Citation Nr: 1329614 Decision Date: 09/16/13 Archive Date: 09/20/13 DOCKET NO. 06-24 541 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for a bilateral knee disability. 2. Entitlement to service connection for a low back disability. 3. Entitlement to an initial rating in excess of 10 percent for ischemic heart disease (previous characterized as coronary artery disease) from April 17, 2002, 30 percent disabling from March 20, 2008, and 60 percent disabling from February 15, 2012. 4. Entitlement to an initial compensable rating for diabetic retinopathy. 5. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD A. Cryan, Counsel INTRODUCTION The Veteran served on active duty from April 1964 to April 1966 and from July 19, 1975, to August 2, 1975. He served in the Republic of Vietnam from July 1965 to April 1966. This matter comes before the Board of Veterans' Appeals (Board) from a December 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California and from a December 2006 rating decision of the VA RO in Los Angeles, California. The Veteran's case is currently under the jurisdiction of the VA RO in Los Angeles, California. In a June 2009 supplemental statement of the case, the Los Angeles VA RO increased the Veteran's disability rating for ischemic heart disease to 30 percent effective March 20, 2008, and in a November 2012 rating decision, the Appeals Management Center (AMC) in Washington, D.C., increased the disability rating for ischemic heart disease to 60 percent effective February 15, 2012. Because the maximum disability rating possible has not been assigned, the appeal for a higher rating remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement (NOD) 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 Veteran testified at a Travel Board hearing before the Board in June 2010. The Board remanded the Veteran's claims for further development in December 2011. The Veteran submitted additional medical evidence received at the Board in December 2012. In April 2013, the Veteran's representative indicated that the Veteran agreed to waive initial consideration of this evidence by the agency of original jurisdiction (AOJ). The Veteran also submitted additional medical evidence in August 2013. In August 2013, the Veteran's representative indicated that the Veteran agreed to waive initial consideration of this evidence by the AOJ. The Veteran is therefore not prejudiced by the Board's adjudication of the issues being decided herein. The issues of entitlement to service connection for a bilateral knee disability, entitlement to service connection for a low back disability, and entitlement to initial increased ratings for ischemic heart disease being remanded are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC in Washington, D.C. VA will notify the appellant if additional action is required on his part. FINDINGS OF FACT 1. The Veteran's retinopathy has been manifested by objective findings of corrected distance vision of 20/40 or better in each eye. 2. Prior to February 13, 2012, the Veteran's PTSD has been manifested by occupational and social impairment productive of no more than reduced reliability and productivity due to symptoms such as disturbances of motivation and mood and difficulty establishing and maintaining effective work and social relationships. 3. From February 13, 2012, the Veteran's PTSD has been manifested by occupational and social impairment with deficiencies in most areas such as family relations, judgment, thinking and mood. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial compensable rating for diabetic retinopathy have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.79, Diagnostic Codes 6099-6079 (2008). 2. Prior to February 13, 2012, the criteria for a rating in excess of 50 percent for PTSD are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.1, 4.7, 4.130, Diagnostic Code 9411 (2012). 3. From February 13, 2012, the criteria for a rating of 70 percent for PTSD are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.1, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claims. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claims; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claims decided herein with an adjudication of the claims by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in September 2003, October 2003, May 2006, October 2006, October 2008, June 2009, September 2011, and January 2012. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the October 2012 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claims decided herein. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Where entitlement to compensation has already been established and an increase in the assigned rating is at issue, it is the present level of disability that is of primary concern. Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service- connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). A. Diabetic Retinopathy The Veteran contends that his service-connected diabetic retinopathy warrants a compensable rating. A noncompensable evaluation has been in effect since April 2002. VA treatment reports reflect that the Veteran's distant visual acuity with correction for the right eye was reported to be 20/60 and the visual acuity with correction for the left eye was 20/50 in January 2005. It is not clear if the finding for the left eye included distant visual acuity or near visual acuity. In April 2006, the Veteran's distant visual acuity with correction was 20/50 and the Veteran's vision with correction was 20/40. The findings do not specify whether the entries were for the bilateral eyes or the left or right eye. In December 2008, the Veteran was noted to have visual acuity without correction of 20/50 in the right eye and 20/40 in the left eye. Again, no findings were included with regard to whether the entries related to distant or near visual acuity. In February 2010, the Veteran's uncorrected visual acuity was reported to be 20/60 in the right eye and 20/30 in the left eye. In April 2010, the Veteran underwent a cataract extraction in the right eye. In May 2010, the Veteran underwent a cataract extraction in the left eye. In July 2010, the Veteran's uncorrected visual acuity was reported to be 20/40 in the right eye and 20/30 in the left eye. In September 2010, the Veteran's vision was reported to be 20/80 in the right eye and 20/30 in the left eye with no reference to whether this was corrected or uncorrected or distant or near visual acuity. In November 2010, the Veteran's uncorrected visual acuity was reported to be 20/30 bilaterally. In March 2012, the Veteran's uncorrected visual acuity was 20/60 in the right eye and 20/25 in the left eye and in August 2012, the Veteran's vision was reported to be 20/40 without correction and 20/20 with correction. Again, no findings were included with regard to whether the entries related to distant or near visual acuity. At a March 2008 VA eye examination, the Veteran reported blurred vision in both eyes. His corrected visual acuity was 20/60 in the right eye and 20/30 in the left eye without improvement on pinhole examination. The examiner diagnosed the Veteran with early cataract changes in both eyes, diabetes without evidence of retinopathy in both eyes, and history of glaucoma with mildly abnormal cup-to-disc ratio in both eyes with normal pressures on examination. In undated addendum, the Veteran was noted to have corrected near vision of 20/30 in both eyes. An examiner indicated that both visual fields were found to be within normal limits with no visual field loss or scotoma in both eyes. It remains unclear what the Veteran's corrected distance visual acuity was at the time of that examination. The Veteran testified at a hearing before the Board in June 2010. The Veteran testified that he had recently undergone cataract surgery. He indicated that he was able to see clearly in terms of the "fog" being gone. However, he indicated that he had floaters in the right eye. He reported that he had to get a new pair of glasses. The Veteran testified that he was prescribed drops for his eyes. He stated that he believed that his vision was 20/60 in the right eye and 20/30 or 20/40 in the left eye. Treatment reports submitted by the Social Security Administration (SSA) do not include any pertinent findings related to the Veteran's service-connected diabetic retinopathy. At a March 2012 VA eye examination, the Veteran's corrected distant vision was 20/40 or better bilaterally and his corrected near vision was 20/50 in the right eye and 20/40 or better in the left eye. The Veteran was diagnosed with mild diabetic retinopathy bilaterally. During the course of this appeal, VA revised the criteria for rating eye disabilities, effective December 10, 2008. 73 Fed. Reg. 66,543 (2008) (codified at 38 C.F.R. §§ 4.75- 4.79). However, because the Veteran filed his claim prior to December 10, 2008, the appeal will be considered under the old criteria. 73 Fed. Reg. 66543 (Nov. 10, 2008). The Veteran is currently rated under Diagnostic Code 6099- 6079 for his service-connected diabetic retinopathy. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2012). Diagnostic Code 6099 refers to an unlisted disability of the eye. 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. The severity of visual acuity loss is determined by applying the criteria set forth at 38 C.F.R. § 4.84a. Under these criteria, impairment of central visual acuity is evaluated from noncompensable to 100 percent based upon the degree of the resulting impairment of visual acuity. 38 C.F.R. § 4.84a, Diagnostic Codes 6061 to 6079. A disability rating for visual impairment is based on the best distant vision obtainable after the best correction by glasses. 38 C.F.R. § 4.75 (2008). The percentage evaluation will be found from Table V by intersecting the horizontal row appropriate for the Snellen index for one eye and the vertical column appropriate to the Snellen index of the other eye. 38 C.F.R. § 4.83a, Table V (2008). Combined ratings for disabilities of the same eye should not exceed the amount for total loss of vision of that eye unless there is an enucleation or a serious cosmetic defect added to the total loss of vision. 38 C.F.R. § 4.80 (2008). In this respect, a noncompensable rating is warranted for vision in both eyes that is correctable to 20/40. A 10 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) when vision in one eye is correctable to 20/50 and vision in the other eye is correctable to 20/40; (2) when vision in both eyes is correctable to 20/50; (3) when vision in one eye is correctable to 20/70 and vision in the other eye is correctable to 20/40; or (4) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/40. 38 C.F.R. § 4.84a, Diagnostic Codes 6078, 6079 (2008). In this case, while some of the entries contained in the VA outpatient treatment reports related to the Veteran's visual acuity appear to meet the threshold for a 10 percent rating, the rating criteria require that the best distant vision obtainable after the best correction by glasses be used to rate the disability at issue. The entries contained in the VA outpatient treatment reports do not include any pertinent findings that meet the rating criteria for a 10 percent rating because as noted, the entries included in these records do not meet the necessary criteria to rate the disability at issue. The same is true of the findings from the March 2008 VA examination. The examiner failed to include the Veteran's best distant vision obtainable after best correction by glasses. Consequently, the findings reported by the examiner do meet the pertinent rating criteria. The only pertinent findings of record were included in the most recent VA examination in March 2012 when the Veteran's corrected distant vision was reported to be 20/40 or better bilaterally which equates to a noncompensable rating. Accordingly, the Board finds that the criteria for an initial compensable rating for service-connected diabetic retinopathy have not been met during any portion of the appeal period. The preponderance of the evidence is against the claim for increase and the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. PTSD The Veteran's PTSD has been rated as 50 percent disabling under Diagnostic Code 9411. The criteria of Diagnostic Code 9411 provide for a 100 percent rating where the evidence shows total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The criteria provide for a 70 percent rating where the evidence shows occupational and social impairment, with deficiencies in most areas, such as work, school, family relations judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence) spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. The criteria provide for a 50 percent rating where the evidence shows 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; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (GAF) score is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness. A GAF score of 61-70 is defined as some mild symptoms (depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 51-60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 41-50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 31-40 is indicative of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant); or, major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood). Richard v. Brown, 9 Vet. App. 266 (1996); American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Relevant VA outpatient treatment reports reflect that the Veteran was seen for PTSD treatment for the period from June 2005 through September 2012. The records reflect GAF scores ranging from 35 to 60. In June 2005, the Veteran was noted to have appropriate hygiene and grooming and he was cooperative with good eye contact. His speech was spontaneous with normal tone, rate, rhythm and volume. His affect was constricted with a congruent mood. His thought process was linear and goal-directed with no suicidal or homicidal ideations or audio or visual hallucinations. His insight and judgment were reported to be fair. He was assessed with chronic PTSD and assigned a GAF score of 60. In August 2005, the Veteran was noted to live with his wife. He reported that his sleep was fair and his memory and concentration had decreased. He reported nightmares and flashbacks as well as periods of irritability. Mental status examination revealed adequate grooming, normal speech, fair insight and judgment, and the Veteran was oriented in three spheres. He was assessed with chronic PTSD and assigned a GAF score of 55-59. The examiner indicated that the Veteran's PTSD symptoms were moderate. Similar findings were reported in October 2005. The Veteran was noted to have a slightly constricted affect with linear thought process at that time. In January 2006, the Veteran's irritability was noted to have improved but he reported some difficulty concentrating. His sleep was noted to be suboptimal with three to four hours per night. Mental status examination revealed that the Veteran was adequately groomed and cooperative with a full affect, linear thought process, and fair insight and judgment. He was oriented in three spheres. He was assigned a GAF score of 65 at that time. In June 2006, the Veteran was noted to be irritable and anxious with increased nightmares and intrusive thoughts due to the war in Iraq. Mental status examination revealed that he had adequate grooming and hygiene. He had good eye contact, a constricted affect, linear thought process, and fair insight and judgment. He was alert and oriented in three spheres. The examiner assigned a GAF score of 55 at that time. In August, September, and December 2006, the Veteran was noted to be alert and oriented in three spheres with normal rate, rhythm and volume of speech. His thought process was linear and his affect was constricted. His insight and judgment were fair and his thought content was devoid of suicidal and homicidal ideation, hallucinations, and delusions. He was assessed GAF scores of 60, 58, and 60, respectively, at those times. In January and February 2007, the Veteran was alert and oriented in three spheres, he was well-groomed and dressed, his speech was normal, his affect was minimally constricted, his thought process was linear, and his insight and judgment were good. There was no evidence of suicidal or homicidal ideations, hallucinations, or delusions. He was assigned a GAF score of 60 at those times. In February and June 2008, the Veteran was noted to have fluctuating mood more on the depressed side. His sleep was interrupted by nightmares. He was noted to have been married for more than forty years. He reported that he heard thoughts or audio hallucinations of someone talking to him. It is of note that the examiner indicated that there were no auditory hallucinations present on mental status examination. Mental status examination revealed good cooperation and eye contact, moderate psychomotor retardation, slow monotonous speech, blunted affect, linear thought process, and poor insight and judgment. The Veteran denied suicidal and homicidal ideations, delusions, and audio and visual hallucinations. He was alert and oriented in three spheres. He was assigned a GAF score of 35 at those times. A group therapy entry dated in October 2008 indicates that the Veteran's grooming was fair. He was cooperative with good eye contact and decreased spontaneous movement. His speech was slow and monotonous with mild volume and increased latency. His affect was blunted, his thought process was linear, he was oriented in three spheres, and his insight and judgment were reported to be poor. There were no suicidal or homicidal ideations or auditory or visual hallucinations. He was assessed with a GAF score of 35. The examiner indicated that the Veteran had PTSD with questionable psychotic features. However, the examination does not indicate that any psychotic features were present. At a group session in November 2008, a GAF score of 35 was also assigned. In June 2009, the Veteran reported recurrent intrusive thoughts, flashbacks, exaggerated startle response, and irritability as well as poor sleep and nightmares. Mental status examination revealed adequate grooming, a cooperative attitude, good eye contact, a frustrated mood, normal speech, linear and goal- directed thought process, no delusions or suicidal or homicidal ideations, fair to good insight and judgment and the Veteran was alert and oriented. He was assigned a GAF score of 45. In February and March 2010, similar findings were reported. On two occasions in September 2010, the Veteran was noted to have a depressed mood with mild constriction. He had normal speech, adequate grooming, a cooperative attitude, linear and goal-directed thought process, and fair to good judgment at those times. He was assessed with a GAF score of 45 on both occasions. Similar findings were reported in November 2010. In June, July, and September 2011, the Veteran was noted to have periodic recurrent intrusive thoughts, flashbacks, an exaggerated startle response, and he was irritable. Mental status examination revealed adequate grooming and casual dress, a cooperative attitude, mild constriction of affect, normal speech, linear and goal-directed thought process, no delusions, no suicidal or homicidal ideations or audio or visual hallucinations, and fair to good judgment. The Veteran was alert and oriented in three spheres. The Veteran was assigned a GAF score of 45 at those times. In November 2011, the Veteran was noted to attend bi-monthly group therapy sessions. In January, May, and July 2012, the Veteran was noted to have good grooming and casual dress, a cooperative attitude with good eye contact, mildly constricted affect, normal speech, linear and goal-directed thought process, no delusions, no homicidal or suicidal ideations, and no auditory or visual hallucinations. He was alert and oriented and his insight and judgment were fair. He was assigned a GAF score of 45 at those times. In February 2012, the Veteran reported an incident in a parking lot where he had a verbal altercation with someone over a parking spot. In November 2012, the Veteran's treating psychiatrist indicated that the Veteran was under his care for chronic PTSD and has tried multiple psychotropic medications without noticeable benefits. He noted that the Veteran had recurrent intrusive thoughts, periodic flashbacks, easy startle response, and irritability. He reported that the Veteran avoided interaction with people but volunteered at VA once a week to call veterans to remind them of their appointments. The psychiatrist assigned a GAF score of 45. At a VA PTSD examination in November 2006, the Veteran reported that his wife and children are supportive about his PTSD symptoms which help him to get aggravated less. The Veteran indicated that he avoided crowds, watched sports, was close with his family and group members in his PTSD group, and attended church. He said he watched sports and stayed home with his family most of the time and liked to have "alone time." He denied a history of suicide attempts and a history of violence/assaultiveness. Clinical evaluation of the Veteran revealed that the Veteran was clean and neatly groomed with a friendly and cooperative attitude. His affect was normal, his psychomotor activities were unremarkable, his mood was agitated and he was oriented in three spheres. His thought process was racing and his thought content was unremarkable. He did not have delusions and his judgment and insight were intact. The Veteran was noted to have nightmares that woke him up, no hallucinations, no inappropriate behavior, no obsessive/ritualistic behavior, no panic attacks and no homicidal or suicidal thoughts. His impulse control was good and he denied episodes of violence. He was able to maintain minimum personal hygiene and his memory was normal. The examiner indicated that the Veteran's PTSD symptoms included recurrent and intrusive distressing recollections of the event, recurrent distressing dreams of the event, and intense psychological distress and physiological reactivity on exposure to internal or external cues that symbolized the traumatic event, efforts to avoid thoughts, feelings, or conversations associated with the trauma, efforts to avoid activities, places, or people that aroused recollections of the event, markedly diminished interest or participation in significant activities, and a sense of foreshortened future. The Veteran also endorsed difficulty falling/staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. The Veteran was noted to have retired in 2002 due to physical problems. The examiner diagnosed the Veteran with chronic PTSD and assigned a GAF score of 54. At a VA PTSD examination in November 2008, the Veteran reported that he was married and had contact with his three children and five grandchildren. He endorsed irritability and a desire to isolate from them at times. He reported losing his temper with his wife daily and indicated that he avoided crowds and loud noises. The Veteran indicated that his family was very supportive of his problems related to PTSD. The Veteran stated that he had two good friends with whom he spent time weekly, either at his home or occasionally at restaurants. He indicated that he attended church once or twice a month, watched sports on television, and accompanied his wife on errands. He denied a history of suicide attempts and violence/assaultiveness. Clinical evaluation of the Veteran revealed that he was clean and casually dressed. His psychomotor activity was noted to be lethargic, his speech was impoverished and slow, his attitude was cooperative, his affect was constricted, and his mood was dysphoric. He was oriented in three spheres, his thought process was evasive, tangential, and his thought content was unremarkable. There were no delusions present and his judgment and insight were intact. He denied hallucinations and did not exhibit any inappropriate behavior. There was no evidence of obsessive/ritualistic behavior, panic attacks, or homicidal or suicidal thoughts. His impulse control was reported to be fair and he was reported to be verbally aggressive toward his wife and others. The Veteran's spouse reported that he was unconcerned with his hygiene and may go up to three days without showering unless prompted by her. His memory was reported to be normal. The examiner indicated that the Veteran's PTSD symptoms included recurrent and intrusive distressing recollections of the event, recurrent distressing dreams of the event, and intense psychological distress and physiological reactivity on exposure to internal or external cues that symbolized the traumatic event, efforts to avoid thoughts, feelings, or conversations associated with the trauma, efforts to avoid activities, places, or people that aroused recollections of the event, markedly diminished interest or participation in significant activities, and a sense of foreshortened future. The Veteran also endorsed difficulty falling/staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. The Veteran was noted to be retired due to physical problems. The examiner diagnosed the Veteran with recurrent PTSD and assigned a GAF score of 50. At a hearing before the Board in June 2010, the Veteran testified that he received treatment for his PTSD at VA. The Veteran indicated that he had panic attacks once or twice weekly. He also reported that he had flashbacks daily, a good relationship with his children, and obsessively checked the lock on his door at night. He testified that his PTSD caused him to get upset and aggravated when dealing with his spouse. He stated that he avoided people but had a good relationship with his neighbors and had difficulty sleeping at night. At a VA PTSD examination on February 13, 2012, the Veteran's mood was described as fair. He was oriented in three spheres. He endorsed depressed mood, lack of motivation to do things, lack of pleasure in things, difficulty concentrating/focusing attention, insomnia, less of an appetite, and anger/irritability. The Veteran reported anxiety at times and some rituals at night. The examiner assessed the Veteran with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner indicated that the Veteran's overall PTSD symptoms were moderate to severe and were having a significant impact on his daily functioning. The examiner noted that he had prior episodes of verbal altercations; although retired, the Veteran's PTSD likely kept him from performing to his optimal abilities at work; his PTSD symptoms have gotten in the way of his ability to be a good father and husband; he had difficulties with attention and concentration; and a history of chronic sleep impairments resulting in concentration problems. The examiner indicated that the Veteran endorsed depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty adapting to stressful circumstances, including work or a worklike setting, and neglect of personal appearance and hygiene. The examiner diagnosed the Veteran with chronic PTSD and assigned a GAF score of 48. Period prior to February 13, 2012 For the period prior to February 13, 2012, having reviewed the complete record, the Board finds that the preponderance of the evidence is against granting a rating in excess of 50 percent. The medical evidence, consisting of VA outpatient treatment reports dated from June 2005 to November 2011 and VA examination reports dated in November 2006 and November 2008 demonstrate findings consistent with anger, irritability, anxiety, panic attacks, and disturbances of motivation and mood. However, the Veteran's disability was not manifested by suicidal ideation, obsessional rituals which interfered with routine activities, near-continuous panic or depression, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, or an overall level of symptomatology supportive of a higher rating. The Board finds that the evidence supports no more than a 50 percent rating under Diagnostic Code 9411 for this time period at issue, which contemplates occupational and social impairment with some reduced reliability and productivity due to symptoms such as impairment of judgment, disturbances of motivation and mood, and difficulty maintaining effective relationships. The evidence does not indicate that the Veteran's PTSD was manifested by persistent delusions, obsessional rituals which interfered with routine activities, near-continuous panic or depression, spatial disorientation, or neglect of personal appearance and hygiene as none of those symptoms are shown in the record. The Board acknowledges that the Veteran indicated that he heard voices at entries dated in February and June 2008. However, mental status examinations revealed no auditory or visual hallucinations at those times and all other entries are negative for any reference to auditory hallucinations. The Veteran's symptoms best approximate occupational and social impairment with reduced reliability and productivity. Consequently, the Board finds that the greater weight of the evidence is against granting an evaluation in excess of 50 percent at any point during this time period at issue. With respect to the Veteran's GAF scores, the evidence of record documents GAF scores ranging from 35 to 60 for the time period at issue which contemplate moderate to severe symptoms. GAF scores are not, in and of themselves, the dispositive element in rating a disability, and the Board generally places more probative weight on the specific clinical findings noted on examinations. In this case, the clinical findings during the time period at issue do not substantiate a GAF score indicative of more than moderate symptomatology. The evidence does not establish that the Veteran's PTSD symptomatology resulted in major deficiencies or met the symptomatology for a rating greater than 50 percent. The Board finds that the clinical findings of record demonstrate a degree of impairment consistent with no more than a 50 percent rating. Accordingly, the Board finds that the criteria for a rating higher than 50 percent for the period prior to February 13, 2012, have not been met. The preponderance of the evidence is against the claim for increase and the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Period from February 13, 2012 For the period from February 13, 2012, having reviewed the complete record, the Board finds that the preponderance of the evidence warrants a grant of a 70 percent rating. The medical evidence, consisting of VA treatment reports dated since February 2012 and a February 2012 VA examination, demonstrates findings consistent with depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, and neglect of personal appearance which resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. However, the Veteran's disability was not manifested by total occupational or social impairment due to such symptoms as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living, disorientation to time or place, memory loss for names of close relatives, own occupation or own name, or an overall level of symptomatology supportive of a higher rating. The Board finds that the evidence supports a rating of 70 percent and no more under Diagnostic Code 9411 for the time period at issue, which contemplates occupational and social impairment with deficiencies in most areas. The evidence does not indicate that the Veteran's PTSD was manifested by gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior; persistent danger of hurting self or others, intermittent inability to perform activities of daily living, disorientation to time or place, memory loss for names of close relatives, own occupation or own name or other symptoms approximating a greater level of impairment. Consequently, the Board finds that the greater weight of the evidence is against granting an evaluation in excess of 70 percent at any time during the time period at issue. With respect to the Veteran's GAF scores, the evidence of record documents GAF scores ranging from 45 to 48 which contemplate serious symptoms. GAF scores are not, in and of themselves, the dispositive element in rating a disability, and the Board generally places more probative weight on the specific clinical findings noted on examinations. In this case, the clinical findings during the time period at issue do not substantiate a GAF score indicative of more than severe symptomatology as there was no evidence of impairment of reality. The Board finds that the clinical findings of record demonstrate a degree of impairment consistent with no more than a 70 percent rating. Accordingly, the Board finds that the criteria for a rating of 70 percent and no more since February 13, 2012, have been met. C. Extraschedular Consideration The Board has considered whether an extraschedular rating is warranted in this case. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993); 38 C.F.R. § 3.321(b)(1) (2012). Factors for consideration in determining whether referral for an extraschedular rating is necessary include marked interference with employment or frequent periods of hospitalization that indicate that application of the regular schedular standards would be impracticable. Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321(b)(1) (2012). The Board finds that referral is not warranted in this case. The evidence of record does not show that the Veteran's service-connected diabetic retinopathy and PTSD markedly interfere with employment, beyond that contemplated in the assigned rating, or warrant frequent periods of hospitalization. None of the examiners of record have indicated that the Veteran's service-connected disabilities markedly interfered with his employment. As noted above, the Veteran is unemployed due to physical ailments. Although the most recent VA psychiatric examiner indicated that the Veteran's PTSD likely kept him from performing to his optimal abilities, that finding is not tantamount to marked interference with employment. Moreover, the service- connected diabetic retinopathy and PTSD have not required frequent periods of hospitalization. Consequently, the Board finds that the evidence does not show that the criteria for referral are met because marked interference with employment and frequent hospitalizations are not shown. 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). ORDER Entitlement to an initial compensable rating for diabetic retinopathy is denied. Entitlement to a rating in excess of 50 percent for PTSD prior to February 13, 2012, is denied. A 70 percent, but no higher, rating for PTSD is granted, subject to controlling regulations applicable to the payment of monetary benefits. REMAND A review of the claims file reveals that a remand is necessary in order to properly adjudicate the remaining claims. With regard to the claims of entitlement to service connection for a bilateral knee disability and for a low back disability, the Veteran's claims were previously remanded, in pertinent part, to obtain VA examinations to determine the nature and etiology of the claimed disabilities. The Veteran was afforded a VA examination in February 2012. At that time he was diagnosed with spondylosis of the lumbar spine with degenerative changes in the lower lumbar spine noted on x-rays. The Veteran was also diagnosed with degenerative joint disease (DJD) of the bilateral knees confirmed by magnetic resonance imaging (MRI). The examiner opined that the claimed disabilities were less likely than not incurred in or caused by service. The examiner's rationale was that while the service treatment reports (STRs) reflected bilateral knee complaints, an orthopaedic specialist indicated that the knees were normal in service. With regard to the low back disability, the STRs were negative for any reference to low back complaints and the examiner indicated that he would have expected to see some notation of back pain during service. He also noted that service likely contributed to a degenerative change but should not be solely attributable to it. The examiner's opinion is contradictory as he seems to suggest that service contributed to degenerative changes; however, he concludes that it is less likely than not that either disability was caused or aggravated by service. Consequently, another examination with opinions regarding etiology is necessary in order to properly adjudicate the claims. With regard to the claim for an increased rating for ischemic heart disease, the Veteran was last afforded a VA examination in February 2012. Medical evidence associated with the claims file reveals that the Veteran underwent a coronary artery bypass graft at VA in December 2012. As it is possible that the Veteran's service-connected ischemic heart disease may have worsened in severity since the last examination, another VA examination is necessary in order to determine the current severity of the service-connected disability. Associated with the claims file are VA outpatient treatment reports dated through September 2012. Because there may be outstanding VA medical records that contain information pertinent to the Veteran's claims, an attempt to obtain any VA records dated after September 2012 should be made. 38 C.F.R. § 3.159(c)(2) (2012); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's VA treatment records dated since September 2012. 2. Following completion of the above, schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of the claimed bilateral knee and low back disabilities. A complete rationale for any opinions must be provided. The examiner should review the claims file and note that review in the report. The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's low back disability (diagnosed as spondylosis of the lumbar spine with degenerative changes in the lower lumbar spine) and bilateral knee disability (diagnosed as degenerative joint disease of the bilateral knees) were caused or aggravated (increased in severity beyond the natural course of the condition) by the Veteran's period of active duty service. The examiner must consider the Veteran's statements regarding the incurrence of the symptoms of his claimed disabilities in service and his statements regarding the continuity of symptomatology since service. Dalton v. Nicholson, 21 Vet App. 23 (2007). The examiner should consider the STRs noting right knee complaints in service with regard to the claimed bilateral knee disability and whether the back disability was due to repeated heavy lifting in service or due to his bilateral knee disability. To the extent possible, the examiner should reconcile his/her opinions with the opinion of the February 2012 VA examiner. 3. The Veteran should be scheduled for a VA examination to with the appropriate expert to determine the current severity of the service-connected ischemic heart disease. The examiner should review the claims file and note that review in the report. All indicated studies should be completed. 4. Then, readjudicate the claims. If action remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or 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). ______________________________________________ BARBARA COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs