Citation Nr: 1331369 Decision Date: 09/30/13 Archive Date: 10/02/13 DOCKET NO. 07-24 448A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a rating in excess of 20 percent for diabetes mellitus. 2. Entitlement to a rating in excess of 10 percent for hypertension. 3. Entitlement to a compensable rating for erectile dysfunction. 4. Entitlement to an increased rating for posttraumatic stress disorder (PTSD), rated as 30 percent disabling prior to August 16, 2011 and 50 percent thereafter. 5. Entitlement to an increased rating for left lower extremity atherosclerotic arterial occlusive disease, rated as 20 percent disabling prior to August 29, 2012 and 40 percent thereafter. 6. Entitlement to an increased rating for right lower extremity atherosclerotic arterial occlusive disease, rated as 20 percent disabling prior to August 29, 2012 and 40 percent thereafter. 7. Entitlement to a total rating based upon individual unemployability due to service-connected disabilities (TDIU) prior to June 30, 2010. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran and his brother ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service July 1967 to July 1969. These matters come to the Board of Veterans' Appeals (Board) on appeal from a March 2006 rating decision decided by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which, in pertinent part, denied the Veteran's claims for an increased rating for PTSD, diabetes mellitus, right and left lower extremity atherosclerotic arterial occlusive disease, hypertension and erectile dysfunction. In addition, the Veteran appeals from a July 2007 rating decision that denied the Veteran's claim for TDIU. An April 2013 rating decision partially granted the Veteran's claim for an increased rating for PTSD and assigned a 50 percent rating, effective August 16, 2011. In addition, his claims for an increased rating for right and left lower extremity atherosclerotic arterial occlusive disease were partially granted and assigned a 40 percent rating for each extremity, effective August 29, 2012. However, inasmuch as a higher rating is available for these disabilities, and the Veteran is presumed to seek the maximum available benefit for a disability, the claims for a higher rating has remained viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In May 2013, the Veteran testified before the undersigned at hearing sitting at the RO. A hearing transcript has been associated with the claims file. At the May 2013 hearing, the Veteran submitted additional evidence in support of his claims, accompanied by a waiver of initial RO review. As the Veteran waived initial RO consideration, the Board may properly consider such newly received evidence. See 38 C.F.R. § 20.1304 (2012). In August 2013, the Veteran was provided copies of two VA examination reports as he had requested in a March 2013 letter. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file does reveals VA treatment records dated through February 2011 and a transcript of the May 2013 hearing. The issues of an increased rating for left and right lower extremity atherosclerotic arterial occlusive disease as well as a claim for a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. Since the September 2005 claim for an increased rating, the Veteran's diabetes mellitus has required insulin and a restricted diet, but has not required a regulation of his activities within the meaning of the applicable diagnostic criteria. 2. Since the September 2005 claim for an increased rating, the Veteran's diastolic blood pressure has predominantly been less than 110, and systolic blood pressure has been predominately less than 200. 3. The Veteran's erectile dysfunction is manifested by loss of erectile power without deformity of the penis. 4. For the period prior to and beginning August 16, 2011, the Veteran's PTSD symptoms more closely approximate total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for diabetes mellitus are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.119, 7913 (2013). 2. The criteria for a rating in excess of 10 percent for hypertension are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.104, 7101 (2013). 3. The criteria for a separate initial compensable rating for erectile dysfunction have not been met. 38 U.S.C.A. §§ 1144, 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.20, 4.27, 4.31, 4.115b, Diagnostic Code 7522 (2013). 4. The criteria for an increased rating of 100 percent for PTSD prior to August 16, 2011 and beginning August 16, 2011 have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a letter dated in October 2005, sent prior to the rating decision issued in March 2006, advised the Veteran of the evidence and information necessary to substantiate his claims for an increased rating. This letter advised him of his and VA's respective responsibilities in obtaining such evidence and information. Further, a September 2006 letter provided general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. The August 2007 statement of the case (SOC) reflects readjudication of the claims after issuance of the March 2006 letter. Hence, the Veteran is not shown to be prejudiced by the timing of the notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). After the March 2006 rating decision, and the Veteran's disagreement with the assigned ratings, the August 2007 SOC set forth the criteria for higher ratings for the disabilities on appeal, to include the General Formula for Diseases Mental Disorders, diabetes mellitus, hypertension and for a deformity of the penis. The January supplemental SOC (SSOC) reflects readjudication of the claims after the issuance of this August 2007 SOC, and the Veteran is hence not shown to be prejudiced by the notice. See Mayfield, supra; see also Prickett, supra. In addition, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of any notice provided. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Relevant to the duty to assist, the Veteran's service treatment records and VA treatment records have been obtained and considered. During his May 2013 hearing, the Veteran testified that he did not receive Social Security Administration disability benefits. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran was afforded multiple VA examinations in conjunction with the claims decided herein, including VA examinations conducted in November 2005, May 2007 and August 2011 to determine the severity of his PTSD and in June 2010 and February 2013 to determine the severity of his remaining service-connected disabilities. Neither the Veteran nor his representative has alleged that these VA examinations are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected disabilities decided herein as they include interviews with the Veteran, a review of the record, and full examinations, addressing the relevant rating criteria. Moreover, neither the Veteran nor his representative has alleged that his disabilities have worsened in severity since the most recent VA examinations. Rather, with respect to such claims, they argue that the evidence reveals that these disabilities have been more severe than the currently assigned ratings for the duration of the appeal period. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (the passage of time alone, without an allegation of worsening, does not warrant a new examination). Therefore, the Board finds that the examinations of record are adequate to adjudicate the Veteran's claims for an increased rating and no further examination is necessary. Additionally, in May 2013, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned. In Bryant v. Shinseki, the Court held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or VLJ who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the May 2013 hearing, the undersigned enumerated the issues on appeal. The undersigned explained to the Veteran that the evidence would need to establish that the severity of his symptoms warranted a higher rating. Also, information was solicited regarding the Veteran's current symptoms. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. Id. at 497. Moreover, the hearing discussion did not reveal any additional evidence pertinent to the claims decided herein. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Increased Rating Claims Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, 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, 126 (1999). The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, are expected in all instances. 38 C.F.R. § 4.21. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). A. Diabetes Mellitus The Veteran filed his claim for an increased rating for diabetes mellitus in September 2005. He contends that he was entitled to a higher rating as he took six shots of insulin per day, eats a restricted diet and has "lost all [his] strength." Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes mellitus that requires insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. A 40 percent rating is assigned for diabetes mellitus that requires the use of insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted in cases requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119. "Regulation of activities" has been defined as the situation where a veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,443 (May 7, 1996) (defining "regulation of activities," as used by VA in 7913). Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). In addition, a note following the rating criteria indicates that compensable complications from diabetes mellitus are evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are considered part of the diabetic process under 7913. Considering the pertinent evidence in light of the above, the Board finds that a rating greater than 20 percent for the Veteran's diabetes mellitus is not warranted at any point pertinent to this appeal. A December 2005 VA diabetes mellitus examination report indicated that the Veteran was insulin dependent and that he was required to use approximately 100 units of insulin per 24 hour period. In a May 2007 VA examination report, the Veteran indicated that he had hypoglycemic symptoms once or twice per week for which he ate some sweets and that he followed a diabetic diet and used insulin. He saw his diabetic care provider every three months. Severe symptoms, ketoacidosis, the use of emergency services or the restriction of activities due to diabetes mellitus were denied by the Veteran. A June 2010 VA genitourinary examination reflected the Veteran's reports that he had high and low blood sugar reactions, specifically that he got weak and sweaty when they were low and felt light-headed when they were high. He was on a restricted diet but had not been hospitalized for a high or low blood sugar reaction and visited his diabetic care provider every three months. During a May 2013 hearing, the Veteran testified that he used insulin every time he ate and that it has destroyed his body. In accordance with Note (1), the Board will first consider the Veteran's complications of diabetes. The Board notes that the Veteran receives a noncompensable rating for service-connected erectile dysfunction and special monthly compensation based on loss of use of a creative organ. Also, the Veteran already has been awarded separate disability ratings for his complications of diabetic nephropathy, coronary artery disease, diabetic retinopathy with cataracts, peripheral neuropathy of the left and right upper extremities, peripheral neuropathy of the left and right lower extremities and hypertension. As the Veteran is separately rated for each of his complications of diabetes, no consideration of those complications is warranted as part of the current claim for a higher rating for diabetes mellitus. Additionally, the record does not document that the Veteran has any complications of diabetes mellitus other than those for which he already receives separate disability ratings. Turning to the criteria for a rating in excess of 20 percent for diabetes mellitus under Diagnostic Code 7913, the Board concludes, after a review of the record, that at no time since the filing of the claim for an increased rating, has the Veteran's disability met the criteria for an increase to a 40 percent disability rating. Specifically, while the evidence shows the Veteran took insulin and was instructed to maintain a diabetic diet, the evidence does not support finding that the Veteran requires regulation of activities due to his service-connected diabetes mellitus, as detailed by Diagnostic Code 7913 (regulation of activities as the avoidance of strenuous occupational and recreational activities). 38 C.F.R. § 4.119, Diagnostic Code 7913. The Veteran is competent to report on symptoms and credible to the extent that he believes that the severity of his diabetes mellitus is such that a higher rating is warranted. His competent and credible lay evidence, however, is outweighed by competent and credible medical evidence that evaluates the true extent of the diabetes mellitus based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. Indeed, as noted above, medical evidence is required to show that occupational and recreational activities have been restricted which is not shown here. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. The medical evidence shows that a higher rating is not warranted. The probative evidence of record thus shows that the Veteran has not been required to regulate his activities--within the regulations for rating purposes. Therefore, the criteria for an increased rating for diabetes mellitus under the criteria of Diagnostic Code 7913 are not met. As the criteria for the next higher, 40 percent, rating are not met, it follows that the criteria for an even higher rating (60 or 100 percent) likewise are not met. B. Hypertension The Veteran filed his claim for an increased rating for diabetes mellitus in September 2005. He contends that he is entitled to a higher rating because he now took 10 pills per day for his hypertension and his blood pressure still ran high. Under Diagnostic Code 7101, a 10 percent rating requires diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; a history of diastolic pressure predominantly 100 or more requiring continuous medication for control. A 20 percent rating requires diastolic pressure predominately 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent rating requires diastolic pressure predominantly 120 or more while a 60 percent rating requires diastolic pressure predominantly 130 or more. 38 C.F.R. § 4.104. Considering the pertinent evidence in light of the above, the Board finds that a rating greater than 10 percent for the Veteran's hypertension is not warranted at any point pertinent to this appeal. The Veteran underwent VA examination in December 2005. His blood pressure had been measured to be 170/90, 174/90, 168/91 and 160/90 and he was noted to use several prescription medications to treat his hypertension. VA treatment records confirm that the Veteran has been taking medication to control his hypertension. VA treatment records reflect multiple blood pressure readings with results of: 195/104 (September 2005), 204/112 (September 2005), 144/84 (October 2005), 188/101 (October 2005), 154/78 (November 2005), 163/84 (November 2005), 162/84 (February 2006), 157/86 (March 2006), 132/79 (March 2006), 136/80 (May 2006), 137/71 (May 2006), 126/71 (May 2006), 163/85 (May 2006), 134/76 (June 2006), 149/80 (June 2006), 163/83 (June 2006), 146/77 (July 2006), 150/89 (August 2006), 167/93 (September 2006), 146/78 (October 2006), 150/90 (October 2006), 179/94 (October 2006), 152/87 (November 2006), 168/96 (November 2006), 150/83 (November 2006), 128/80 (December 2006), 139/81 (February 2007), 136/70 (April 2007), 113/64 (May 2007), 126/74 (May 2007), 148/52 (June 2007), 157/101 (June 2007), 186/92 (September 2007), 194/94 (September 2007), 178/96 (September 2007), 177/87 (October 2007), 192/98 (October 2007), 174/81 (October 2007), 159/97 (November 2007), 162/87 (January 2008), 140/71 (April 2008), 159/83 (May 2008), 140/83 (August 2008), 162/91 (September 2008), 172/80 (October 2008), 169/70 (December 2008), 143/87 (June 2009), 150/81 (July 2009), 171/79 (January 2010), 153/86 (April 2010), 162/75 (May 2010), 190/100 (June 2010), 190/100 (March 2011) and 200/120 (March 2011). The foregoing reflects that, since the September 2005 claim for an increased rating, the Veteran's diastolic pressure has not been predominantly 110 or more and his systolic pressure has not been predominantly 200 or more. While the Veteran's diastolic and systolic pressure readings have, on occasion, exceeded 110 and 200 (in September 2005 and March 2011), respectively, they have not predominantly been in excess of those readings. The Veteran is competent to report on symptoms and credible to the extent that he believes that the severity of his hypertension is such that a higher rating is warranted. His competent and credible lay evidence, however, is outweighed by competent and credible medical evidence that evaluates the true extent of the hypertension disability based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. The medical evidence shows that a higher rating is not warranted. Under these circumstances, the criteria for the next higher, 20 percent rating under Diagnostic Code 7101 are not met. It logically follows that the criteria for an even higher rating for hypertension are, likewise, not met. C. Erectile Dysfunction In an April 2004 rating decision, the RO granted service connection for erectile dysfunction and assigned an initial noncompensable rating. This disability was rated by analogy under the diagnostic codes for an unlisted disease of the genitourinary system and a penis deformity with the loss of erectile power. 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. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" as follows: the first two digits will be selected from that part of the schedule most closely identifying the part, or system of the body involved, in this case, the peripheral nerves system, and the last two digits will be "99" for all unlisted conditions. Then, the disability is rated by analogy under a diagnostic code for a closely related disability that affects the same anatomical functions and has closely analogous symptomatology. 38 C.F.R. §§ 4.20, 4.27 The Veteran has alleges that he is entitled to a separate compensable rating for erectile dysfunction due to the impact of this disability on his mental and emotional health, specifically that it prevents him from establishing intimate relationships. Pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7522, a 20 percent rating is warranted for deformity of the penis with the loss of erectile power. There is no other alternative criterion which warrants assignment of a compensable disability rating and a 20 percent rating is the only schedular rating provided. In this case, the record reflects the Veteran's erectile dysfunction is manifested by the loss of erectile power but not by deformity of the penis. The Veteran reported in a December 2005 VA examination that he had a "total loss" due to erectile dysfunction and that he received no current treatment. A March 2011 VA examination indicated that there were no abnormalities of the Veteran's penis or testicles. In addition, he testified at his May 2013 hearing that his erectile dysfunction prevented him from having a close relationship but did not indicate that he suffered from a penile deformity. A review of the evidence of record does not otherwise show evidence of penis deformity and the Veteran has not otherwise alleged such a deformity. The Veteran is competent to report on symptoms and credible to the extent that he believes that the severity of his erectile dysfunction is such that a higher rating is warranted. His competent and credible lay evidence, however, is outweighed by competent and credible medical evidence that evaluates the true extent of his erectile dysfunction based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. The medical evidence shows that a higher rating is not warranted. Therefore, the Veteran does not meet or nearly approximate the criteria for a separate compensable initial rating under Diagnostic Code 7522. See 38 C.F.R. § 4.31. D. PTSD The Veteran filed his claim for an increased rating for PTSD in September 2005. He contends that he is entitled to a higher rating due to his irritability and inability to sustain effective relationships. PTSD is evaluated under VA's General Rating Formula for Mental Disorders. Under the formula, a 30 percent rating is warranted for 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty 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. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; 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. Id. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). On the other hand, if the evidence shows that a Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The United States Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Ultimately in Mauerhan, the Court upheld the Board's decision noting that the Board had considered all of the Veteran's psychiatric symptoms, whether listed in the rating criteria or not, and had assigned a rating based on the level of occupational and social impairment. Mauerhan, supra at 444. The Global Assessment of Functioning (GAF) scale is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, supra. An assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). A September 2005 VA treatment note indicated that the Veteran had nine siblings, that he had a supportive and good relationship with all of his siblings, that he had five children including two who resided with him, and that he was close or somewhat close with four of his children. He reported that he had been married two times, that he had divorced his second wife due to physical abuse and that he had four criminal domestic violence charges against him in the 1970s. A November 2005 VA psychiatric examination report reflected the Veteran's complaints that he could not stand crowds, nightmares two or three times per month and sleep disturbances several times per month. He reported that his nephew had been killed in Iraq in 2005, that he had joint custody of his three year old child and that he has had conflict with his new supervisor. Social activity was somewhat limited as his current activities included watching television and going to sporting events. He also reported good effects with his prescribed medication. Mental status examination found the Veteran to be calm, with psychomotor activity that was slow but within normal limits, and verbal communication that was clear. The examiner noted that the Veteran had reached a fairly good social and general psychological adjustment and that his PTSD was between a mild and moderate degree. A GAF of 50 was assigned. A November 2005 VA treatment note contained the Veteran's complaints of low energy, a tendency to isolate, low motivation, nightmares and one to two incidents of hearing "popping" sounds at night. Periods of low mood, worthlessness, hopelessness or suicidality were denied. His sleep was reported to be improved despite his "unusual schedule." Mental status examination found the Veteran to be alert and oriented with speech that was normal in rate, tone and volume. Affect was found to be restricted but more reactive upon initial greeting, thought processes were linear and judgment and insight were fair. He was noted to be casually dressed and fairly groomed. Suicidal and homicidal ideations were denied. The examiner noted that the Veteran's PTSD symptoms were less frequent and he reported an overall better mood. A GAF of 50 was assigned. A second November 2005 VA treatment note indicated that the Veteran had presented as mildly depressed but talkative and motivated. He described a recent work conflict in which he became quickly angered in the presence of Vietnamese people. A January 2006 VA treatment note reflected the Veteran's reports that he had been doing well with his anger and irritability, which he attributed to his medication, and that he slept approximately seven hours per night and felt well-rested. Suicidal thoughts were denied. Mental status examination found the Veteran to be alert and oriented, his speech to be fluent, his thought process to be linear and his insight and judgment to be fair. Thought content included occasional flashbacks, nightmares and intrusive memories, which were improved overall. He was noted to be fairly groomed. A GAF of 50 was assigned. A May 2007 VA examination report reflected the Veteran's complaints of the avoidance of others, irritability, anxiety/fear about dying in his sleep as a result of his medical condition, nightmares several times per month, feelings of anger, intolerance of others and severe depression that had worsened due to the deterioration of his physical health due to polymyositis and that his ex-girlfriend and child were moving in January 2007. He reported that having "mixed relationships" with his other five children, that he currently resided with his adult son, his ex-girlfriend and his youngest child but that he was extremely distressed about his current living situation and wanted to be left alone. Activities and leisure pursuits included watching sports on television. On mental status examination conducted in May 2007, the Veteran was found to be a very angry, bitter individual with many complaints about what he saw as mistreatment due to a dysfunctional society. Speech was found to be spontaneous, clear and coherent but laced with frequent profanity with unremarkable psychomotor activity. Mood was noted to be hopeless and angry, he was oriented to person, time and place and attention was intact. Thought processes were rambling and tangential with perseveration while thought content contained homicidal ideations about killing his ex-girlfriend, preoccupation with one or two topics, ruminations and paranoid ideations. Homicidal or suicidal thoughts were present but plan or attempt was denied. He displayed inappropriate behavior in that he used a lot of profanity and was very angry and embittered but that he understood the outcome of his behavior and that he had a problem. There were no delusions or hallucinations, obsessive/ritualistic behavior or panic attacks. Remote, recent and immediate memory was found to be normal. A GAF score of 50 was assigned, with the examiner noting that the Veteran was currently more debilitated by depression than PTSD, and that anything that would bring the Veteran into contact with a large number of people would be impaired. In a March 2011 statement, the Veteran's son indicated that the Veteran was very withdrawn, that he only left the house to attend doctor's appointments and that he no longer participated in activities he used to love such as attending sporting events and tailgating. An August 16, 2011 VA examination report reflected the Veteran's complaints of nightmares when particular medications are taken together, insomnia for two to three hours, dysphoria about his overall health, social isolation due to fear of falling, irritability, emotional withdrawal and panic attacks that occurred one to two times per week. Other symptoms included near-continuous panic or depression, chronic sleep impairment, mild memory loss, difficulty in adapting to stressful circumstances, diminished interest, poor concentration and fatigue. He reported that he was not married, that he was alienated from all people he knew, that his son lived with him, his brothers called and sometimes brought food and that he had sharply limited his recreational activities due to physical limitations. Mental status examination conducted by the August 2011 examiner found that the Veteran's affect to be irritable while thought processes were found to be clear, logical, linear, coherent and goal-directed. Rate and flow of speech was found to be within normal limits, there was no impairment of thought processes or communication found and he was found to be oriented to person, place and time. The examiner determined that the Veteran was "intact psychiatrically" as to maintain minimal personal hygiene but was quite limited by his physical disability. Obsessive or ritualistic behavior, impaired impulse control, delusions, hallucinations, a history of suicide attempts, suicidal ideations and homicidal ideations were not found. A GAF of 50 was assigned. The examiner opined that the Veteran's depression and amotivational syndrome would impair his ability to be productive on the job, his irritability would cause impairment in establishing working relationships, that he had isolated himself and had no healthy relationships left, had one rewarding social relationship and had no enjoyable recreational activities. Following a review of the relevant evidence of record, which includes VA treatment records, the Veteran's own statements, and the VA examination reports dated in November 2005, May 2007 and on August 16, 2011, the Board concludes that the Veteran is entitled to a rating of 100 percent prior to and beginning August 16, 2011 for his PTSD. In this regard, the Board finds that such disability is manifested by periods of difficulty performing tasks as a result of nightmares, chronic sleep disturbances, feelings of anger and irritability, chronic depression, isolation, low motivation, episodic tangential thought processes, mild memory loss, diminished interest, poor concentration, panic attacks two to three times per week, episodic suicidal thoughts and episodic homicidal thoughts. The Veteran has deficiencies in most areas (work-like settings, family relations, judgment, thinking, and mood) due to such symptoms. The Veteran's judgment and insight have been intermittently fair. His grooming has been reported as fair. The Veteran's affect has been described as restricted. At his August 2011 VA examination, the Veteran reported near-continuous panic or depression and difficulty in adapting to stressful circumstances. In 2005 he reported that he divorced his second wife due to physical abuse and that he had four criminal domestic violence charges against him in the 1970s. In May 2007, he had homicidal ideations about killing his ex-girlfriend. The May 2007 VA examiner also indicated that the Veteran displayed inappropriate behavior. The August 2011 VA examiner found that the Veteran's PTSD symptoms would impair his ability to be productive on the job or in establishing working relationships. The examiner also indicated that the Veteran engaged in isolative behavior and that he had no healthy relationships left; he had one rewarding social relationship but it was conducted primarily over the phone. The Veteran also had no enjoyable recreational activities. The examiner also explained that the Veteran's depression and anxiety were medically considered a secondary manifestation of the Veteran's PTSD rather than a separate mental disability. The examiner added, however, that the Veteran had also become significantly depressed due to his progressively worsening physical health. The examiner maintained that the symptoms of both depressions were intertwined and to tease out the effects of the depression due to PTSD would be a matter of pure speculation. When it is not possible to separate the effects of the service-connected condition and the nonservice-connected condition, VA regulations at 38 C.F.R. § 3.102, which require that reasonable doubt on any issue be resolved in the appellant's favor, dictate that such signs and symptoms be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Accordingly, all of the Veteran's symptoms must be attributed to the PTSD disability for evaluation purposes. In addition, in connection with his erectile dysfunction, the Board notes that the Veteran indicated that the condition prevented him from establishing intimate relationships. This is further evidence of the Veteran's inability to establish and maintain effective relationships. The Board finds no clear demarcation line showing the Veteran's PTSD exhibited distinct symptoms that would warrant different ratings for different periods. Throughout the appeal period the Veteran's symptoms have been more or less consistent. Indeed, the Veteran was assigned a GAF score of 50 in November 2005, May 2007 and August 2011. 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 evidence simply does not show that the Veteran would be effective in a work-like setting, and the evidence shows that while not total, the Veteran does have severe impairment in social functioning. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2013). Otherwise, the lower rating will be assigned. Id. Here, the Board finds that the symptomatology associated with the Veteran's PTSD more nearly approximates the criteria for a 100 percent rating. Accordingly, the Board finds that the Veteran is entitled to a rating of 100 percent for PTSD prior to and beginning August 16, 2011. F. Extra-Schedular Rating The above-noted determinations are based on consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no pertinent point has the disabilities under consideration been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disabilities at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996). Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. In this case, the Board finds that the applicable schedular criteria are adequate to rate the disabilities under consideration at all points pertinent to this appeal. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than that assigned based on more significant functional impairment. Significantly, there is no medical indication or argument that the applicable criteria are otherwise inadequate to rate the disabilities. Indeed, the Veteran has been awarded the highest rating possible for a disability for his PTSD. As for his diabetes mellitus and hypertension, the Veteran has not described any unusual or exceptional features of these disabilities. As for his erectile dysfunction, the Veteran's complaint that this condition prevented him from establishing intimate relationships was a factor the Board used to justify a total rating for his PTSD. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER A rating in excess of 20 percent for diabetes mellitus is denied. A rating in excess of 10 percent for hypertension is denied. A compensable rating for erectile dysfunction is denied. A higher rating of 100 percent for service-connected PTSD prior to and beginning August 16, 2011 is granted, subject to the law and regulations governing the payment of monetary benefits. REMAND With respect to the remaining issues on appeal, the Board finds that a remand is necessary in order to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C.A. §§ 5107(a), 5103A ; 38 C.F.R. § 3.159(c). Regarding the claims for a higher rating for left and right lower extremity atherosclerotic arterial occlusive disease, the Board notes that the Veteran was last afforded a VA examination in February 2013. This examination determined that claudication was present in the Veteran's bilateral lower extremities on walking less than 25 yards; ankle/brachial index (ABI) testing, however, was not performed and it is not clear from the examination report why such testing was not conducted. The diagnostic code for arteriosclerosis obiliterans considers ABI testing results in determining the severity of the Veteran's disability. On remand, such testing should be conducted or the examiner should indicate why such testing would not be appropriate for this Veteran. Additionally, as relevant to the Veteran's claim for a TDIU prior to June 30, 2010, prior to 2008, the Board treated a 100 percent schedular rating as subsuming the need for TDIU consideration on the basis that the 100 percent schedular rating delivered more benefits than could be obtained by a TDIU rating. The Board's treatment in this regard stemmed primarily from a June 1999 opinion of VA's General Counsel (GC), which held that receipt of a 100 percent schedular rating for a service-connected disability rendered moot any pending claim for a TDIU and required dismissal of the TDIU claim. See VA O.G.C. Prec. Op. No. 6-99; Green v. West, 11 Vet. App. 472, 476 (1998); Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In 2008, however, the Court issued Bradley v. Peake, 22 Vet. App. 280 (2008), which is contrary to GC's previously noted precedent opinion, since withdrawn in response to Bradley. According to Bradley, although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of a TDIU predicated on a single disability (perhaps not ratable at the schedular 100 percent level) when considered together with another disability separately rated at 60 percent or more may warrant payment of special monthly compensation (SMC) under 38 U.S.C.A. § 1114(s). The Court reasoned that it might therefore benefit the Veteran to obtain or retain a TDIU rating even where a 100 percent schedular rating is already in effect. SMC is payable at the (s) rate when a veteran has a single service-connected disability rated as 100 percent disabling and, in addition: (1) has a service-connected disability or disabilities independently ratable at 60 percent, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C.A. § 1114(s) (West 2002). These benefits are not available when the 100 percent disability rating is based on multiple disabilities, none of which is rated 100 percent disabling, or which arise from a single etiology or accident. Buie v. Shinseki, 24 Vet. App. 242, 249-50 (2010); Bradley v. Peake, 22 Vet. App. 280, 290-91 (2008). In light of the Board's award of a total rating for the Veteran's service connected PTSD, the Board finds that the RO/AMC should reconsider the TDIU issue. Finally, due to the length of time which will elapse on remand, updated VA treatment records dated from April 2011 to the present from the Dallas, Texas VA Medical Center (VAMC) that are not already associated with the claims file should be obtained for consideration in the Veteran's appeals. Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's updated treatment records from the Dallas VAMC dated from April 2011 to the present that are not already of record. All efforts to obtain these records should be documented in the claims file. If no such records are available, the Veteran should be so informed and also told of the efforts to obtain the records. 2. After obtaining any outstanding records, the Veteran should be afforded an appropriate VA examination to determine the current nature and severity of his service-connected left and right lower extremity atherosclerotic arterial occlusive disease, including any associated neurological manifestations. All indicated tests and studies should be undertaken. The claims file must be made available for review of the Veteran's pertinent medical history. The examiner is asked to provide specific findings as to the ankle/brachial index of the Veteran's lower extremities. [Note: The ankle/brachial index is the ratio of the systolic blood pressure at the ankle (determined by Doppler study) divided by the simultaneous brachial artery systolic blood pressure.] The examiner should also comment on the presence (including degree) or absence of diminished peripheral pulses, trophic changes, persistent coldness of the extremity, ischemic limb pain at rest, or deep ischemic ulcers. The examiner should also indicate whether this left and right lower extremity disability is characterized by claudication on walking more than 100 yards, between 25 and 100 yards on a level grade at 2 miles per hour, or less than 25 yards on a level grade at 2 miles per hour. If any such testing cannot be performed, the examiner should explain why. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements. The rationale for any opinion offered should be provided. 3. Reconsider the issue of entitlement to a TDIU in light of the Board's award of a total rating for the Veteran's service connected PTSD, including consideration of 38 U.S.C.A. § 1114(s) (West 2002). 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence, to include all of the evidence received since the issuance of the March 2013 supplemental statement of the case. If the claims remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs