Board's decision above has granted an increased evaluation of 30 percent for the Veteran's postoperative coarctation of the aorta, effective December 16, 2009. Consequently, the Veteran now meets the scheduler percentage criteria for obtaining a TDIU. 38 C.F.R. §§ 3.340, 3.341, 4.16. This represents a material change to the facts relating to the issue of TDIU. See 38 C.F.R. § 19.31 (2012); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that when a determination on one issue could have a significant impact on the outcome of another issue, such issues are considered inextricably intertwined and VA is required to decide those issues together). Accordingly, remand is required for RO consideration of the issue of TDIU, including consideration of the Board's decision herein. Accordingly, the case is remanded for the following action: After implementing the Board's decision above, readjudicate the issue of TDIU, prior to February 10, 2012. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs