Citation Nr: 1329363 Decision Date: 09/13/13 Archive Date: 09/20/13 DOCKET NO. 09-14 523 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for post-traumatic stress disorder (PTSD) with secondary major depressive disorder. 2. Entitlement to an initial, compensable disability rating for asbestos-related pleural disease with pleural nodules. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from December 1950 to October 1954. These matters come to the Board of Veterans' Appeals (Board) on appeal from a January 2007 decision of the RO that denied a disability rating in excess of 50 percent for service- connected PTSD with secondary major depressive disorder; and from a June 2010 decision of the RO that granted service connection for asbestos-related pleural disease with pleural nodules evaluated as 0 percent (noncompensable) disabling effective February 3, 2009. The Veteran timely appealed for higher disability ratings. In June 2013, the Veteran testified during a hearing before the undersigned at the RO. The Court has recently held that a request for a TDIU, whether expressly raised by the Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Board notes that the Veteran's original claim for TDIU was denied in March 2005 on the basis that the evidence did not show that the Veteran was unable to work because of service- connected disabilities. While the Veteran has indicated that he became too disabled to work in 1971, there is no showing that his service-connected disabilities prevent him from obtaining or maintaining substantially gainful employment. The RO again denied the Veteran's claim for entitlement to TDIU benefits in April 2013; and, to date, the Veteran has not appealed the decision. Under these circumstances, the matter has been addressed by the RO, and the Board finds it unnecessary to remand the matter for further action. Lastly, in addition to reviewing the Veteran's paper claims file, the Board has surveyed the contents of his Virtual VA file. 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). FINDINGS OF FACT 1. The Veteran's PTSD with major depressive disorder is manifested by symptoms such as anxiety, depression, flat affect, sleep impairment, irritability, concentration problems, startle response, short-term memory problems, and isolation-all resulting in moderate social and occupational impairment. 2. Throughout the course of the rating period on appeal, pulmonary function testing revealed diffusion capacity of the lung for carbon monoxide (DLCO) between 56- to 65- percent of predicted, and forced vital capacity (FVC) between 65 and 74-percent of predicted; the Veteran does not have cor pulmonale or pulmonary hypertension, or require outpatient oxygen therapy. CONCLUSIONS OF LAW 1. The criteria for a disability rating greater than 50 percent for PTSD with major depressive disorder are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2012). 2. Throughout the course of the rating action on appeal, the criteria for an initial 30 percent disability rating, but no higher, for asbestos-related pleural disease with pleural nodules have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.20, 4.27, 4.7, 4.97, Diagnostic Code 6833 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist 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, 3.326(a) (2012). VA should notify the Veteran of: (1) the evidence that is needed to substantiate the claim(s); (2) the evidence, if any, to be obtained by VA; and (3) the evidence, if any, to be provided by the claimant. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (codified at 38 C.F.R. Part 3). The Veteran's claim for a higher initial rating arises from his disagreement with the initial evaluation assigned, following the grant of service connection for asbestos- related pleural disease with pleural nodules. Courts have held that 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). Moreover, a decision by the United States Court of Appeals for the Federal Circuit has addressed the amount of notice required for increased rating claims, essentially stating that general notice is adequate and notice need not be tailored to each specific Veteran's case. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Through a July 2006 letter, the RO notified the Veteran of elements of an increased rating claim and the evidence needed to establish each element. This document served to provide notice of the information and evidence needed to substantiate the claim for an increased rating for PTSD. In the July 2006 letter, the RO specifically notified the Veteran of the process by which initial disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Defects as to the timeliness of the statutory and regulatory notice are rendered moot because each the Veteran's claims decided on appeal has been fully developed and re- adjudicated by an agency of original jurisdiction after notice was provided. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). There is no indication that any additional action is needed to comply with the duty to assist the Veteran. The RO has obtained copies of the service treatment records and outpatient treatment records, and has arranged for VA examinations in connection with the claims on appeal, reports of which are of record and are adequate for rating purposes. The Veteran has not identified, and the record does not otherwise indicate, any existing pertinent evidence that has not been obtained. A January 2013 notice from the Social Security Administration reflects that the Veteran's medical records have been destroyed and are no longer available. The Veteran indicated that he had been awarded Social Security disability long ago for a non-service-connected disability, and specifically waived any due process concern pertaining to those records. In Bryant v. Shinseki, 23 Vet App 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that the Veterans Law Judge who chairs a Board hearing fulfill two duties to comply with 38 C.F.R. § 3.103(c)(2). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. Here, during the hearing, the Veterans Law Judge sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked, or was outstanding that might substantiate the claims. It was suggested that any evidence tending to show a worsening in severity of current symptoms would be helpful in substantiating the claims for higher disability ratings. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2); and no prejudice has been identified in the conduct of the Board hearing. Given these facts, it appears that all available records have been obtained. There is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claims. 38 U.S.C.A. § 5103A(a)(2). II. Analysis Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making disability evaluations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of PTSD and lung disease. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. The Board will consider not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. A. PTSD with Secondary Major Depressive Disorder The Veteran's service-connected PTSD with major depressive disorder has been evaluated as 50 percent disability rating under 38 C.F.R. § 4.130, Diagnostic Code 9411, pertaining to anxiety disorders. The actual criteria for rating psychiatric disabilities other than eating disorders are contained in a General Rating Formula. Under that formula, a 50 percent rating is assigned when 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 (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. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. In a case such as this, in which, given the nature of the symptoms, there is likely some overlap, and no physician has indicated that it is possible to separate the symptoms and effects of the Veteran's anxiety disorder from his mood disorder, the Board has attributed all of the Veteran's symptoms to the service-connected PTSD with major depressive disorder. See, e.g., Mittleider v. West, 11 Vet. App. 181, 183 (1998). In this regard, the Board notes that awarding separate disability ratings under both Diagnostic Code 9411 for PTSD and under Diagnostic Code 9433 for a major depressive disorder would clearly violate the anti- pyramiding provisions of 38 C.F.R. § 4.14 (2012). In essence, all anxiety disorders and mood disorders, regardless of the nomenclature employed, are evaluated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130 (2012). VA treatment records, dated in June 2006, show that the Veteran was neatly dressed in casual clothing and well groomed. A VA physician noted that the Veteran's mood and affect were moderately depressed and anxious; and that his speech was monotone, but with fair spontaneous production than at last visit. The Veteran's thought process was found to be vague and preservative, and his thought content was centered on a number of stressors and health concerns and depressive themes. The Veteran did not report suicidal or homicidal or psychotic ideation. Assessments included PTSD and major depression, with symptoms recently worsened due to Memorial Day, world events, and health stressors. During a VA examination in August 2006, the Veteran reported "I just blow up for no reason at all; I don't know what is going on." He had to be taken out of a senior center on Mexican Day. Current symptoms included nightmares, waking up in a cold sweat, sleeping three-to-four hours nightly, and walking the floor quite a bit at night. The Veteran reported that his wife watched the Iraqi news, which made him mad. He became irritable and had anger outbursts, both of which the examiner noted had worsened since last evaluated. The Veteran reportedly tried to go places with his wife, go to the senior center and play cards, and go for a ride with a friend who delivered meals to seniors. His interest in pleasurable things was the same as when last evaluated. The Veteran reported that he did not feel depressed in the last year and a half. He reportedly isolated himself, which his wife referred to as his depression. The Veteran reportedly preferred to keep to himself to avoid arguing and fighting. His concentration and energy level were about the same as when last evaluated. The Veteran reported poor sleep, and reported no suicidal ideation. He reported that his relationship with his wife was good and he could not understand how she put up with him. He had no friends in the area, and did not like talking on the phone. Examination in August 2006 revealed that the Veteran was oriented to person and time, but was not sure as to where he was for the evaluation, and was not sure about the reason for the evaluation. He was casually dressed and used a cane to help him walk. The Veteran was cooperative throughout the evaluation. His affect was appropriate to material discussed, and his mood was reported to be normal. The Veteran was deemed to have a normal thought process. He did not report nor appear to have hallucinations or delusions. His concentration level was average to above-average; his short-term memory was also average to above-average, and he denied suicidal ideation. The August 2006 VA examiner found that the Veteran's PTSD was mild to moderate, and that depression symptoms were reported. The examiner also indicated that the Veteran's PTSD symptoms seemed to be elevated from his last evaluation, and that his depression symptoms seemed to be improved. A Global assessment of functioning (GAF) score of 61 was assigned. In August 2007, the Veteran's VA treating psychiatrist reported that the Veteran had undergone cognitive and behavioral therapy, supportive therapy, and many anti- depressant trials; and that he continued to be quite symptomatic. The psychiatrist also indicated that the Veteran's symptoms have accelerated significantly in frequent years due to worsening health and the war in Iraq. Current symptoms included daily disturbing memories and nightmares, flashbacks, disturbance of mood when reminded of war experiences, loss of interest in usual activities, feeling distant and cut off from other people, feeling emotionally numb, having trouble falling and staying asleep nightly, frequently being irritable and angry, and having difficulty concentrating. The psychiatrist also indicated that the Veteran had become very reclusive and difficult to live with because of his PTSD symptoms. His depression symptoms also have worsened significantly and were unresponsive to medication. The report of an April 2008 VA examination reflects that the Veteran's wife talked at length about the Veteran's increasing irritability towards her, and towards others. He criticized what she did around the house, and he became angry with various stores and agencies. She reported that the Veteran was asked to leave the senior center due to his irritability and criticism of foreign people. She reported that they did see some friends about once a week, although the Veteran at times withdrew to the bedroom. The Veteran reported having depression symptoms "on and off" in April 2008, and denied any suicidal ideation or any difficulties with his appetite. Mental status examination in April 2008 revealed that the Veteran was somewhat tangential to the topic at hand, and that his quality of speech was clear in articulation; he was easily understandable. He was correctly oriented to person, place, time, and purpose. There were no signs of major psychopathology such as hallucinations, delusions, or preoccupations. His affect was slightly agitated and mood was irritable. He denied feeling depressed. Attention, concentration, and short-term memory were grossly intact. The Veteran showed some difficulties with remote memory. He provided concrete interpretation of proverbs. His relationship with the examiner was cooperative, yet somewhat distant. The April 2008 examiner found that the Veteran's PTSD may have slightly worsened since last examined in August 2006, and that his depression had remained about the same. The Veteran reported sporadic, low level depression. A GAF score of 58 was assigned. VA treatment records, dated in December 2008, show that the Veteran had completed PTSD classes but had been reluctant to attend Vet Center counseling services due to lack of comfort in group settings. The interventions that he had found most helpful have been the use of light therapy and intermittent supportive counseling sessions. A GAF score of 55 was assigned. The report of an October 2011 VA examination reflects that the Veteran is socially isolated and that he avoids family gatherings. He also complained of irritability and spent his time watching television. Current symptoms, which were noted as occurring frequently, included depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; and impaired impulse control, with unprovoked irritability. Following psychological examination, the Axis I diagnosis was PTSD with associated depression. A GAF score of 55 was assigned. VA treatment records show that the Veteran reported problems with anxiety and nervousness in July 2012. Clinical evaluation in December 2012 show that the Veteran was alert, friendly, cooperative, and fully oriented. His mood was euthymic. There were no signs of suicidal ideation or homicidal ideation. Thought processes were linear and goal- directed. Thought content was without paranoia or suspiciousness. The Veteran was focused on helping his elderly wife. Formal cognitive testing was not performed. Records show that the Veteran was to undergo clinical psychotherapy and anxiety management. In June 2013, the Veteran testified as to the severity of the in-service stressors that lead to his PTSD, how it has affected his view of others, especially children, the fact that he remains in bed most of the time because of his inability to walkd, and that he generally went into his bedroom whenever company came to his house. While the GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" (DSM-IV), the assigned GAF score in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, it must be considered in light of the actual symptoms of the Veteran's disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). Here, the GAF scores assigned have ranged from 55 to 61. These GAF scores (51-60, primarily) indicate moderate symptoms of PTSD with depression (e.g., flat affect and circumstantial speech, occasional panic attacks); and are indicative of moderate difficulty in social and occupational functioning (e.g., few friends, unable to keep a job). In this case, the Veteran's manifestations include anxiety, depression, flat affect, sleep impairment, irritability, concentration problems, startle response, short-term memory problems, disturbances of mood and motivation, and isolation. However, the Veteran does not express suicidal ideation, display obsessional rituals which interfere with routine activities, exhibit illogical or obscure or irrelevant speech, or exhibit neglect for personal appearance or hygiene. The Board acknowledges that a Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court noted in Mauerhan, without the examples provided in the rating criteria, differentiating a 50 percent evaluation from a 70 percent evaluation would be extremely ambiguous. Specifically, the Board is to consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified with assigned GAF scores. If the evidence demonstrates that a Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the General Rating Formula, the appropriate equivalent rating should be assigned. Id. Here, the Board concludes that the Veteran's PTSD with major depressive disorder does not cause occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, as necessary to warrant a 70 percent rating. Nor does the Veteran exhibit total occupational and social impairment as contemplated for a 100 percent rating. With respect to the Veteran's occupational functioning and impairment, the Board observes that the Veteran retired from working in the mid-1970's due to a head injury. The October 2011 examiner found that the Veteran's PTSD with depression symptoms would cause moderate vocational effects by rendering the Veteran irritable and short-tempered with co- workers and bosses; and indicated that the Veteran could work in loosely supervised settings with few others around. Under these circumstances, the Board finds that the Veteran does not have deficiencies in work functioning as contemplated for a 70 percent rating or total occupational impairment as contemplated for a 100 percent rating. In this regard, the Board notes that the 50 percent rating currently assigned is in recognition of significant industrial impairment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). As to the Veteran's social functioning and impairment, the Board observes that he prefers not to socially interact and reported being "socially isolated" in general, and is easily irritated when interacting with others. As the Veteran socializes infrequently, he still retains the ability to socialize in public. For example, he has reported seeing visitors to his home infrequently and running errands occasionally. The Board acknowledges that both private physicians and VA examiners have opined that the Veteran is moderately compromised in his ability to sustain social relationships. The Board certainly is sympathetic to the social difficulties experienced by the Veteran and his family as a result of his PTSD with major depressive disorder symptoms; however, the Veteran does retain the ability to function in both the home and his community. As such, while the Veteran may have significant social impairment due to his PTSD with major depressive disorder, the Board finds that based on the lay and medical evidence of record he does not have deficiencies in social functioning as contemplated for a 70 percent rating or total social impairment as contemplated for a 100 percent rating. In summary, the Veteran does not have deficiencies in social or occupational functioning as contemplated for a 70 percent rating or total social and occupational impairment as contemplated for a 100 percent rating. He does have deficiencies in these areas, but greater weight of the evidence demonstrates that it is to a degree as contemplated by the 50 percent rating currently assigned. Furthermore, even resolving any reasonable doubt in the Veteran's favor, the Board finds that he does not meet the requirements for an evaluation greater than the current 50 percent schedular rating. His overall level of disability is equivalent to moderate impairment in social and occupational functioning. Here, the assigned GAF scores do not support an increased rating, even if taken alone; and the actual reported symptoms and manifestations repeatedly noted in the record are commensurate with the degree of social and industrial impairment required for the assignment of the current 50 percent disability evaluation. The Veteran's speech is neither illogical, nor obscure, nor irrelevant. He is not in a near-continuous state of depression. He can function independently, and he does not experience hallucinations. Although he exhibits some impairment in attention and concentration, his thought process and communication is overall logical and coherent. He does not exhibit inappropriate behavior. His personal hygiene is appropriate. He does have moderate social impairment, but he has maintained relationships with some family members. Again, in determining that a rating in excess of 50 percent is not warranted, the Board has considered the Veteran's complaints regardless of whether they are listed in the rating criteria, but concludes that the Veteran's level of social and occupational impairment does not warrant a rating in excess of the currently assigned 50 percent disability rating. Here, the preponderance of the evidence is against granting an increased rating for the Veteran's PTSD with major depressive disorder, and thus, the benefit-of-the- doubt rule does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). B. Asbestos-Related Pleural Disease with Pleural Nodules Service connection has been established for asbestos-related pleural disease with pleural nodules. The RO evaluated the Veteran's disability as asbestosis under a General Rating Formula for interstitial lung disease, and assigned an initial 0 percent (noncompensable) disability rating based on findings of "normal" diffusing capacity. See 38 C.F.R. § 4.97, Diagnostic Code 6899-6833. A hyphenated diagnostic code generally reflects a rating by analogy (see 38 C.F.R. §§ 4.20 and 4.27). Historically, the Veteran was exposed to asbestos aboard a Navy ship in active service. Records show that he slept under asbestos-covered pipes. The Veteran also reported no tobacco history, and that he first developed left-sided chest pain in 1993 and dyspnea in 1994. Chest X-rays then revealed questionable pleural thickening. Examination in March 1995 revealed no evidence of pulmonary pathology. Further diagnostic testing in January 1998 did not reveal clear evidence of asbestos-induced interstitial lung disease; total lung capacity was normal at the time. Private treatment records, dated in March 2000, show that the Veteran's symptoms were complex and nonspecific; and that his previous evaluation was negative for evidence of asbestosis. Procedural Matters In a May 2008 decision, the Board concluded that new and material evidence had not been submitted to reopen a previously denied claim for service connection for a lung disability, claimed as secondary to asbestos exposure. This decision subsumed a September 2003 rating decision, which had denied the Veteran's April 2003 petition to reopen the claim. Upon further review, additional evidence that had been submitted untimely to the Board in July 2007 was not accepted for consideration by the Board as part of the May 2008 decision, pursuant to provisions of 38 C.F.R. § 20.1304(b). Those records appear to have included an October 2006 petition by the Veteran to reopen a claim for service connection for asbestosis. The RO reopened the claim in September 2009, but denied it on the merits. The Veteran submitted additional evidence the next month, and the RO again denied the Veteran's claim in October 2009. A notice of disagreement was filed by the Veteran in November 2009, which subsequently led to the grant of service connection for asbestos-related pleural disease with pleural nodules by a Decision Review Officer in June 2010. The Veteran now appeals for a higher initial rating. In situations where the Board denied a benefit sought in the pending appeal, and any evidence so referred which was received prior to the date of the Board's decision, together with evidence already of record, is subsequently found to be the basis of an allowance of that benefit, the effective date of the award will be the same as if the benefit had been granted by the Board as a result of the appeal which was pending at the time that the additional evidence was received. 38 C.F.R. § 20.1304(b)(i). Rating Criteria Under the General Rating Formula for interstitial lung disease, a 10 percent rating is warranted for a forced vital capacity (FVC) of 75- to 80-percent predicted, or a diffusion capacity of the lung for carbon monoxide by the single breath method (DLCO (SB)) of 66- to 80-percent predicted. A 30 percent rating requires a FVC of 65- to 74- percent predicted, or a DLCO (SB) of 56- to 65-percent predicted. A 60 percent rating requires a FVC of 50- to 64- percent predicted, or a DLCO (SB) of 40- to 55-percent predicted, or maximum exercise capacity of 15 to 20 ml/kg/min oxygen consumption with cardio respiratory limitation. A 100 percent rating requires a FVC of less than 50-percent predicted, or a DLCO (SB) less than 40- percent predicted, or maximum exercise capacity less than 15 ml/kg/min oxygen consumption with cardio respiratory limitation, or cor pulmonale or pulmonary hypertension, or requires outpatient oxygen therapy. 38 C.F.R. § 4.97, Diagnostic Code 6833. Facts and Analysis Pulmonary function testing in April 2002 had primarily shown that overall ventilator function was normal. However, the DLCO result at that time fell within the range required for a 30 percent rating under the applicable criteria. X-rays taken of the Veteran's chest in September 2003 revealed bilateral pleural thickening. A private physician then opined that there is a reasonable probability that this was caused by the Veteran's previous asbestos exposure history. Pulmonary function testing in April 2004, post- bronchodilator, revealed an FVC of 78 percent predicted. DLCO (SB) was 65.6 percent predicted. During a VA pulmonary consultation in July 2004, the Veteran reported dyspnea on exertion for the past 20 years, progressively worsening, plus other symptoms. The VA physician indicated that the Veteran's dyspnea was an atypical presentation for any particular disorder; and that the pulmonary function testing results were essentially normal, with FVC at lower limits suggesting possible mild restrictive disease; and DLCO at lower limits, indicating possible very mild parenchymal disorder. An exercise test was suggested to recreate symptoms. Records show that the Veteran declined to use any inhalers, due to reported headaches in the past. Computed tomography in October 2008 revealed benign stable small pleural nodules. During an August 2009 VA examination, the Veteran reported that he could not walk up hills; and that stairs were limited to a few steps. He had minimal cough along with yellow sputum production and occasional wheezing. There was no history of pneumonia or bronchitis. He was awakened at night two or three times because of dyspnea. Following examination and diagnostic workup, there was no evidence of interstitial lung disease by computed tomography or by chest X-ray. Pulmonary function testing in August 2009 (post- bronchodilator) revealed a FVC of 89 percent predicted; diffusing capacity was normal. An examiner opined that the evidence was consistent with asbestos-related pleural disease. Private treatment records, received in October 2009, include a diagnosis of asbestosis, as well as findings of a mild obstructive lung defect. Diffusing capacity was normal. Records show continuing complaints of chest pain. Computed tomography in January 2010 revealed stable calcified pleural plaques and pleural thickening. There were no concerning pulmonary nodules. Private treatment records, received in November 2010, include findings of pulmonary function testing. The treating physician at the time indicated that the Veteran did not use any bronchodilators. Pulmonary function testing results, pre-bronchodilator, revealed a FVC of 83 percent predicted. DLCO (SB) was shown as 17.7 mL/mmHg/min; percent predicted was not revealed. The report of an October 2011 VA examination reflects that the Veteran was diagnosed with an interstitial lung disease in 1993. The examiner noted that the Veteran's respiratory condition resulted in cardiopulmonary complications. Lung sounds were clear, but diminished throughout. Chest X-rays revealed stable cardiomegaly. The examiner noted that pulmonary function testing was not repeated because the Veteran had three Emergency Department visits for respiratory difficulty and chest pain, though he was not hospitalized. Exercise capacity testing had not been performed. Regarding the pulmonary function testing results from October 2010, the examiner also indicated that the DLCO (SB) was the most accurate test result, which reflected the Veteran's current pulmonary function. Post-bronchodilator testing had not been completed because the Veteran had significantly diminished diffusion capacity and mildly reduced FCV. In a March 2012 addendum, the VA examiner again indicated that the DLCO (SB) most accurately reflected the Veteran's asbestosis; and because asbestosis would not be responsive to bronchodilator, it was not requested. VA treatment records, dated in March 2012, show that pulmonary function testing in August 2009 revealed a mild obstructive defect, with a FVC of 83 percent predicted; and that pulmonary function testing in April 2002 revealed questionable mild restriction, given the mild reduction of a FVC of 70 percent predicted and the DLCO (SB) shown as 16, or as 65 percent predicted. In an April 2012 addendum, the VA examiner noted that the DLCO (SB) test was not performed in 2010; and that the DLCO (SB) test performed in 2009 was shown as 17.3 mL/mmHg/min, with an estimated 89 percent predicted. VA treatment records, dated in May 2012, show that the Veteran was hospitalized in March 2012 for evaluation of dyspnea. He described the dyspnea as a "burning pain in the lungs," which prevented him from sleeping more than two-to- three hours nightly. Records show that the Veteran was unable to perform the plethysmography portion of pulmonary function testing because he had a "panic attack" in the booth, during which his symptoms of dyspnea were replicated. Pulmonary function testing results at the time revealed a FVC of 72 percent predicted. The report of an October 2012 VA examination reflects a diagnosis of asthma. Computed tomography then revealed no acute changes within the lungs. The examiner noted that the Veteran was unable to complete pulmonary function testing in 2009 due to breathing, and that no further pulmonary function testing had been recommended. The examiner opined that the Veteran's restrictive airway disease, also diagnosed as asthma, was thought to be as least as likely as not due to chronic asbestosis; and that all was considered asbestos-related lung disease. There was no evidence of pleural effusion. In this case, a single rating will be assigned under Diagnostic Code 6833 which reflects the predominant disability, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. See 38 C.F.R. § 4.96. Here, the overall evidence shows that the Veteran's asbestos-related pleural disease with pleural nodules meets the criteria for an initial 30 percent disability rating. Pulmonary function testing showed a FVC of 70 percent predicted, and a DLCO (SB) of 65 percent predicted in April 2002; and a DLCO (SB) of 65.6 percent in April 2004. Moreover, since 2009, the Veteran reportedly has had breathing troubles which interfered with completion of further pulmonary function testing. While he was hospitalized in March 2012 for dyspnea, pulmonary function testing revealed a FVC of 72 percent predicted. Given the objective evidence of significantly diminished diffusion capacity and mildly reduced FVC as noted by the October 2011 examiner, the Veteran's disability, in essence, meets the criteria for an initial 30 percent disability rating under the general rating formula for interstitial lung disease. 38 C.F.R. §§ 4.7, 4.21. Here, staged ratings, pursuant to Fenderson, supra, are not appropriate. While the Veteran also has been diagnosed with a restrictive airway disease, computed tomography in October 2012 did not reveal any acute changes within the lungs. The evidence does not show that the overall severity of the Veteran's asbestos-related pleural disease with pleural nodules meets or approximates the criteria for an initial disability rating in excess of 30 percent at any time. There is no showing of a FVC of 50- to 64-percent predicted, or a DLCO (SB) of 40- to 55-percent predicted. Exercise capacity testing had not been performed. Hence, there is no basis for a disability evaluation in excess of 30 percent for the Veteran's asbestos-related pleural disease with pleural nodules. See 38 C.F.R. § 4.97, Diagnostic Code 6833 (2012). The Veteran has been found not to have cor pulmonale, and none of the pulmonary function testing results approximates the criteria for a 100 percent rating. There have been no reports of pulmonary hypertension or outpatient oxygen therapy. Thus, the weight of the evidence supports the grant of an initial 30 percent, but no higher, disability rating. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21 (2012). C. Extraschedular Consideration Finally, an extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that the schedular evaluations assigned for the Veteran's service-connected asbestos-related pleural disease with pleural nodules and PTSD with major depressive disorder are adequate in this case. While examiners have noted the severity of the Veteran's PTSD with major depressive disorder, and that his asbestos-related pleural disease with pleural nodules limits him to sedentary activities, any functional impairment is contemplated in the applicable General Rating Formula for each disability. Specifically, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's service- connected disabilities. Therefore, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An initial 30 percent disability rating for asbestos-related pleural disease with pleural nodules is granted, subject to the pertinent legal authority governing the payment of monetary awards. A disability evaluation in excess of 50 percent for PTSD with major depressive disorder is denied. ____________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs