Citation Nr: 1331769 Decision Date: 10/02/13 Archive Date: 10/07/13 DOCKET NO. 10-46 208 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial disability rating greater than 30 percent for post-traumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based upon individual unemployability (TDIU). ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1967 to April 1977. He was awarded the Vietnam Campaign Medal, among other decorations. This matter comes before the Board of Veterans' Appeals (Board) from a January 2010 RO decision that granted service connection PTSD and assigned a 30 percent disability rating. The Veteran perfected a timely appeal as to the disability rating assigned and is also requesting a total disability rating based upon unemployability due to his PTSD. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. Giving the Veteran the benefit of the doubt, prior to January 17, 2010 his PTSD was manifest by flattened affect, frequent flashbacks, disturbance of motivation and mood, and difficulty establishing and maintaining relationships resulting in occupational and social impairment with reduced reliability and productivity. 2. As of January 17, 2010, the Veteran's PTSD has been manifest by disturbance of mood, affect, and sleep most consistent with occupational and social impairment resulting in occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks but otherwise generally functioning satisfactorily with routine behavior, self-care and conversation. 3. The Veteran's service-connected disability alone is not of such nature and severity as to prevent him from securing or following any substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 50 percent, but no higher, have been met prior to January 17, 2010. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code (DC) 9411 (2013). 2. The criteria for an initial rating greater than 30 percent for PTSD have not been met as of January 17, 2010. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code (DC) 9411 (2013). 3. The criteria for a TDIU due to PTSD are not met. 38 U.S.C.A. §§ 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. If there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C.A. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). In its evaluation, the Board shall consider all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. Id. Another way stated, VA has an equipoise standard akin to the rule in baseball that "the tie goes to the runner." Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Notably, the benefit of the doubt doctrine is not applicable based on pure speculation or remote possibility. See 38 C.F.R. § 3.102. The Veteran's PTSD is currently evaluated as 30 percent disabling, effective July 16, 2009, under the criteria of Diagnostic Code 9411. See 38 C.F.R. § 4.13. A 30 percent rating is assigned where there is 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). Id. Important for this case, a 50 percent rating contemplates 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; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation 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; intermittently illogical obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where 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; and memory loss for names of close relatives, own occupation, or own name. Id. Symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The nomenclature employed in the portion of VA's Rating Schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "DSM-IV"). 38 C.F.R. § 4.130. DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. Higher scores correspond to better functioning of the individual. Under DSM-IV, GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 41 and 50 are assigned when there are 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). GAF scores ranging between 31 and 40 are assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126(b). In this case, the Board has considered the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the Veteran's disability in his favor. The evidence shows the Veteran first sought treatment for PTSD with a private doctor in August 2009. The doctor diagnosed him with PTSD and alcohol dependence and assigned a GAF of 40. The doctor noted that the Veteran reported that since returning from Vietnam he has had frequent nightmares about his experience, has heightened anxiety, is easily startled, gets anxious and irritable, has flashbacks, and has trouble sleeping. He also has had problems with alcohol and drugs. The Veteran reported withdrawing socially and said his marriage dissolved due to his drinking and high risk behavior. He said he avoids crowds and socialization. The Veteran reported he continues to drink daily but at a much lower volume than 15 years ago. The examiner found the Veteran appeared slightly disheveled but had good eye contact and was able to relate very well. His speech was normal, he had no psychomotor agitation or retardation. His mood was anxious with a congruent affect. His thought process was goal-directed and logical and he had good concentration, focus, insight, and judgment. The doctor prescribed citalopram and trazodone. Later in the month the Veteran reported somewhat improved sleep and the doctor found he had a dull, constricted affect. In December 2009 he continued to report some trouble sleeping and that he had no energy or motivation. He reported continued flashbacks and nightmares and said he stayed home most of the time. The doctor increased his trazodone and prescribed Celexa. On January 17, 2010 the Veteran underwent a VA examination. He reported he has sleep difficulties and nightmares. He said he avoids talking about the war. He said he has lost interest in usual activities, has difficulty with anger and irritability, and has frequent intrusive memories about the war. He also startles easily and is hypervigilant. The examiner noted no evidence of panic attacks or delusions or hallucinations. The Veteran did report being suspicious of others. The Veteran reported he is divorced and has had no success with relationships since then. He said he began drinking alcohol excessively in Vietnam but stopped five months ago. The examiner found the Veteran was oriented with appropriate behavior and hygiene, normal speech and concentration, and good eye contact. His affect and mood were depressed. His thought processes were normal and judgment and memory intact. The examiner diagnosed PTSD and alcohol abuse in remission and assigned a GAF of 60. The examiner noted the Veteran has had difficulty in maintaining relationships and relating to supervisors and co-workers. The examiner opined that the Veteran's symptoms cause occupation and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although functioning satisfactorily with routine behavior, self care, and normal conversation. In March 2010 the Veteran returned to his private doctor and reported some improvement with his sleep but continued flashbacks and nightmares. He denied using alcohol or drugs. In June 2010 the Veteran reported continued mood issues and flashbacks and said he has little social interaction, poor energy, and felt anxious. The doctor increased his Celexa. In September he reported he continues to avoid crowds and feels nervous and restless. He said he has not been drinking for 10 months. The doctor noted he had a flat affect. In June 2011 the Veteran reported continued flashbacks and nightmares. He said little things stress him out and he feels depressed. He also reported feeling anxious and restless. In September 2011 the Veteran complained of some memory problems, said he avoids people and stays home most of the time, and feels depressed sometime. The doctor noted poor eye contact. In January 2012 the Veteran reported continued flashbacks and nightmares. The doctor noted a constricted affect and increased his medication. In April 2012 the Veteran reported trouble concentrating and poor energy level. The doctor prescribed Zoloft. In August 2012 the Veteran reported less depression but continued anxiety and trouble concentration on a task. He said he avoids crowds and noise. The doctor noted the Veteran had a constricted affect and was anxious. He had good eye contract and was able to relate well. The doctor assigned a GAF of 45. In November 2012 the Veteran reported he had been depressed lately by the death of a family member. He said he continues the have flashbacks and nightmares, feels anxious, and is annoyed by being around people. In February 2013 the Veteran reported he had been diagnosed with lung cancer and has been restless and anxious but was not scared. In May 2013 the doctor noted the Veteran was happy the cancer was responding to chemotherapy and was worried but had a positive attitude. In June 2013 the Veteran was afforded another VA examination. The examiner found the Veteran experiences 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. The Veteran reported he has a good relationship with his daughter and her family as well as with his siblings and sees them regularly. The Veteran reported on a daily basis he does things around the house, works on his computer, and has lunch and plays bingo with senior citizens at the community center. He also reported spending time with friends at the neighborhood store. The Veteran reported he prefers to spend time alone but does not have significant mood problems being around others. The examiner found that the Veteran reported several symptoms, including irritability and concentration difficulties, that could be associated with decreased work efficiency, but found that they do not impair his functioning to such an extent that they would preclude gainful employment. The examiner noted no evidence of interference from mental health issues with the Veteran's employment while he was working. The examiner assigned a GAF of 62, stating that it was consistent with continued improvement through psychiatric treatment in the past three years and continued sobriety. The examiner explained that the GAF of 40 assigned in August 2009 and the GAF of 60 assigned in January 2010 was likely reflective of the fact that during five months between the two examinations the Veteran commenced private psychiatric treatment and was sober and stabilized through outpatient psychiatric treatment. The Board finds that a higher initial rating is warranted prior to January 17, 2010 but not thereafter. The Veteran began mental health treatment for his PTSD in August 2009, attending three sessions with a private doctor through the end of the year, beginning psychiatric medication that was altered in December 2007, and stopping drinking alcohol after many years of heavy drinking. The evidence shows that while his private doctor assigned the Veteran a GAF of 40 when he started treatment, in January 2010 a VA examiner found the Veteran's condition warranted a GAF of 60. The June 2013 VA examiner explained the divergent GAF scores by noting that the Veteran was sober and stabilized through outpatient psychiatric treatment during that time. Thus, the Board finds that the evidence supports and improvement in the Veteran's condition as of January 17, 2010. The evidence from prior to January 17, 2010 suggests the Veteran's condition more closely approximated a 50 percent disability rating for that period. The Veteran reported to his private physician that he stayed home most of the time and felt anxious and keyed up all the time. He reported difficulty sleeping. He also reported nightmares and flashbacks. He stated that he had no energy or motivation, in December 2009 telling his private doctor that after walking a block he would feel like he needed to go back. His doctor found his affect to be dull and constricted and the Veteran's appearance to be slightly disheveled. The GAF of 40 assigned by the Veteran's private doctor reflects the upper end of the scale for some impairment in reality testing or communication, suggesting the Veteran's condition warrants greater than a 30 percent rating. Overall, giving him the benefit of the doubt, the Board finds the Veteran's condition suggests occupational and social impairment with reduced reliability and productivity, specifically due to his flattened affect, frequent flashbacks, disturbance of motivation and mood, and difficulty establishing and maintaining relationships. Thus, the Board finds he is entitled to a 50 percent disability rating. However, the Board finds a higher, 70 percent, rating is not warranted prior to January 17, 2010 as his condition does not manifest with occupational and social impairment with deficiencies in most areas due to symptoms such as (for example only) suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. Specifically, the Board notes that although the Veteran was assigned a GAF of 40, the symptoms described by the private doctor do not include any involving impairment in reality testing or communication. In fact, the doctor found the Veteran was able to "relate very well" with normal speech and thought processes that were goal-directed and logical. Thus, notwithstanding the GAF score, the Board finds the Veteran's condition prior to January 17, 2010 does not meet the criteria for a rating in excess of 50 percent. The Board further finds that the Veteran's condition as of January 17, 2010 does not warrant an initial rating higher than 30 percent. As discussed above, the evidence suggests an improvement in the Veteran's condition as of that date. The January 2010 VA examiner assigned a GAF of 60 and specifically noted the Veteran did not report panic attacks and had appropriate behavior and hygiene. The examiner opined that the Veteran's condition caused occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although functioning satisfactorily with routine behavior, self care, and normal conversation, which is reflective of a 30 percent rating. By June 2013 the Veteran was reporting significant social interaction, including a good relationship with family, eating lunch and playing bingo daily at the community center, and spending time with long-time friends. He reported no significant mood problems being around others. Notably, even the Veteran's private doctor noted an improvement in his condition during the course of his treatment, assessing a higher GAF in August 2012 than the score he assigned in August 2009. While the GAF of 45 assigned by the private doctor in August 2012 is still lower than the GAF scores of 60 and 62 assigned by the VA examiners in 2010 and 2013, it nonetheless reflects an improved assessment by the Veteran's private doctor. The Veteran also reported specific improvements to his private doctor, including improved sleep in March 2010 and September 2010, at which time he also reported his mood was good as long as he wasn't around other people. The Board recognizes that the Veteran has consistently reported continued flashbacks and nightmares and some anxiousness. In this regard, it is important for the Veteran to understand that without problems associated with his PTSD, there would be no basis for a compensable evaluation, let alone a 30 percent evaluation. Even considering the symptoms described by the Veteran, the Board finds that the medical evidence clearly supports a finding, overall, of a mild disability or, at minimum, a disability that does not met the requirements of the next higher 50 percent evaluation as of January 17, 2010. The Veteran has never reported suicidal or homicidal ideation, hallucinations, or panic attacks. His thought processes and judgment have always been found to be intact. His speech has consistently been normal and his eye contact good. Although he reported a period of avoiding others, the evidence does not suggest an inability or difficulty in maintaining relationships, and in fact, at his June 2013 VA examination, the Veteran reported having long-time friends as well as good relationships with his family. Thus, the Veteran's own statements regarding the nature and extent of his symptoms (overall) provides the basis to find a higher evaluation is not warranted. The GAF scores of 60 and 62 assigned by the VA examiners in January 2010 and June 2013 represent mild to moderate symptomatology and are in line with a disability evaluation of 30 percent. The Board recognizes the lower score of 45 assigned by the Veteran's private doctor in August 2012, which represents serious impairment. However, notwithstanding that score, the evidence, including the descriptions of the Veteran's symptoms in his private treatment records and VA examination reports, supports a finding that a disability rating in excess of 30 percent is not warranted. The GAF, while important, is not the only evidence the Board looks at in deciding a claim. In this regard, the Board finds that the Veteran's own statements to his examiners provide, overall, highly probative evidence that the Veteran has a level of functioning that is significantly greater than the GAF of 45 assigned by the private doctor suggests. The Board finds the Veteran's treatment records provide more probative evidence that the severity of the Veteran's PTSD is more closely represented by a 30 percent rating. As of January 17, 2010 the evidence does not show the criteria for a 50 percent rating, including occupational and social impairment with reduced reliability and productivity due to such symptoms as (for example only) circumstantial, circumlocutory, or stereotyped speech; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships, notwithstanding the GAF of 45 assigned by the private examiner. Nor does his PTSD meet the higher requirements for the 70 or 100 percent ratings the Veteran requested in his notice of disagreement. As the preponderance of the evidence is against a rating higher than 50 percent prior to January 17, 2010 and greater than 30 percent thereafter, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. Extraschedular Rating The Board must also consider whether the Veteran is entitled to consideration for referral for the assignment of an extraschedular rating for his service-connected PTSD. 38 C.F.R. § 3.321; Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record). An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that schedular evaluation assigned for the Veteran's service-connected PTSD is not inadequate in this case. The diagnostic criteria adequately describe the severity and symptomatology of the Veteran's service-connected PTSD. His nightmares, flashbacks, anxiousness, and avoidance of crowds are all among the symptoms considered by the rating schedule. The evidence does not demonstrate other related factors such as marked interference with employment and frequent hospitalization. Therefore, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Entitlement to a TDIU The Veteran contends that he is unable to secure gainful employment due to his service-connected PTSD. Total disability ratings for compensation based on individual unemployability may be assigned when the combined schedular rating for the service-connected disabilities is less than 100 percent and when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, this disability is ratable at 60 percent or more, or, if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16. If the above percentages are not met, the Veteran's claim may still be referred to the Director, Compensation and Pension Service for an extraschedular rating, when the evidence of record shows that Veteran is "unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities." 38 C.F.R. § 4.16(b). The Veteran's service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran's employment history, his educational and vocational attainment, as well as his particular physical disabilities are to be considered in making a determination on unemployability. The Veteran's only service-connected disability is PTSD. Because the Veteran does not have one service-connected disability rated as at least 60 percent, or two or more disabilities with a combined rating of at least 70 percent, the initial criteria for schedular consideration for the grant of TDIU under 38 C.F.R. § 4.16(a) are not met. Nevertheless, the Board must determine whether the Veteran's TDIU claim should be submitted to the Director of Compensation and Pension service for consideration of TDIU on an extraschedular basis. See 38 C.F.R. § 4.16(b). The Veteran reported he last worked in November 2008 as a mechanic. He said was laid off due to a lack of work. He reported he had not lost any time during the preceding 12 months due to disability. He told the January 2010 VA examiner he was a high school graduate and worked as a heavy equipment operator for most of his life. The examiner noted a difficulty in employment in relating to supervisors and co-workers but opined only that the Veteran's symptoms cause an occasional decrease in work efficiency and intermittent ability to perform occupational tasks. He told the June 2013 VA examiner that after being laid off after working as a mechanic for 42 years he looked for work in the mechanical field in his geographic area but could not find work. The examiner opined that the Veteran's symptoms do not impair his functioning to such an extent that they would preclude gainful employment. Thus, the evidence shows that while the Veteran is unemployed, he did not lose his job as a result of his PTSD and has not claimed to have missed time at work due to his PTSD. Although he reports being unable to find work, he has not suggested his search was unsuccessful due to his own unemployability due to PTSD, but rather an unavailability of mechanic jobs in his area. Neither VA examiner opined that the Veteran's PTSD would preclude gainful employment. Therefore, based on the foregoing, the Board finds that referral to the Director of Compensation and Pension Service for consideration of TDIU on an extraschedular basis under 38 C.F.R. § 4.16(b) is not warranted because the most competent, credible, and probative evidence of record does not reflect that the Veteran is unable to follow or secure substantially gainful employment due to his service-connected disability alone. In summary, and for the foregoing reasons and bases, the Board finds the preponderance of the evidence is against the grant of TDIU under 38 C.F.R. § 4.16(a) and (b), and there is no reasonable doubt to be resolved. See Gilbert, 1 Vet. App. at 55. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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 C.F.R. § 3.159(b)(1). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the required notice should be furnished prior to the issuance of the appealed rating decision, any initial errors of notice will not be prejudicial if: 1) corrective actions (e.g., issuance of a post-adjudication notice letter containing the required information) are taken, and 2) the appeal is readjudicated (e.g., in a Supplemental Statement of the Case). See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). In this case, the claim for a higher rating arises from the Veteran's disagreement with the initial rating assigned after the grant of service connection. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or address prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (2003). Rather, if the disagreement is not resolved, the provisions of 38 U.S.C.A. § 7105(d) require VA to issue a Statement of the Case (SOC) concerning the downstream issue. Here, the RO provided this necessary SOC in November 2010, wherein the applicable statutes and regulations concerning the issue on appeal were cited and the reasons and bases for not assigning a higher initial rating were discussed. VA also has a duty to assist the Veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished. The RO has obtained the private treatment records identified by the Veteran. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. The Veteran was afforded a VA medical examination in January 2010 and June 2013. The examiners, medical professionals, obtained an accurate history and listened to the Veteran's assertions. The examiners provided the Board with sufficient information to rate the Veteran's disability. Therefore, the Board finds that the examinations are adequate and contains sufficient information to decide the issue on appeal. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, 16 Vet. App. 183. ORDER Entitlement to an initial disability rating of 50 percent, but no higher, is granted for PTSD prior to January 17, 2010, subject to the laws and regulations controlling the disbursement of monetary benefits. Entitlement to an initial disability rating higher than 30 percent for PTSD as of January 17, 2010 is denied. Entitlement to a total disability rating based upon individual unemployability is denied. ____________________________________________ M. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs