Citation Nr: 1330416 Decision Date: 09/23/13 Archive Date: 09/30/13 DOCKET NO. 10-47 447 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. For the period prior to May 5, 2010, entitlement to an initial evaluation in excess of 10 percent disabling for posttraumatic stress disorder (PTSD). 2. For the period from May 5, 2010 to December 27, 2010, entitlement to an initial evaluation in excess of 30 percent disabling for PTSD. 3. For the period beginning on December 28, 2010, entitlement to an initial evaluation in excess of 50 percent disabling for PTSD. 4. Entitlement to service connection for a lumbar spine disability. 5. Entitlement to service connection for right ear hearing loss. 6. Entitlement to service connection for a right eye vitreous disorder and iritis. 7. Entitlement to service connection for erectile dysfunction as secondary to PTSD. 8. Entitlement to service connection for a right knee disability. 9. Entitlement to service connection for a gastrointestinal condition, to include as secondary to PTSD. 10. Entitlement to service connection for a sleep disorder as secondary to PTSD. REPRESENTATION Appellant represented by: John S. Berry, Esq. ATTORNEY FOR THE BOARD J. Juliano, Counsel INTRODUCTION The Veteran served on active duty in the Army from October 2005 to August 2007. He also had service in the Army National Guard beginning in November 2004, including a period of active duty for training from April 2005 to August 2005. He is the recipient of the Combat Action Badge. These matters come before the Board of Veterans' Appeals (Board) on appeal from September 2009 and July 2010 rating decisions of the Department of Veterans Affairs (VA) regional office (RO) located in Lincoln, Nebraska. A November 2010 rating decision granted a higher initial rating from 10 percent to 30 percent disabling for the Veteran's PTSD, effective May 5, 2010. A June 2011 rating decision granted a higher rating of 50 percent disabling for the Veteran's PTSD, effective December 28, 2010. As these decisions do not constitute a full grant of the benefit sought on appeal, the Veteran's PTSD initial rating claim remains before the Board. See AB v. Brown, 6 Vet. App. 35 (1993) The Board notes that the Veteran's claim for service connection for right eye floaters, photopsias, and iritis has been recharacterized by the Board to a claim for service connection for a right eye vitreous disorder and iritis because the Veteran is now service-connected for headaches with photopsias, and in light of the medical evidence of record. See Rating Decision, November 2010. The Board notes that the Veteran has not been prejudiced by the recharacterization of his claim, as service connection is being granted herein. A request for a total disability evaluation based on individual unemployability (TDIU), whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if a disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation." Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A TDIU claim is considered reasonably raised when a Veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). Here, the Veteran has not submitted evidence of service-connected unemployability. Therefore, the issue is not raised and entitlement to a TDIU is not before the Board. The issues of entitlement to service connection for a right knee disability, for a gastrointestinal condition, and for a sleep disorder 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. During the entire period on appeal, the Veteran's PTSD has manifested by mild to moderate symptoms, including anxious mood, chronic sleep impairment, a restricted affect, markedly diminished interest in activities, and irritability with periods of violence. 2. The Veteran's lumbar spine condition is not casually or etiologically related to a disease, injury, or incident in service; his lumbar spine condition is attributable to a diagnosed illness. 3. The Veteran's preexisting right ear hearing loss was noted on examination at entrance into service, did not increase in severity in service, and was not otherwise aggravated by service. 4. The Veteran's right eye vitreous disorder and iritis are casually or etiologically related to a disease, injury, or incident in service. 5. The Veteran is not shown by the medical evidence of record to have an erectile dysfunction disability. CONCLUSIONS OF LAW 1. For the period prior to December 28, 2010, the criteria for a 50 percent initial rating, and no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.130, Diagnostic Code 9411 (2012). 2. For the period beginning on December 28, 2010, the criteria for an initial rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.130, Diagnostic Code 9411 (2012). 3. Service connection for a lumbar spine condition is not warranted. 38 U.S.C.A. §§ 1110, 1118, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.317 (2012). 4. Service connection for right ear hearing loss is not warranted. 38 U.S.C.A. §§ 1110, 1111, 1153, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2012). 5. Service connection for a right eye vitreous disorder and iritis is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012) 6. Service connection for erectile dysfunction as secondary to PTSD is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) Service connection for a right eye vitreous disorder and iritis is granted, as explained below. As such, the Board finds that any error under the VCAA with regard to this claim is moot. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With regard to the Veteran's claims for higher initial evaluations for PTSD, and for service connection for a lumbar spine disability, a right knee disability, right ear hearing loss, and erectile dysfunction, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5102, 5103(a), 5103A, 5106 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is generally required to "notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided . . . that is necessary to substantiate the claim." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). As part of that notice, VA must "indicate which portion of that information and evidence, if any, is to be provided by the claimant and which portion, if any, the Secretary . . will attempt to obtain on behalf of the claimant." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). With regard to the Veteran's PTSD rating claim, where service connection has been granted and the initial rating has been assigned, the claim of service connection has been more than substantiated, as it has been proven. As such, 38 U.S.C.A. § 5103(a) notice is no longer required because the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, any defect as to 38 U.S.C.A. § 5103(a) notice is nonprejudicial. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). With regard to the Veteran's claims for service connection, the Board finds that VCAA letters dated in June 2009 and April 2010 fully satisfied the duty to notify provisions. The letters explained what evidence was needed to substantiate the claims, which evidence the Veteran was responsible for submitting, and which evidence VA would obtain. The April 2010 letter also explained how to substantiate a claim for secondary service connection. Also, the letters explained how VA assigns disability ratings and effective dates. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board also concludes that VA's duty to assist has been satisfied. The Veteran's VA treatment records dated since September 2007, around the time of his discharge, have all been associated with the claims file. Additionally, all of the Veteran's available service treatment records are in the claims file. In this regard, the Board acknowledges that while several service treatment records are in the claims file dated from 2004 to 2008, including his November 2004 enlistment examination report (Army National Guard), there is no separate examination report dated around the time of his unit mobilization in October 2005. The RO requested copies of all of the Veteran's service treatment records from the Records Management Center and National Personnel Records Center in June 2009. All of the Veteran's available records, to include records from the National Guard, were mailed and associated with the claims file. The Board finds that the RO has exhausted all administrative efforts to obtain the Veteran's full service treatment records, and that it appears that any further efforts would be futile. VA's duty to assist generally includes the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). In rating cases, where the evidence of record does not reflect the current state of a veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991); 38 C.F.R. § 3.327(a) (2012). With regard to the Veteran's PTSD rating claim, the Veteran was provided with VA examinations in July 2009 and May 2010. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's PTSD since the time of the last VA examination. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. VAOPGCPREC 11-95. The Board finds the July 2009 and May 2010 VA examinations to be thorough and adequate upon which to base a decision with regard to the Veteran's claim. The VA examiners personally interviewed and examined the Veteran and provided the information necessary to evaluate the Veteran's PTSD. With regard to the Veteran's service connection claims for a lumbar spine disability, right ear hearing loss, and erectile dysfunction, the Veteran was provided with VA examinations in July 2009 (hearing loss; spine) and May 2010 (erectile dysfunction). Additionally examiners offered opinions as to the etiology of the hearing loss and spine in July 2009 and August 2010. The Board finds that these VA examinations and medical opinions are adequate upon which to base a decision with regard to the Veteran's claims. The VA examination reports and VA medical opinions reflect that the VA examiners reviewed the claims file, interviewed and examined the Veteran, and provided thorough rationales for their conclusions (as clarified by the addendum VA medical opinions). Although an opinion has not been obtained with respect to the erectile dysfunction claim, that is because a current diagnosis of the disability is not of record. 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, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Analysis The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports a 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. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A. PTSD Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of a veteran. 38 C.F.R. § 4.3 (2012). A veteran's entire history is reviewed when making a disability determination. 38 C.F.R. § 4.1 (2012). When a veteran timely appeals an initial rating for a service-connected disability within one year of the rating decision, VA must consider whether the veteran is entitled to "staged" ratings to compensate him for periods of time since the filing of his claim when his disability may have been more severe than others. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected PTSD is evaluated under Diagnostic Code 9411. The regulations establish a general rating formula for mental disabilities. 38 C.F.R. § 4.130 (2012). Ratings are assigned according to the manifestation of particular symptoms. Notably, the term "such as" in 38 C.F.R. § 4.130 precedes lists of symptoms that are not exhaustive, but rather serve as examples of the type and degree of symptoms and their effects that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F. R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The criteria for a 10 percent rating are as follows: Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. The criteria for a 30 percent rating are as follows: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). The criteria for a 50 percent rating are as follows: 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. The criteria for a 70 percent rating are as follows: 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 work-like setting); inability to establish and maintain effective relationships. The criteria for a 100 percent rating are as follows: 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. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score is, of course, just one part of the medical evidence to be considered and is not dispositive. The same is true of any physician's statement as to the severity of a disability. It remains the Board's responsibility to evaluate the probative value of any doctor's opinion in light of all the evidence of record. GAF scores from 61 to 70 indicate some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores from 51 to 60 represent moderate symptoms, such as flat affect and circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school function (such as few friends, conflicts with peers or coworkers). GAF scores ranging from 41 to 50 reflect 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). The Veteran's PTSD is currently assigned a 10 percent disability rating under Diagnostic Code 9411 for the period prior to May 5, 2010. A 30 percent rating is assigned for the period from May 5, 2010 to December 27, 2010. A 50 percent rating is assigned effective December 28, 2010. See 38 C.F.R. § 4.130 (2012). A July 2009 VA examination report reflects that the examiner noted that October 2007 VA records noted that the Veteran complained of insomnia, that he reported a good relationship with his girlfriend, and that he spends time with close friends and has a family network. The examiner noted that the Veteran was experiencing symptoms including difficulty getting to sleep, and tossing and turning, a restricted range of affect, irritability or outbursts of anger (albeit no episodes of violence was noted). The examiner noted that the Veteran's memory was normal, speech was clear, no panic attacks were reported, no difficulty in understanding complex commands was noted, judgment was normal, thought was unremarkable, he denied suicidal thoughts, had no obsessional rituals or behavior, he maintained minimum personal hygiene, no delusions or hallucinations were noted, no grossly inappropriate behavior, and he was noted as oriented as to time, place, and person. The examiner opined that the Veteran's symptoms caused him to have difficulty getting things done, and caused him to miss National Guard drills. Overall, the examiner opined that his symptoms are mild. A diagnosis of PTSD, chronic, was recorded, and a GAF score of 67. The examiner opined that the Veteran's PTSD symptoms are transient and mild and decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. A May 2010 VA examination report reflects that the examiner noted in detail the Veteran's treatment notes from the VA medical center dated since June 2009, showing that the Veteran maintained a supportive romantic relationship with his girlfriend of three years, and that he was able to maintain employment, and that he had an upcoming sentencing hearing for an aggravated assault and concealed weapons charges. The examiner attributed that incident, as well as a similar incident the Veteran reported having occurred in the past week in a parking lot, to his diagnosed personality disorder NOS (with narcissistic and paranoid traits). The examiner also attributed the Veteran's irritability with violent outbursts to his personality disorder, and went on to document the Veteran's antagonistic behavior towards the examiner during the examination and his threats of violence at the VA medical center. With regard to the Veteran's PTSD, the examiner noted that the Veteran's symptoms included an anxious mood, "mild" hypervigilance, "mild" difficulty falling asleep and nightmares, a restricted or constricted affect, and markedly diminished interest in activities. The examiner noted that the Veteran's memory was normal, speech was clear, no panic attacks were reported, no difficulty in understanding complex commands was noted, judgment was normal, thought was unremarkable, he denied suicidal ideation, had no obsessional rituals or behavior, maintained hygiene, no delusions or hallucinations were noted, no grossly inappropriate behavior, and he was noted as oriented as to time, place, and person. The examiner recorded diagnoses of PTSD and cannabis and alcohol dependence. The examiner noted that for the Veteran's PTSD only, a GAF score of 60 was assigned. The examiner noted that psychometric data showed overall moderate symptoms. Also, the examiner noted that the Veteran's PTSD symptoms did not result in reduced reliability and productivity. Rather, the examiner opined that his symptoms caused occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks, but generally functioning satisfactorily. Subsequent VA treatment records reflect that the Veteran has continued to be followed at the VA medical center for his diagnosed PTSD. A December 2010 VA treatment record reflects that the Veteran reported symptoms of anger and irritability, social isolation, night sweats and restless sleep. He reported he was experiencing less outbursts due to utilizing "time outs," and that he was focusing on compassion. A diagnosis of PTSD with significant irritability was recorded, as well as a GAF score of 55. An April 4, 2011 VA treatment record reflects that the Veteran reported an improvement in managing his anger and irritability, less social isolation, and stabilization of his depression and anxiety, and that his romantic relationship continued to be a source of strength and support. He also reported that his employment laying floors was positive. He was noted as mild to moderately anxious at the time of the examination. In response to several questions, the Veteran responded that he was experiencing quite a bit of loss of interest in activities, extreme difficulty sleeping, moderate irritability and anger outbursts, and moderate difficulty concentrating. The clinician noted a diagnosis of PTSD, and a GAF score of 55. In light of all of the evidence, the Board finds that a higher, 50 percent rating is warranted throughout the appeal period. Specifically, the Veteran has reported throughout the entire period on appeal that his main symptoms are anxiety and chronic sleep impairment. These symptoms are contemplated by the 30 percent rating criteria. However, he has also demonstrated some symptoms contemplated by the 50 percent rating criteria, such as a flattened affect and a markedly diminished interest in activities evidencing a disturbance of motivation and mood. With regard to the higher still rating of 70 percent, the Board notes that the Veteran has also shown instances of irritability and outbursts of anger, some which have included violence. The Board acknowledges that the May 2010 VA examiner attributed the Veteran's irritability and violence to his diagnosed personality disorder, including his aggravated assault charge. At the same time, however, the July 2009 VA examiner did not attribute the Veteran's irritability and anger to a personality disorder, but rather, attributed it to his service-connected PTSD. Likewise, the VA treating clinicians have attributed his irritability and anger to his PTSD. As such, the Board is left with conflicting opinions as to which condition his irritability and violent symptoms relate; therefore, the Board will attribute his irritability with violence to his service-connected PTSD. That said, however, the Veteran's overall disability picture is not on par with the remaining symptoms contemplated by the 70 percent criteria. In particular, that level of severity contemplates spatial disorientation, suicidal ideation, illogical, obscure or irrelevant speech, and near-continuous panic affecting the ability to function independently. None of these symptoms have been shown by the record; nor have symptoms on par with this level of severity have been shown. Therefore, the higher 70 percent rating is not appropriate in this case. Overall, the Board finds that the 50 percent rating category adequately accounts for the Veteran's symptoms of anxiety, sleep impairment, and anger. Furthermore, while the Board acknowledges that the Veteran was noted as "not violent" by the July 2009 VA examiner, because it was subsequently such a short a period of time leading up to his arrest for aggravated assault, with a weapon, the Board finds that the evidence is sufficient to grant the higher rating for the entire period on appeal. The Board notes that a 50 percent rating is consistent with the Veteran's GAF scores, which have mostly ranged from 55 to 67, with only the May 2010 VA examination showing a score of 50 in light of the Veteran's recent aggravated assault charge. GAF scores from 51 to 60 represent moderate symptoms, and GAF scores of 41 to 50 represent serious symptoms. The Veteran's GAF scores have all been in the mild-to-moderate range except for the one-time GAF May 2010 score of 50 that was based on the aggravated assault charge. In that regard, the Board notes that the Veteran's irritability and violence as demonstrated by the aggravated assault has been the greatest factor in granting the higher, 50 percent rating herein. Also, the Board notes that the July 2009 VA examiner recorded a GAF score of only 67, indicating only mild symptoms, and the May 2010 VA examiner noted that the Veteran's PTSD symptoms were mostly "mild." Therefore, in light of the above, the Board finds that the evidence supports a grant of a 50 percent disability rating for the period prior to December 28, 2010, but no more. Further, the Board finds that the preponderance of the evidence is against granting a rating in excess of 50 percent disabling thereafter. The Board has also considered whether the record raises the matter of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). That section applies when the rating schedule is inadequate to compensate for the average impairment of earning capacity for a particular disability. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, a comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The competent evidence does not that the disability at issue causes marked interference with employment, requires frequent hospitalizations, or otherwise produces impairment unrecognized by the Schedule. Thus, the Veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. B. Lumbar Spine The Veteran served on active duty in the Army as a Calvary scout from October 2005 to August 2007, including service in Iraq from March 2006 to June 2007. He also had service in the Army National Guard beginning in November 2004, including a period of active duty for training from April 2005 to August 2005. He is the recipient of the Combat Action Badge. The Veteran claims that he has a lumbar spine disability that is related to service. Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2012). With specific regard to National Guard and Reserve service, service connection may be granted for disability resulting from either disease or injury incurred in, or aggravated while performing, active duty for training (ACDUTRA). With respect to time periods of inactive duty training (INACDUTRA), service connection may only be granted for injury so incurred or aggravated. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131 (West 2002). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Referable to the first element, that of current diagnosis, the Veteran was provided with a VA examination in July 2009. The Veteran reported to the examiner that he had experienced back pain once or twice a month since 2004 or 2005, and he referred to the pain as "back kidney pain." The VA examiner noted that the August 2008 report of medical history of record reflects that the Veteran denied any back pain at that time. It was noted that the Veteran was not under any treatment and that his back had not previously been x-rayed. An x-ray revealed a normal lumbar spine. Physical examination revealed normal posture, and no other abnormalities except pain with motion was noted. The examiner recorded a diagnosis of lumbar strain. Therefore, the first element is established. Regarding the second element, that of an in-service event, the service treatment records are silent for treatment of any back complaints. However, a September 2007 VA OEF/OIF assessment record reflects that the Veteran reported a history of back problems since service. This is directly contradicted by the November 2008 report of medical history for the National Guard, on which the Veteran checked the box denying back pain. Regardless, the Veteran now contends that he did have back pain in service. As he is in receipt of the combat action badge, and as back pain is consistent with the circumstances of his service, the Board accepts his statement as to having pain in service as sufficient to meet the second element. The remaining element required to establish service connection is that of a nexus between the current disability and service. In the July 2009 examination, the reviewing examiner opined that the Veteran's condition was less likely as not related to service. The examiner reasoned that the Veteran had never been seen for any back issues (while he had sought treatment for other maladies, such as his right knee, such that this is not a case of a lack of contemporaneous records, but rather, a lack of complaint), and because he checked the box on the August 2008 report of medical history denying back trouble. The examiner added that the medical evidence of record (including the Veteran's own documented reports) reflect that he had been involved in a motorcycle accident in October 2007 (post-service). An August 2010 VA medical opinion from the same examiner reflects that the examiner addressed the Veteran's alleged exposure to burning trash (see, e.g., VA Examination Report - Eyes, July 2009). The examiner opined that the Veteran's lumbar spine condition was less likely as not related to an in-service exposure event. The examiner reasoned that there was no causative exposure event shown in the claims file. The examiner also noted that the Veteran's lumbar spine condition does not constitute an undiagnosed illness because it is a condition with a clear and specific etiology and diagnosis. See 38 U.S.C.A. § 1118 (West 2002); 38 C.F.R. § 3.317 (2012). The Board finds the opinions of the July 2009 and August 2010 VA examiner to be the most probative evidence of record with regard to whether the Veteran's lumbar strain is related to his active service (or active duty for training). The Board notes that there is no medical opinion of record that contradicts the opinion of the VA examiner. While the Board acknowledges that the Veteran's lay opinion is that his lumbar spine condition is in fact related to service, the Board finds that based on the VA examiner's education, training, and experience, his medical opinion regarding etiology is by far more probative. Furthermore, the Board finds that the Veteran is not competent to render an opinion as the etiology of his back pain, as it involves complex medical matters, as opposed to being capable of observation by a lay person. The Board acknowledges that the Veteran has asserted that he has experienced back pain since service (2004 or 2005). However, the Board finds his reports to be not credible in light of the fact that his August 2008 report of medical history reflects that he denied any back pain, which contradicts his report in this case. Hathaway v. Merit Systems Protection Board, 981 F.2d 1237 (Fed. Cir. 1992) (Board did not err by crediting different parts of witness testimonies; a fact finder is not obliged to accept or reject a witness' testimony in toto, but should rather evaluate the testimony in light of other evidence to determine whether and how much of the witness' testimony is credible). see also DeSarno v. Department of Commerce, 761 F.2d 657, 661 (Fed.Cir.1985) ("That some parts of a witness' testimony may be attacked is a common phenomenon. It supplies no basis, however, for holding that the fact-finder is not entitled to credit other parts of that witness' testimony."). Furthermore, to the extent that he alleges continuity of symptomatology for the purpose of establishing service connection, the Federal Circuit has held that section 3.303(b) on continuity of symptomatology applies only to those chronic conditions specifically listed in 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Lumbar strain is not a listed chronic disability. To the extent that the Veteran contends that his back pain is due to an undiagnosed illness, the Board finds the argument without merit. His back pain has been specifically attributed to the diagnosis of lumbar strain. In light of the above, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a lumbar spine disability; the benefit of the doubt rule is not for application. C. Right Ear Hearing Loss The Veteran claims that he has right ear hearing loss due to acoustic trauma in service, including his combat service in Iraq. With respect to hearing loss, VA has specifically defined what is meant by a "disability" for the purposes of service connection. See 38 C.F.R. § 3.385 (2012). "[I]mpaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent." Service connection may also be granted on a presumptive basis for certain chronic diseases, including sensorineural hearing loss, if manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2012). "With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes." 38 C.F.R. § 3.303(b) (2012). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, and disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002). "When no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both preexisting and not aggravated by service." Wagner v. Principi, 370 F.3d 1089, 1096-1097 (Fed. Cir. 2004); VAOPGPREC 3-2003 at 10-11 (July 16, 2003). The veteran is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOPGCPREC 3-2003 at 10-11 (July 16, 2003). When a preexisting disease or injury is noted on the entrance examination report, 38 U.S.C.A. § 1153 provides that "[a] preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease." 38 C.F.R. § 3.306(a) (2012). With regard to veterans who served during a period of war or after December 31, 1946, clear and unmistakable evidence is required to rebut the presumption of aggravation where a pre-service condition underwent an increase in severity during service. 38 C.F.R. § 3.306(b) (2012); Cotant v. Principi, 17 Vet. App. 116, 124, 130 (2003). Temporary or intermittent flare-ups of symptoms of a preexisting condition alone do not constitute sufficient evidence for a non-combat veteran to show increased disability for section 1153 purposes unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346- 47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The Board notes that the Court has held that the threshold for normal hearing is from 0 to 20 decibels, and that higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). As noted above, the Veteran served on active duty in the Army as a Calvary scout from October 2005 to August 2007, including service in Iraq from March 2006 to June 2007, and he is the recipient of the Combat Action Badge. Based thereon, acoustic trauma in service is conceded in this case. See 38 U.S.C.A. § 1154(b). The Board also acknowledges that the Veteran is presently service-connected for tinnitus. See Rating Decision, September 2009. A November 2004 enlistment audiological examination report (for the Army National Guard prior to mobilization) reflects pure tone thresholds were as follows: Hertz (decibels) 500 1000 2000 3000 4000 6000 RIGHT 15 30 25 35 40 40 Hearing loss profile of "H1" was recorded. Because the November 2004 enlistment examination report reflects that the Veteran's right ear pure tone thresholds exceeded 26 decibels at 1000, 3000, and 4000 hertz, he met the VA criteria for a right ear hearing loss disability on entry into service. See 38 C.F.R. § 3.385 (2012). Therefore, by definition for VA purposes, right ear hearing loss was noted on entry, and the presumption of soundness does not apply in this case. See, e.g., Ogrodnik v. Shinseki, No. 11-2145, 2013 WL 1156135 (March 21, 2013), and McPherson v. Nicholson, 25 Vet.App. 115 (Table) (2007) (both applying 38 C.F.R. § 3.385 to entrance examination pure tone thresholds in discussing whether the presumption of soundness applied to claimed hearing loss). While the Board acknowledges that the Veteran in November 2004 enlisted into the National Guard for active duty for training, but was not mobilized for active duty until October 2005 (and that there is no separate report of examination dated in October 2005 in the claims file), the Board nevertheless finds that given the proximity in time of his mobilization shortly after the November 2004 examination, the November 2004 examination report suffices to show that his hearing loss was noted on entry for 38 U.S.C.A. §§ 1111 and 1153 purposes. A June 2007 service audiological evaluation report reflects that pure tone thresholds were as follows: Hertz (decibels) 500 1000 2000 3000 4000 6000 RIGHT 10 30 25 40 30 50 An August 2008 service audiological evaluation report reflects that pure tone thresholds were as follows: Hertz (decibels) 500 1000 2000 3000 4000 6000 RIGHT 5 30 25 30 40 30 It was noted that the hearing threshold increased by 10 decibels at 4000 hertz, but the audiologist noted that this threshold shift was not significant. It was also noted that formed earplug type hearing protection had been used. Again, hearing loss code H1 was recorded. A September 2008 post-service VA audiology evaluation record reflects that pure tone thresholds were as follows: Hertz (decibels) 500 1000 2000 4000 8000 RIGHT 15 25 25 5 45 On his November 2008 report of medical history (for the National Guard), the Veteran checked the box denying any hearing loss. A July 2009 VA examination report reflects that the examiner noted the Veteran's history of noise exposure from gunfire, mortars, artillery, IEDs, jet engines, and from his barracks having been near the flightline in Iraq. It was noted that hearing protection was used consistently. Also noted was the Veteran's post-service noise exposure to construction work, again with hearing protection used, and his noise exposure from hunting. Audiological testing revealed pure tone thresholds as follows: Hertz (decibels) 500 1000 2000 3000 4000 Avg. RIGHT 15 25 30 30 30 45 Speech recognition was 94 percent in the right ear using Maryland CNC word lists. The examiner recorded a diagnosis of normal to mild sensorineural hearing loss. The examiner opined that the Veteran's right ear hearing loss is less likely as not related to service. The examiner reasoned that the Veteran's enlistment audiological examination revealed mild, high frequency hearing loss, that his test results at the time of examination were consistent with his enlistment hearing levels, and showed no significant shift in thresholds. He also noted that the Veteran's thresholds had not worsened more than 10 decibels in any of the frequencies since his entrance into service, and that according to literature, thresholds can vary from test-to-test by as much as 10 degrees, such that for a threshold shift to be significant, it must change by over 10 decibels. Also, the examiner again noted that the Veteran had post-service occupational and recreational noise exposure. The Board finds the opinion of the July 2009 VA examiner to be the most probative evidence of record with regard to whether the Veteran's right ear hearing loss preexisted service. Again, the Board notes that the examiner reasoned that the Veteran's pure tone thresholds exceeded 26 decibels at 1000, 3000, and 4000 hertz on enlistment in November 2004. The Board notes that there is no medical opinion of record that contradicts the opinions of the VA examiner. As noted by the VA examiner, at no time in service did any of the Veteran's pure tone thresholds shift more than 10 decibels, and the examiner explained that according to literature, thresholds can vary from test-to-test by as much as 10 degrees, such that for a threshold shift to be significant, it must change by over 10 decibels. Therefore, in light of the VA examiner's explanation, the Board finds that there was not an increase in severity of the Veteran's right ear hearing loss in service; therefore the presumption of aggravation does not apply. See 38 U.S.C.A. § 1153; Paulson v. Brown, 7 Vet.App. 466 (1995). Finally, the Board finds that the opinion of the July 2009 VA examiner is the most probative evidence of record with regard to whether the Veteran's preexisting right ear hearing loss was aggravated by service. Again, there is no medical opinion of record that contradicts the opinion of the VA examiner, and the examiner provided a thorough rationale for his conclusion that it was not aggravated by service. Therefore, in summary, the Board finds that the preponderance of the evidence shows that the Veteran's right ear hearing loss was noted on entry, preexisted service, and was not aggravated by service; the benefit-of-the-doubt rule is not for application. D. Right Eye The Veteran also claims that he has right eye floaters and iritis that are related to his exposure to burning trash during his service in Iraq. March 2007 to April 2007 service treatment records reflect that the Veteran reported experiencing in his right eye white flashes, blurriness, and loss of vision. Diagnoses of a right eye vitreous disorder and iritis were recorded, and he was prescribed eye drops for treatment. Immediately post-service, a September 2007 VA treatment record reflects that the Veteran reported experiencing floaters and flashes in his right eye, and an ophthalmology consult was ordered. An October 2007 VA ophthalmology consultation record reflects that a diagnosis of right eye panuveitis (vitreal cell) was recorded, and it was noted as having an initial onset of six months prior (during service). A July 2009 VA examination report reflects that the Veteran reported experiencing flashes and floaters in his vision ever since he was in Iraq. The examiner recorded diagnoses of vitreous syneresis (which he explained was consistent with the description of floaters), and iritis. The examiner opined that the Veteran's right eye conditions are not caused by or related to service, reasoning that there was no evidence of a mechanical evident (such as posterior vitreous detachment, retinal tear or detachment), or of any inflammatory process in service (such as focal inflammation or infection of the retina). The Board notes, however, that at the time of the July 2009 VA examination, it appears that the March 2007 to April 2007 service treatment records discussed above had not been associated with the claims file. A September 2010 VA medical opinion was obtained in which the VA examiner reviewed the claims file and opined that the eye drops prescribed to the Veteran for treatment in April 2007 did not cause his right eye conditions, but rather, treated his iritis condition. In light of the above, the Board finds that service connection is warranted for a right eye vitreous cell disorder and iritis. As shown above, the Veteran was treated for a right eye vitreous cell disorder and iritis in service in April 2007, he was diagnosed with the same at the time of the July 2009 VA examination, on the basis of the same reported symptoms that he has experienced during his service in Iraq. The Board adds that there is no evidence of any intercurrent right eye injury or infection, or of any preexisting right eye condition. While the Board acknowledges that the July 2009 VA examiner did not attribute the Veteran's right eye condition to service, the Board emphasizes that the March 2007 and April 2007 service treatment records discussed above appear to not have been associated with the claims file at the time of the VA examination, and the Board finds that a remand for another opinion would only cause undue delay for a claim that could otherwise be granted herein. Therefore, in summary, the Board finds that a preponderance of the evidence is in favor of granting service connection for a right eye vitreous cell disorder and iritis. E. Erectile Dysfunction The Veteran claims that he has erectile dysfunction secondary to his service-connected PTSD. A "disability which is proximately due to or the result of a service-connected disease or injury shall be service connected." 38 C.F.R. § 3.310(a) (2012). "Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence." 38 C.F.R. § 3.310(b) (2012); Allen v. Brown, 7 Vet. App. 439 (1995). As an initial matter, there is no record of treatment for erectile dysfunction in the claims file, including the Veteran's service treatment records and VA treatment records. The Veteran was provided with a VA examination in May 2010. The examiner noted that the Veteran denied problems with erectile dysfunction, and instead reported decreased libido and delayed ejaculation since 2010, noted by the examiner as a side effect of his citalopram. The examiner recorded diagnoses of decreased libido and delayed ejaculation secondary to citaprolam taken for PTSD. As shown above, there is no record of any diagnosed erectile dysfunction. The Board notes that the threshold requirement for service connection to be granted is competent medical evidence of the current existence of the claimed disorder. See Degmetich v. Brown, 104 F.3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Without a current diagnosis of erectile dysfunction, there may be no service connection for this claimed disability. The Board acknowledges the Veteran's belief that he suffers from "erectile dysfunction." As shown above, however, the competent medical evidence of record reflects that the Veteran does not in fact suffer from "erectile dysfunction." Rather, he is noted as experiencing decreased libido and delayed ejaculation, but not medically defined erectile dysfunction in particular. The Board adds that while the Veteran, as a lay person, is certainly more than capable of reporting his symptoms of decreased libido and the like, he is not medically qualified to diagnose erectile dysfunction, which requires medical training. To the extent that he is qualified to described the effects of erectile dysfunction, the Board finds that those statements are not credible, in light of the conflicting evidence of record. Specifically, while he brought a claim for erectile dysfunction, indicating his belief that he had it, he then denied having it on examination. Therefore, the Board finds the opinion of the VA examiner to be by far more probative. See 38 C.F.R. § 3.159(a) (2012); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In summary, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection for erectile dysfunction, and the benefit-of-the-doubt rule is not for application. ORDER For the period prior to December 28, 2010, an initial rating of 50 percent for PTSD is granted, subject to regulations applicable to the payment of monetary benefits. For the period beginning on December 28, 2010, entitlement to an initial rating in excess of 50 percent for PTSD is denied. Entitlement to service connection for a lumbar spine disability is denied. Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for a right eye vitreous disorder and iritis is granted. Entitlement to service connection for erectile dysfunction as secondary to PTSD is denied. REMAND A. Right Knee The Veteran also claims that he has a right knee disability as a result of his service. With regard to his service treatment records, August 2005 service treatment records reflect that the Veteran complained of right knee pain for a week, but that an x-ray revealed a normal right knee. A November 2005 service treatment records reflect that the Veteran complained of right knee pain since September, aggravated by running, and he also reported right knee pain the past spring during basic training at Ft. Knox (during his ADT in the National Guard). It was noted that he was placed on a 3-day profile 10 days priorto, and that he reported his knee was swollen a few days ago. A diagnosis of right knee pain was recorded and he was placed on profile. Various treatment records in the claims file indicate that the Veteran was involved in a motorcycle accident in October 2007, and that he tore his right ACL and/or meniscus and underwent surgical treatment. In fact, on his November 2008 report of medical history, the Veteran checked the boxes noting he had experienced knee trouble and that he had underwent knee surgery. The Veteran wrote an explanation that he blew out his ACL and meniscus in October 2007 and was treated privately by Dr. C. The Veteran was provided with a VA examination in July 2009, and the same examiner provided an August 2010 VA medical opinion. The examiner recorded a diagnosis of right knee injury, status post ACL and meniscus surgery, degenerative joint disease, possible patellar fracture. The examiner opined that the Veteran's right knee condition is less likely as not related to service. The examiner continued to state that, "most of his additional new knee issues occurred from the motorcycle trauma in October 2007 (after service)." This begs the question as to whether some of his knee issues were prior to the motorcycle accident. Because the reasoning is inadequate, a clarifying opinion is required. The claims file does not, however, include any of the private treatment records from the October 2007 motorcycle accident. The duty to assist requires that this claim be remanded so that any outstanding private treatment records relating to the October 2007 motorcycle accident and resultant right knee treatment can be associated with the claims file. B. Gastrointestinal Condition The Veteran also claims that he has a gastrointestinal condition as a result of his service-connected PTSD. The Veteran was provided with a VA examination in May 2010. The examiner's report indicates that the Veteran may have a "gastrointestinal condition," see page 92, that began in 2005, but it is not clear as to the diagnosis or whether any diagnosed condition was caused or aggravated by the Veteran's PTSD. A diagnosed mild right chronic inguinal ligament strain is noted in an addendum VA medical opinion. VA treatment records reflect that the Veteran has been followed for diagnosed abdominal pain of the right lower quadrant. See, e.g., June 26, 2009. In light of the above, the Board finds that a remand is necessary to obtain a new VA examination to clarify all of the Veteran's gastrointestinal disorders, and whether each such disorder was caused or aggravated by his service-connected PTSD. C. Sleep Disorder The Veteran also claims that he has a sleep disorder secondary to his service-connected PTSD. A "disability which is proximately due to or the result of a service-connected disease or injury shall be service connected." 38 C.F.R. § 3.310(a) (2012). "Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence." 38 C.F.R. § 3.310(b) (2012); Allen v. Brown, 7 Vet. App. 439 (1995). As discussed in detail above, chronic sleep impairment (which includes difficulty falling asleep as well as nightmares) is one of the symptoms of the Veteran's service-connected PTSD for which he is presently compensated. Nevertheless, a June 2010 VA medical opinion was obtained to address whether the Veteran has a distinct sleeping disorder secondary to his service-connected PTSD. The June 2010 VA examiner opined that the Veteran does not meet the DSM criteria for a separate sleep disorder. The examiner noted that criteria D for PTSD involves difficulty falling asleep or staying asleep, and that the medical evidence of record notes sleep impairment that is specific to his PTSD. In this regard, the Board notes that the DSM-IV lists the following types of sleep disorders: primary insomnia, primary hypersomnia, narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, dyssomnia not otherwise specified, nightmare disorder, sleep terror disorder, sleep walking disorder, parasomnia not otherwise specified, insomnia related to [indicate the Axis I or Axis II disorder], hypersomnia related to [indicate the Axis I or Axis II disorder], sleep disorder due to [indicate the general medical condition], and sleep-induced sleep disorder. In this particular case, without further explanation as to why the Veteran does not meet the criteria for a separate sleep disorder under the DSM, the Board finds that a remand is necessary to obtain such clarification. The Board adds that it may not offer its own medical conclusions. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to identify all private treatment relating to his October 2007 motorcycle accident and his right knee ACL and meniscus injuries therefrom; to that end, provide the Veteran with Forms 21-4142. Also, ask the Veteran to provide completed Forms 21-4142 so that any such records from Dr. C. and from Bryan East may be obtained. 2. After the above development is completed, forward the Veteran's claims folder to the examiner who provided the August 2010 medical opinion referable to the knee disability (or a suitable substitute if this individual is unavailable) for an addendum. The examiner is requested again to review the claims folder, to include any additional records of the October 2007 accident treatment, in order to render an opinion as to whether it is at least as likely as not (probability of fifty percent or more) that the Veteran's current knee disability is related to the in-service complaints of knee pain. Recognizing that the October 2007 motorcycle accident took place, the examiner is asked to specifically explain what was meant by the statement in August 2010 that "most of his additional new knee issues occurred from the motorcycle trauma in October 2007 (after service)" (emphasis added). The underlying reasons for the opinion expressed must be included in the opinion. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 3. Provide the Veteran with a VA examination to determine the current nature and the etiology of his claimed gastrointestinal condition. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The complete claims folder must be provided to the examiner for review in conjunction with the examination, and the examiner must note that the claims folder has been reviewed. The examiner is asked to opine as to the following: a. whether it is at least as likely as not (meaning likelihood of at least 50 percent) that any current gastrointestinal condition was caused by the Veteran's service-connected PTSD. b. whether it is at least as likely as not (meaning likelihood of at least 50 percent) that any current gastrointestinal condition was aggravated by the Veteran's service-connected PTSD. By aggravation, it is meant that there is a permanent worsening of the condition beyond its natural progression. c. whether it is at least as likely as not (meaning likelihood of at least 50 percent) that any current gastrointestinal condition had its onset in service or is otherwise related to service. Please note the Veteran has credibly reported exposure in service to burning trash. See, e.g., VA Examination Report - Eyes, July 2009. If any gastrointestinal condition found on examination is not found to be related to service, please explain the rationale for such opinion. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 4. Ask the VA examiner who prepared the June 2010 medical opinion relating to the Veteran's claimed sleep disorder (or a suitable substitute if this individual is unavailable) to clarify whether the Veteran meets the diagnostic criteria for each of the sleep disorders listed in the DSM. If the Veteran does not meet the diagnostic criteria for a disorder listed in the DSM, a rationale is required (e.g., addressing a criterion not met). 5. Then, readjudicate the Veteran's claims. If the claims remain denied, the Veteran should be provided with a Supplemental Statement of the Case (SSOC). After the Veteran and his representative have been given the applicable time to submit additional argument, the claims should be returned to the Board for further review. The appellant 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). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs