Citation Nr: 1329428 Decision Date: 09/13/13 Archive Date: 09/20/13 DOCKET NO. 06-36 836 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a psychiatric disorder other than PTSD to include mental disturbance, poor concentration, and trauma flashbacks, claimed as residuals of a lightning strike. 3. Entitlement to service connection for visual disturbance, claimed as a residual of a lightning strike in service and as secondary to service-connected headaches. 4. Entitlement to service connection for Reiter's syndrome. 5. Entitlement to service connection for a cervical spine disorder. 6. Entitlement to service connection for a left knee disorder. 7. Entitlement to a disability evaluation in excess of 10 percent prior to April 13, 2007 for service-connected posttraumatic headaches. 8. Entitlement to a disability evaluation in excess of 50 percent from April 13, 2007 for service-connected posttraumatic headaches. 9. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and his wife ATTORNEY FOR THE BOARD A. G. Alderman, Counsel INTRODUCTION The Veteran had active service from May 1966 to June 1970. Thereafter he served with the National Guard, to include a period of active service from February 1987 to May 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2004, May 2007, May 2008, and December 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The Veteran and his wife testified before a Decision Review Officer (DRO) at the RO in August 2006. During this hearing, the Veteran's representative clarified that the claim for service connection for poor concentration is part of the claim for service connection for a psychiatric disorder other than PTSD. DRO Transcript, p. 1-2. The Veteran also indicated that his vision disturbance could also be secondary to his service-connected posttraumatic headaches. Therefore, the Board has recharacterized the issues as noted on the title page. In light of the Veteran's contentions that his service- connected disabilities render him unemployable, the Board has amended the issues on appeal to include entitlement to a TDIU as reflected above. Rice v. Shinseki, 22 Vet. App. 447 (2009). In October 2009, the Veteran testified before the undersigned Acting Veterans Law Judge via videoconference regarding all issues listed on the title page of this decision with the exception of a TDIU. A copy of the transcript has been associated with the claims file. In February 2010, the Board remanded all issues, except for TDIU, for further development, which has been substantially completed. See Stegall v. West, 11 Vet. App. 268 (1998). By rating decision dated in March 2012, the RO increased the Veteran's disability rating for posttraumatic headaches from 10 percent disabling to 50 percent disabling effective April 13, 2007, the date of a VA examination report. However, the Veteran's appeal for a higher rating remains before the Board both prior to and beginning April 13, 2007. See AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the appellant's claims. A review of the documents in such file reveals that some of the documents in the Virtual VA paperless claims file, i.e., some VA treatment records dated through October 2012 (specifically, a September 2012 VA psychiatric examination), are relevant to the issues on appeal and are not duplicative of the evidence in the paper claims file. While, notably, this evidence has not been considered by the RO, the Veteran waived his procedural right to have this evidence considered by the RO in April 2012. The issues of entitlement to service connection for a psychiatric disorder other than PTSD; visual disturbance claimed as due to lightning strike and as secondary to service-connected headaches; cervical spine disorder; left knee disorder; and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The evidence is in relative equipoise as to whether the Veteran's PTSD is due to combat stressors. 2. The Veteran's Reiter's syndrome completely resolved by the time of separation from service and did not persist subsequent to service. 3. The Veteran's disability picture more nearly approximates the criteria for a 50 percent rating for posttraumatic headaches prior to April 13, 2007 based on the Veteran's reports of daily headaches lasting 2 to 3 hours that involve throbbing, photophobia, alternate blurred vision, watery eyes, occasional nausea and vomiting, jaw pain, dizziness, and retreat to dark, quiet rooms. 4. The schedular criteria do not provide for a disability rating in excess of 50 percent for posttraumatic headaches when rated as analogous to migraines, and the Veteran's residuals of his traumatic brain injury are not of the severity to warrant a rating in excess of 50 percent under the table for rating "Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are met. 38 U.S.C.A. §§ 1110, 1031, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. The criteria for service connection for Reiter's syndrome are not met. 38 U.S.C.A. §§ 1110, 1031, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). 3. The criteria for a disability evaluation of 50 percent prior to April 13, 2007 have been met for service-connected posttraumatic headaches. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.21, 4.124a, Diagnostic Code 8045-8100 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8045-8011 (effective prior to October 23, 2008). 4. The criteria for a disability evaluation in excess of 50 percent from April 13, 2007 for service-connected posttraumatic headaches have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.21, 4.124a, Diagnostic Code 8045-8100 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8045-8011 (effective prior to October 23, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Duties to Notify and Assist With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (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). In addition, the notice requirements apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. For increased ratings claims, VA must notify the Veteran that he must submit, or request that VA obtain, evidence of the worsening of his disabilities and the different types of evidence available to substantiate his claim for a higher rating. Notice must also indicate the requirements to obtain higher ratings and of the need to submit evidence of how such worsening effected his employment. See Vazquez- Flores v. Shinseki, 580 F.3d 1270, 1275-82 (2009). The Veteran filed a claim for service connection for Reiter's disease in November 2003 and a claim for service connection for PTSD in May 2007. Notice letters sent in January 2004 and August 2007 satisfied the duty to notify as the letters addressed all notice elements and were sent prior to the initial RO decision in these matters. The letters informed the Veteran of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. The August 2007 letter also provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. See Dingess/Hartman, 19 Vet. App. at 486. The January 2004 letter did not address either the rating criteria or effective date provisions that are pertinent to the Veteran's claim for service connection for Reiter's disease; however, such error was harmless given that service connection is being denied, and hence no rating or effective date will be assigned with respect to this claimed condition. The Veteran filed a claim for an increased rating for service-connected posttraumatic headaches in February 2006. In May 2006, the RO notified the Veteran that he must submit, or request that VA obtain, evidence of the worsening of his disability and of the different types of evidence available to substantiate his claim for a higher rating. The letter informed him of the requirements to obtain higher ratings and notified him of the need to submit evidence of how such worsening effected his employment. See Vazquez- Flores v. Shinseki, 580 F.3d 1270, 1275-82 (2009). For these reasons, the Board finds that no further development is required regarding the duty to notify. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The duty to assist the Veteran has been satisfied in this case. The RO has obtained the Veteran's service treatment records and his identified VA and private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO has also exhausted all available avenues to verify the Veteran's stressor alleging having been struck by lightning during service and made a formal finding that the stressor could not be verified. Moreover, the Veteran has been afforded VA examinations that are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Specifically, the Veteran had VA mental health examinations in November 2010, February 2012, and September 2012. He had a VA examination for Reiter's syndrome in January 2009. The examiners reviewed the claims folders and provided etiology opinions with supporting rationale regarding the claimed disorders. As such, the examination reports are adequate for rating purposes. Regarding posttraumatic headaches, the Veteran had VA examinations for posttraumatic headaches and Traumatic Brain Injury (TBI) in April 2007, November 2010, February 2012, and August 2012. The examiners took into account the Veteran's statements and treatment records addressing his posttraumatic headaches, which allowed for fully-informed evaluations of the claimed disability. Id. The Veteran also had an examination in December 2007. The examiner did not have the claims files for review; however, the Veteran has not been prejudiced by this oversight since the examination was scheduled to determine the current severity of his headaches. Further, subsequent examiners reviewed the claims files in conjunction with examination and drafting examination reports. During the Board hearing, the Veteran said he was not receiving benefits from the Social Security Administration (SSA) due to excessive income from his wife's employment. There is no indication that medical evidence was developed or obtained by SSA prior to the Veteran being informed that his claim would be denied on this basis. Under these circumstances, there is no reason to seek to obtain SSA records because there is no indication that relevant records were developed or obtained. As for the Veteran's October 2009 Board hearing, the Board notes that the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Acting Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the October 2009 hearing, the undersigned Acting Veterans Law Judge enumerated the issues on appeal. See Hearing Transcript (T.) at p. 2. Also, information was solicited regarding the history of his claimed his disorders, the current symptoms of his headaches, and whether there were any outstanding medical records available. See T. at p. 3-17. Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the appellant's claims. As such, the Board finds that, consistent with Bryant, the undersigned Acting Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2), and that the hearing was legally sufficient. 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, 18 Vet. App. at 120. 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); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303(a) (2012). To prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. A. Psychiatric Disorders The Veteran seeks service connection for PTSD and a psychiatric disorder other than PTSD characterized by mental disturbance, flashbacks, and poor concentration. He argues that his disorders are the result of being struck by lightning during service. He has also claimed that his PTSD is due to his combat experiences in the Vietnam War. Treatment records dated during the pendency of the claim show that the Veteran has been diagnosed with PTSD, bipolar disorder, anxiety, depression, and cognitive disorder. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) and 38 C.F.R. § 4.125 (2012). Diagnoses of PTSD must be rendered in accordance with the diagnostic criteria for the condition set forth in the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM- IV). See 38 C.F.R. § 4.125 (noting that VA has adopted the nomenclature of the DSM-IV). The evidence needed to establish the occurrence of a claimed in-service stressor is typically dependent upon whether the Veteran engaged in combat with the enemy, as well as whether the claimed in-service stressor is related to such combat; or, if not, whether there is objective evidence to verify the occurrence of the claimed stressor. See 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128, 147 (1997); Moreau v. Brown, 9 Vet. App. 389, 395 (1996); see also 38 U.S.C.A. 1154(b) (West 2002). If a stressor claimed by a veteran is related to fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 75 Fed. Reg. 39,843, 39,852 (Jul. 13, 2010) (codified at 38 C.F.R. § 3.304(f)(3)). During the pendency of his claim, the Veteran has alleged that his PTSD is due to being struck by lightning during service and a result of his exposure to combat in Vietnam. The AMC attempted to verify the alleged lightning strike but the Joint Services Records Research Center (JSRRC) and Defense Personnel Records Information System (DPRIS) said the 1967 unit histories from the Veteran's unit did not verify the incident. However, unit histories stated that the Veteran's unit came under heavy hostile fire in July 1967 resulting in three U.S. Army casualties. No casualties were noted as due to a lightning strike. JSRRC did not have access to morning reports. The AMC requested a search of morning reports from the National Personnel Records Center (NPRC). The response was negative. In December 2011, the AMC made a formal finding that the stressor involving the lightning strike could not be verified and that additional attempts would be futile. Based on the foregoing, since the lightning strike could not be verified, the Board finds that the only verified stressor for PTSD purposes is the Veteran's exposure to combat. In this case, a February 2007 mental health intake form, a May 2011 letter from the Veteran's VA mental health provider, and the September 2012 VA examination report each indicate that the Veteran's PTSD is due to, at least in part, his combat experience in Vietnam. Specifically, the September 2012 VA examiner wrote that the Veteran's PTSD was associated with combat during the Vietnam era while stationed along the DMZ in Korea and shooting at North Koreans. Other VA examination reports indicate that PTSD is due to the lightning strike. Given this, the Board finds that the medical evidence of record is in equipoise as to whether the Veteran's PTSD is related to his combat exposure, and accordingly, the Board must resolve this issue in favor of the Veteran. As such, service connection for PTSD is granted. Service connection for anxiety and cognitive disorder, including memory and concentration problems, is not warranted. First, the September 2012 VA examiner said the anxiety diagnosis was subsumed under the PTSD diagnosis. Second, anxiety and cognitive symptoms claimed as memory and concentration problems are symptoms of PTSD and will be considered when assigning a disability evaluation for PTSD under 38 C.F.R. § 4.130, the General Rating Formula for Mental Disorders. Thus, the Board finds that an additional finding of service connection for these conditions is not warranted. B. Reiter's Syndrome The Veteran seeks service connection for Reiter's syndrome, which he states has been chronic since his diagnosis during service. Service treatment records show that in April 1970, he was admitted for treatment of joint pain. The diagnosis was acute arthritis and suspected but not proven Reiter's syndrome. He was placed on a medical profile for arthritis, treated and improved and suspected Reiter's, treated and improved. The May 1970 separation examination notes that he was treated in April 1970 for transient arthritis with possible Reiter's syndrome. A current diagnosis was not indicated. The report of medical history notes arthritis or rheumatism. The examining physician said the Veteran was treated for transient arthritis from April 5-14, 1970, and diagnosed with probable Reiter's syndrome. Periodic evaluations for the National Guard show normal clinical evaluations in February 1980, April 1984, and March 1987. The accompanying reports of medical history were silent for complaints or treatment of Reiter's syndrome or arthritis. Private treatment records show that the Veteran complained of generalized joint pain in January 2005. The diagnosis was polymyalgia rheumatica. April 2005 records show worsening joint pain in the knees. The diagnosis was joint pain. A May 2005 treatment record indicates that the Veteran was a moderately poor historian. He complained of worsening joint pain. X-rays of the knees showed osteoarthritis of the right knee and compartment narrowing of the left medial knee. X-rays showed cervical spondylosis and straightening of the lordosis. X-rays of the hands showed possible inflammatory arthritis. The assessment was osteoarthritis of the knees and probable degenerative disc disease of the cervical and lumbar spines. Also noted was bilateral radiculopathy which might represent spinal stenosis. The physician noted a history of Reiter's syndrome. During his August 2006 hearing before the DRO, the Veteran testified that he was diagnosed with Reiter's syndrome during service and that he has had problems with arthritis since service. At the time of his hearing, he was taking over-the-counter medications but was not being treated by medical providers since he did not have insurance. His wife said he was first treated after service in 1978 for his arthritis. He said his arthritis forced him to stop working in 2002 because his hands would not function properly. In January 2007, the Veteran's diagnoses included "Neck Pain/ DJD/ Reiter's or Reactive arthritis." A September 2007 treatment record shows the Veteran was treated for a rash. The Veteran reported a history of Reiter's syndrome and said the condition started with a rash. He claims he has had hand, elbow, and occasional shoulder and knee pain since that time. The Veteran had a VA examination for Reiter's syndrome in January 2009. The examiner said the Veteran was hospitalized for acute migratory arthritis in April 1970 and that the condition was preceded by urethritis. He noted that the Veteran's May 1970 separation examination did not show joint problems. He observed that the Veteran did not have further joint issues or problems until December 2006. He noted that x-rays of the lumbosacral spine taken in 2007 showed mild degenerative joint disease, and said that the question of whether the Veteran had Reiter's syndrome was raised. However, the x-rays showed no findings consistent with a history of Reiter's syndrome. The examiner reviewed joint pains treated and complained of since 2006 and after performing the physical examination, diagnosed degenerative joint disease of the left knee, bilateral chondromalacia of the knees, mild degenerative joint disease of the lumbosacral spine, and acute reactive arthritis in April 1970 with complete resolution by May 1970. The examiner opined that the Veteran had an episode of acute reactive arthritis in April 1970, identified as Reiter's syndrome. However, he found that the Veteran has not developed clinical evidence of chronic reactive arthritis and that he does not have chronic systemic arthritis. The examiner also opined that the degenerative joint disease of the lumbosacral spine and bilateral knees was not caused by or a result of the acute reactive arthritis manifested in April 1970. The examiner explained that the acute migratory arthritis noted in April 1970 had resolved completely by May 1970 and from that point until 2006, the Veteran did not have any symptoms to suggest the continuation of the acute migratory arthritis on a chronic basis. During the Veteran's October 2009 hearing before the Board, the Veteran testified that he was treated during service for Reiter's syndrome and that after service, in 1970 or 1972, his private provider told him he was totally disabled. He said the acute arthritis affected his hands, knees, and back and continued after service. He said VA was treating his Reiter's syndrome with medication. The Board has reviewed the evidence but finds that service connection for Reiter's syndrome or reactive arthritis is not warranted. First, the competent and credible evidence shows that his condition had completely resolved by the time he separated from service in May 1970. Second, the January 2009 VA examiner found that the Veteran has not developed clinical evidence of chronic reactive arthritis and does not have a chronic systemic arthritis. Third, the examiner also found that the current joint problems were not caused by or a result of the acute reactive arthritis manifested in April 1970 because the condition had resolved completely by May 1970 and from that point until 2006, the Veteran did not have any symptoms to suggest the continuation of the acute migratory arthritis on a chronic basis. The Board has considered the Veteran's wife's statements and his complaints of chronic pain since service and points out that as a layperson, the Veteran and his wife are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The Veteran and his wife are also competent to testify about observable symptoms or injury residuals. See 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). Moreover, the Veteran is competent to report a continuity of symptomatology. See Charles v. Principi, 16 Vet. App. 370 (2002). Here, however, the Veteran's assertions of continuity of symptoms are not deemed credible. His assertions that he has had continuous, intermittent symptoms of Reiter's syndrome since service were made in connection with the current claim for monetary benefits and are contradicted by other pertinent, probative evidence, and, thus, are not deemed credible. Specifically, the Veteran denied having any ongoing symptoms during his periodic evaluations while serving with the National Guard and while he filed a claim for service connection for arthritis in 1994, he did not submit any medical or lay evidence in support of his claim. Further, the medical evidence does not show complaints related to his joints until 2005, approximately 35 years after he was treated for Reiter's syndrome during service. The passage of so many years between discharge from active service and the objective documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Furthermore, to whatever extent the Veteran or his wife attempts to assert that there exists a medical relationship between his current joint problems diagnosed many years post service and in-service diagnosis of Reiter's syndrome on the basis of their own assertions, such attempts must fail. Matters of diagnosis and etiology of a disability are matters within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). The Veteran and his wife are not shown to have the medical training or expertise needed to render probative opinions on such medical matters. See Bostain v. West , 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Hence, the lay assertions in this regard have no probative value. For the foregoing reasons, the claim for service connection for Reiter's syndrome or reactive arthritis must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). II. Increased Rating The Veteran seeks a disability rating in excess of 10 percent prior to April 13, 2007 and a disability rating in excess of 50 percent from that date for service-connected posttraumatic headaches. Disability evaluations are determined by the application of a schedule of ratings, which are based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Governing regulations provide that the higher of two evaluations will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2012). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The RO rated the Veteran's service-connected posttraumatic headaches under 38 C.F.R. § 4.124a, Diagnostic Code 8045- 8100 (2012), residuals of a traumatic brain injury (TBI). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2012). The Veteran's claim for an increased rating for posttraumatic headaches was received in February 2006. During the course of the appeal, the regulations for the evaluation of brain disease due to trauma or TBI under Diagnostic Code 8045 were amended, effective October 23, 2008. See 73 Fed. Reg. 54,693 - 54,708 (Sept. 23, 2008). The Federal Register's paragraph addressing the applicability date of the new regulation specifically states: The amendment shall apply to all applications for benefits received by VA on or after October 23, 2008. The old criteria will apply to applications received by VA before that date. However, a Veteran whose residuals of TBI were rated by VA under a prior version of 38 CFR 4.124a, Diagnostic Code 8045, will be permitted to request review under the new criteria, irrespective of whether his or her disability has worsened since the last review or whether VA receives any additional evidence. The effective date of any increase in disability compensation based solely on the new criteria would be no earlier than the effective date of the new criteria. The effective date of any award, or any increase in disability compensation, based solely on these new rating criteria will not be earlier than the effective date of this rule, but will otherwise be assigned under the current regulations governing effective dates, 38 C.F.R. 3.400, etc. The rate of disability compensation will not be reduced based on these new rating criteria. 38 U.S.C.A. § 1155; 73 Fed. Reg. 54,693 (Sept. 23, 2008). Prior to October 23, 2008, Diagnostic Code 8045 provided that purely neurological disabilities such as hemiplegia, epileptiform seizures, facial nerve paralysis, etc., following trauma to the brain, will be rated under the diagnostic codes specifically dealing with such disabilities, with citation of a hyphenated diagnostic code (e.g., 8045-8911). Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10 percent and no more under Diagnostic Code 9304. This 10 percent rating will not be combined with any other rating for a disability due to brain trauma. Ratings in excess of 10 percent for brain disease due to trauma under Diagnostic Code 9304 are not assignable in the absence of a diagnosis of multi- infarct dementia associated with brain trauma. 38 C.F.R. § 4.124a, Diagnostic Code 8045 (effective prior to October 23, 2008). Under the revised Diagnostic Code 8045, effective October 23, 2008, there are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2012). Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Evaluate cognitive impairment under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Id. Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. Id. The rater is to evaluate emotional/behavioral dysfunction under § 4.130 (Schedule of ratings--mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Id. The rater is to evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. Id. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under 38 C.F.R. § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Id. Also for consideration is the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. Evaluation of Cognitive Impairment and Subjective Symptoms: The table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, and labeled "total." However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. Assign a 100- percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent rating if 3 is the highest level of evaluation for any facet. 38 C.F.R. § 4.124a, Diagnostic Code 8045. Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified" with manifestations of a co-morbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Id. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Id. Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self- care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Id. Note (4): The terms "mild," "moderate," and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. Id. Under Diagnostic Code 8100, migraines are evaluated as follows: a non-compensable rating is assigned with less frequent attacks; a 10 percent rating is assigned with characteristic prostrating attacks averaging one in 2 months over last several months; a 30 percent rating is assigned with characteristic prostrating attacks occurring on an average once a month over last several months; and, a 50 percent rating is assigned with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The Veteran had a VA examination in April 2007 for his service-connected posttraumatic headaches. He reported that his headaches had worsened over the last several years, occurring two to three times per week and lasting two to three hours. His headaches involved the whole head with throbbing, photophobia, alternate blurred vision, watery eyes, occasional nausea and vomiting, jaw pain and dizziness. His headaches were worse during storms and were accompanied by sweating and anxiety. He said he would sit in dark rooms until the storms passed. Since 2006, his headaches have occurred almost daily. He said his medication provided little help and that the episodes prevented him from doing things. The diagnosis was posttraumatic headache with some component of PTSD and migraine. The Veteran had another VA examination in December 2007. The examiner did not have the claims file for review. The examiner observed that the Veteran's medication list from VA throughout the 2007 year demonstrated no evidence of migraine headache medications. The examiner said headaches have onset after a memory is triggered or during a storm and that when exposed to a trigger, the Veteran becomes extremely anxious and retreats to a quiet, dark room to attempt to hide from the offending stimulus. The Veteran has three to four episodes of incapacitating headaches per week that last two to three hours. The examiner opined that the Veteran did not have posttraumatic headaches but did have PTSD and tension headaches. A March 2010 VA treatment record shows that the Veteran reported a worsening of his posttraumatic headaches. He said they occurred daily. His headaches and neck pain worsened in August 2010 after a motor vehicle accident (MVA). Records show neck sprain due to the MVA. During the Veteran's October 2009 hearing before the Board, the Veteran said he had headaches every other day and that at least four times per month his headaches required him to lie down and stay quiet. Sometimes his headaches caused nausea and problems balancing. During a November 2010 VA examination, the Veteran said his headaches left him irritable and caused intermittent dizziness and balance problems, photosensitivity, and intermittent blurry vision. He reported ringing in both ears, which had improved. He had headaches two to three times per week with diffuse sharp pains and pressure. He rated the headaches at a 9 on the pain scale of 0 to 10, with 10 being the worst pain. He denied nausea but had some sensitivity to light and loud noises. He treated his headaches with Motrin and Tylenol. Occasionally, he would take Vicodin and do nothing for four to five hours. During these episodes, he retreated to quiet, dark rooms and did not talk to others. The Veteran said that when he was employed, he would miss work due to headaches and chronic pain. The examiner reviewed the service treatment records and determined that the Veteran had a TBI during service caused by the MVA in 1969. After that accident, the Veteran was frequently seen for posttraumatic headaches. The examiner said his other symptoms are subjective and not well documented but that it is as likely as not that they are residuals of the TBI. Residuals include chronic posttraumatic headaches, incapacitating about once per week; photosensitivity; intermittent blurred vision; intermittent tinnitus; and intermittent dizziness. The examiner said the Veteran has three or more subjective symptoms that have persisted since the TBI and that they mildly interfere with work, instrumental activities of daily living, or work, family or other close relationships. The examiner also determined that the chronic posttraumatic headaches with migrainous features are of moderate severity and cause characteristic prostrating attacks averaging once per week over the past 40 years. The headaches were characterized as very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The Veteran had a neuropsychological evaluation in August 2011. Based on the Veteran's history, the provider found that the Veteran sustained a mild TBI during service resulting in persistent residual symptoms of posttraumatic headaches, chronic pain, and dizziness. The provider noted that the July 2011 MRI of the brain showed an abnormality that is nonspecific and not associated with any abnormal enhancement or evidence of hemosiderin deposition or sequalae of previous hemorrhage. The provider said testing revealed signs of emotional and/or motivational factors that affected the Veteran's performance and that he likely performed some of the time at a level that was less than that of which he was capable. Thus, test results may have overestimated possible neurocognitive impairment. The results of the current assessment evidenced cerebral dysfunction. He had impairments in his ability to initiate and mange purposeful motor behavior. He also had impairments in immediate memory for auditory information and delay recall of paragraph-length information. Also noted was moderate anxiety and depression. Regarding the etiology of his current cognitive deficits, the provider said the pattern of results was somewhat atypical for the sequalae of mild TBI. Though the impact of multiple concussions could not be excluded, his history of alcohol and substance abuse are possible contributors. Given his deficits in immediate memory and delay recall, constructional apraxia, and deficits in the executive domain of purposive action, the provider said a dementia process should be ruled out. In February 2012, the Veteran had a VA examination for his service-connected posttraumatic headaches. The Veteran said that for many years, he had headaches at least three days per week. About three years ago he began to have headaches daily. Headaches start at the back of his head and radiate to the front of his forehead and last three to four hours. Pain usually measures an 8 on the pain scale. He typically wakes up with headaches with throbbing sharp pain and often with severe pressure sensation. Headaches will last several hours to a full day. At times he will feel dizzy. He has incapacitating headaches three to four times per week that last two to three hours. He is not able to function during incapacitating headaches. The examiner said the evidence does not show migraine headaches but that more than once per month, he has prostrating attacks of non-migraine headache pain. The MRI of the brain conducted in December 2011 was normal. His condition impacts his ability to work. The Veteran had a VA TBI examination in February 2012. The examiner reviewed the claims file. The examiner stated that the Veteran had mild or occasional headaches and mild anxiety that do not interfere with work, instrumental activities of daily living, or work, family or other relationships. The examiner found no other significant symptoms. The examiner remarked that the Veteran had headaches attributed to TBI that were not disabling and that the Veteran began to experience headaches in 2003 or 2004 which became disabling and related to anxiety and diagnosis of PTSD. The Veteran had a VA examination for posttraumatic headaches in August 2012. The Veteran described his headaches as pulsating or throbbing with pain on both sides of the head, typically lasting less than one day. He said he had prostrating attacks of pain more than once per month. The examiner noted that the December 2011 MRI of the brain was normal. The Veteran said his headaches had worsened, becoming much more frequent and severe since 2006. The examiner opined that the severe tension headaches, which occurred three to four times per week and lasted two to three hours causing incapacitation, would preclude any employment during the headache episodes. Between the headache episodes, the Veteran's chronic headache condition would not preclude any employment. However, the examiner said it was questionable as to whether any employer would hire or accommodate an employee with such a chronic headache condition. In October 2012, the Veteran complained of headaches. He said he was having four per week and that they typically lasted for half to a full day. Another October 2012 record shows that he received occipital nerve blocks for his headaches. Review of the claims file shows VA granted service connection for posttraumatic headaches in 1971. A diagnostic code for rating purposes was not assigned at that time. A June 1995 rating decision shows VA rated the disability under 38 C.F.R. § 4.124a, Diagnostic Code 8199- 8100, as a miscellaneous disease analogous to migraine headaches. In November 2004, VA changed the rating criteria to 38 C.F.R. § 4.124a, Diagnostic Code 9304-8045, residuals of TBI. In March 2012, VA changed the rating criteria to 38 C.F.R. § 4.124a, Diagnostic Code 8045-8100, residuals of TBI rated as analogous to migraine headaches. Since the Veteran's posttraumatic headaches have not been rated consistently under specific diagnostic codes during the course of this appeal, the Board finds that the disability should be rated as analogous to migraines for the entire pendency of the claim. Here, the Board finds that the Veteran's disability picture more nearly approximates the criteria for a 50 percent evaluation under Diagnostic Code 8100 for the entire pendency of the claim. Specifically, during his April 2007 VA examination, the Veteran complained of daily headaches lasting 2 to 3 hours that involved throbbing, photophobia, alternate blurred vision, watery eyes, occasional nausea and vomiting, jaw pain, dizziness, and retreat to dark, quiet rooms. He told the examiner that the severity of his symptoms had worsened over the past several years. Notably, the Veteran filed his claim for an increased evaluation in February 2006, only 14 months prior to his VA examination; consequently, the Board finds that a 50 percent rating should be assigned for the entire pendency of the claim under Diagnostic Code 8199- 8100. This is the highest schedular evaluation provided for under 38 C.F.R. § 4.124a, Diagnostic Code 8100. The Board has also considered whether a higher rating could be granted under the criteria for rating residuals of TBI under 38 C.F.R. § 4.124a, Diagnostic Code 8045-8100. However, prior to October 23, 2008, the maximum schedular disability rating that could be assigned for subjective symptoms such as headaches was 10 percent unless the Veteran had a diagnosis of multi-infarct dementia associated with brain trauma or neurological disabilities. He had neither. Consequently, a rating in excess of 10 percent cannot be granted prior to October 23, 2008 under 38 C.F.R. § 4.124a, Diagnostic Code 8045. The Board has also considered whether a rating in excess of 50 percent could be granted under the revised criteria for rating residuals of TBI, 38 C.F.R. § 4.124a, Diagnostic Code 8045, effective October 23, 2008. However, the November 2010, August 2011, February 2012, and August 2012 VA examiners and/or providers observed, at most, mild residuals of TBI such as headaches and photosensitivity, as well as intermittent blurred vision, tinnitus and dizziness. The November 2010 examiner specifically found that the Veteran has had three or more subjective symptoms persisting since the TBI and that they mildly interfere with work, activities of daily living, or relationships. Under the table for "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified", the Veteran's residuals as documented in VA examination reports would be rated a "1" under subjective symptoms, which translates to a 10 percent rating. Briefly, in addition to subjective complaints such as headaches, pain, and dizziness, the August 2011 provider noted cognitive deficits such as cerebral dysfunction, impairment in ability to initiate and manage purposeful motor behavior, impairment in immediate memory for auditory information, and delayed recall of paragraph length information. However, the provider said the cognitive deficits are atypical for sequalae of mild TBI and that the Veteran's history of alcohol and substance abuse are possible contributors. The provider stated that a dementia process should be ruled out. Since the provider did not attribute the cognitive deficits to the TBI or service- connected posttraumatic headaches, and since subsequent VA examiners did not observe cognitive defects related to TBI, the Board finds that a separate rating for these deficits is not warranted at this time. Based on the foregoing, the Board finds that the Veteran's service-connected posttraumatic headaches should be rated 50 percent disabling for the entire pendency of the claim. A schedular rating in excess of 50 percent is not provided for posttraumatic headaches when rated as analogous to migraines under Diagnostic Code 8045-8100. 38 C.F.R. § 4.124a. Further, the evidence does not support the assignment of a disability rating in excess of 50 percent under the old or revised criteria under Diagnostic Code 8045 for residuals of TBI. To the extent that a 50 percent rating is warranted prior to April 13, 2007 for service-connected posttraumatic headaches, the claim is granted. Finally, the Board must determine whether the schedular evaluation is inadequate, thus requiring that the RO refer the claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service- connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2012). An extra-schedular evaluation is for consideration when a service-connected disability presents an exceptional or unusual disability picture. 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. 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 or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, 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. In this case, the schedular evaluation is adequate as the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's posttraumatic headaches. Moreover, the Veteran has submitted no evidence showing that this disorder has markedly interfered with his employment status beyond that interference contemplated by the assigned evaluation, and there is also no indication that this disorder has necessitated frequent, or indeed any, periods of hospitalization during the pendency of this appeal. As such, the Board is not required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1), which concern the assignment of extra-schedular evaluations in "exceptional" cases. See Thun, 22 Vet. App. 111. ORDER Service connection for PTSD is granted. Service connection for Reiter's syndrome is denied. A 50 percent disability evaluation prior to April 13, 2007 for service-connected posttraumatic headaches is granted. A disability evaluation in excess of 50 percent from April 13, 2007 for service-connected posttraumatic headaches is denied. REMAND The Veteran seeks service connection for psychiatric disabilities other than PTSD. In addition to the diagnoses and symptoms addressed above, he has been diagnosed with bipolar disorder and depression. While VA examinations have been provided to determine the nature and etiology of the Veteran's psychiatric disorders, the examiners have not provided opinions supported by rationale as to whether his depression or bipolar disorder are related to his periods of active service. For example, in November 2010, the examiner said the Veteran self-treated his bipolar disorder for many decades before being prescribed appropriate medications and opined that bipolar disorder is unrelated to service. In February 2012, the examiner opined that bipolar disorder is a biological-based disorder and that it was not exacerbated or caused by service. The September 2012 examiner opined that bipolar disorder is less likely as not associated with military service and as likely as not associated with post- military and biological stressors. None of the examiners provided rationale for their opinions and none addressed depression and whether any current or past depression was related to service. Briefly, while the February 2012 examiner's opinion indicates the possibility that bipolar disorder pre-existed service, no mental health conditions were noted at entry to either period of service and accordingly, the Veteran is presumed to have been in sound condition at service entrance. 38 U.S.C.A. § 1111 (West 2002). Further, the presumption of soundness cannot be rebutted as VA cannot show by clear and unmistakable evidence that the Veteran's bipolar disorder existed prior to either period of active service. VAOPGCPREC 3-2003 (July 16, 2003). Since the VA examiners did not provide an etiology opinion with supporting rationale for bipolar disorder or depression, the Board finds that the current VA examinations are not adequate for rating purposes and that a remand is necessary for an addendum opinion addressing this matter. The Veteran also seeks service connection for a visual disturbance claimed as secondary to being struck by lightning during service and as secondary to his service- connected posttraumatic headaches. During the pendency of his claim, the Veteran has been treated for blurry vision, dry eyes, watery eyes, photophobia, eye irritation, grittiness, pain, and decreased vision. Diagnoses have included conjunctivitis, cataracts, and eye irritation. Some symptoms have been discussed in relation to the Veteran's service-connected posttraumatic headaches. A VA examination has not been provided to determine whether the Veteran has a vision impairment that is related to service or his service-connected posttraumatic headaches. Since treatment records indicate a possible nexus between vision impairments and service-connected posttraumatic headaches, the Board finds that a remand is necessary to allow for the scheduling of a VA examination. 38 U.S.C.A. § 5103A(d)(2) (West 2002); 38 C.F.R. § 3.159(c)(4)(i) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran also seeks service connection for cervical spine and left knee disorders. A VA examination was provided in March 2008. Upon inspection of the examination report, the Board finds that the examiner cited inaccurate dates, misstated pertinent information, and did not consider pertinent diagnoses or treatment records. Consequently, the Board must return this examination report as being inadequate for rating purposes. 38 C.F.R. § 4.2. Finally, the record indicates that the Veteran may be unemployable due to service-connected disabilities. Significantly, during the February 2012 VA psychiatric examination the Veteran reported that he most recently worked as a janitor in 2008. He indicated that he resigned because he was worried about being fired due to missing so much work. VA regulations allow for the assignment of a TDIU rating on a schedular basis when a veteran's schedular rating is less than total and the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that (1) if there is only one such disability, that disability must be ratable at 60 percent or more, or (2) if there are two or more disabilities, there must be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a) (2012). Prior to this decision, the Veteran's service connected disabilities included diabetes mellitus, rated 10 percent disabling, and posttraumatic headaches, rated 50 percent disabling. His combined rating was 60 percent, below the schedular criteria for entitlement to TDIU. While the Board has granted service-connection for PTSD herein, the Board does not have jurisdiction to assign a disability rating and thus cannot determine whether the schedular criteria for TDIU have been met. Further, the RO has not developed this theory of entitlement or adjudicated the issue of TDIU in the first instance. Accordingly, the Board remands to ensure due process. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran additional VCAA notice as to the issue of entitlement to TDIU and conduct any necessary development. 38 U.S.C.A. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159. 2. Send the Veteran a letter asking him to identify any additional private or VA treatment records pertaining to disabilities currently at issue that he wants VA to help him obtain. Thereafter, take appropriate steps to secure any medical treatment records identified that are not already of record, to include all relevant updated VA treatment reports. Efforts to obtain these records should be memorialized in the Veteran's VA claims folder, and all records obtained should be associated with the claims folder. 3. Send a copy of this remand, the Veteran's claims folders, and copies of pertinent records on Virtual VA that are not contained in the claims folders to the mental health examiner that conducted the September 2012 examination. After reviewing the records, the examiner should provide an addendum opinion indicating whether it is at least as likely as not (50 percent or better probability) that the Veteran's depression and/or bipolar disorder had onset during service or are in any way related to service or the Veteran's service-connected PTSD. The examiner should also indicate whether the symptoms of depression and/or bipolar disorder can be differentiated from symptoms of PTSD. The examiner should assume for purposes of this opinion that as a matter of law, the Veteran's bipolar disorder did not pre- exist his service entrance. The examiner must provide a rationale for each opinion expressed. If the examiner is not able to provide an opinion because it would be speculative, the examiner should specify whether there is additional information that would enable him/her to provide the opinion he declined to provide on that examination; or whether the inability to provide the requested opinions was based on the limits of medical knowledge. If the September 2012 examiner is not available to provide the opinion, another examiner with sufficient expertise should be asked to provide it. If the examiner determines that the opinion cannot be provided without examining the Veteran, a VA examination should be scheduled posthaste. 4. Arrange for the Veteran to be scheduled for a VA examination by an examiner with sufficient expertise to determine the nature and etiology of his alleged vision impairments. Any indicated studies should be performed. The claims folders and any pertinent evidence in Virtual VA that is not contained in the claims folders must be made available to and reviewed by the examiner. The examiner must indicate review of the claims folder and Virtual VA records. For any current vision impairment and any vision impairment diagnosed since November 2003, to include conjunctivitis, cataracts, and eye irritation, the examiner should state whether it is at least as likely as not (50 percent or better probability) that the conditions originated in service, are causally related to service, or are due to service- connected posttraumatic headaches. The examiner should also address the etiology of the Veteran's complaints of blurry vision, dry eyes, watery eyes, photophobia, eye irritation, grittiness, pain, and decreased vision. The examiner must provide a rationale for each opinion expressed. If the examiner is not able to provide an opinion because it would be speculative, the examiner should specify whether there is additional information that would enable him/her to provide the opinion he declined to provide on that examination; or whether the inability to provide the requested opinions was based on the limits of medical knowledge. 5. Arrange for the Veteran to be scheduled for a VA examination by an examiner with sufficient expertise to determine the nature and etiology of his alleged cervical spine and left knee disorders. Any indicated studies should be performed. The claims folders and any pertinent evidence in Virtual VA that is not contained in the claims folders must be made available to and reviewed by the examiner. The examiner must indicate review of the claims folder and Virtual VA records. For any current cervical spine and left knee disorder diagnosed since May 2007, the examiner should state whether it is at least as likely as not (50 percent or better probability) that the disorders originated in service or are causally related to service. The examiner must provide a rationale for each opinion expressed. If the examiner is not able to provide an opinion because it would be speculative, the examiner should specify whether there is additional information that would enable him/her to provide the opinion he declined to provide on that examination; or whether the inability to provide the requested opinions was based on the limits of medical knowledge. 6. Conduct any additional development necessary, to include the scheduling of a VA examination to determine whether the Veteran's service-connected disabilities render him unemployable. 7. Then, readjudicate the claims on the merits. If any benefit sought on appeal is not granted to the Veteran's satisfaction, he and his representative should be provided a supplemental statement of the case and the requisite opportunity to respond before the case is returned to the Board for further appellate action. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ APRIL MADDOX Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs