Citation Nr: 1333418 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 09-19 220 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for eye disability, to include dry eye syndrome. 3. Entitlement to service connection for Wolff Parkinson-White syndrome. 4. Entitlement to service connection for high cholesterol. 5. Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION The Veteran had active service from March 2003 to April 2004. He was a member of the Alabama Army National Guard beginning in 1990; his periods of active duty for training (ACDUTRA) are currently unverified. This matter comes before the Board of Veterans' Appeals (Board) from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Veteran was scheduled for a personal hearing before the Board in February 2011; however, he failed to appear. Under the applicable regulation, if an appellant fails to appear for a scheduled hearing and a request for postponement has not been received and granted, the case will be processed as though the request for a hearing had been withdrawn. 38 C.F.R. § 20.702 (d) (2013). No such request has been received. Accordingly, this Veteran's request for a hearing is considered withdrawn. The issues of entitlement to service connection for an eye disability, hypertension, and Wolff Parkinson-White syndrome are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. High cholesterol is a laboratory test result, and is not a disability for VA purposes. 2. The Veteran's PTSD is manifested by reduced reliability and productivity due to sleep disturbance, avoidance, feelings of detachment and estrangement, increased arousal, irritability, and depression. CONCLUSIONS OF LAW 1. Service connection is not warranted for high cholesterol. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 2. For the entire appellate period, the criteria for an initial evaluation of a 50 percent evaluation for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130; Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002). 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. VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which 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. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. A letter dated in July 2007, prior to the adjudication of the Veteran's claims, discussed the evidence necessary to support a claim for service connection. The evidence of record was listed and the Veteran was informed of the allocation of responsibilities between himself and VA. He was also advised of the manner in which VA determines disability ratings and effective dates. The Board finds that the content of the preadjudicatory notice provided to the Veteran fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Board further notes that this is a case in which the Veteran has challenged the initial evaluation assigned following the grant of service connection for PTSD. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. With respect to VA's duty to assist, VA and private treatment records have been obtained and associated with the record. Records have also been obtained from the Social Security Administration (SSA). VA psychiatric examinations have been conducted. The Board finds that the examinations are adequate, in that the examinations were conducted by a clinician who reviewed the record, interviewed the Veteran, and performed appropriate examinations. The Veteran has not otherwise identified any additional available evidence or information which could be obtained to substantiate the claim. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations. The Board notes that the Veteran was not afforded an examination in his high cholesterol claim. A VA examination is not necessary because there is no reasonable possibility that such assistance would aid in substantiating the claim; even if hypercholesterolemia were found upon examination, there is no reasonable possibility that this finding could substantiate the claim because such a finding does not provide evidence of a current disability. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d). For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. Analysis Service Connection for High Cholesterol Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a claimant must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). The Veteran seeks service connection for high cholesterol. He has not identified an underlying disability associated with documented findings of elevated cholesterol. Hyperlipidemia and elevated cholesterol are laboratory findings and are not disabilities in and of themselves for which VA compensation benefits are payable. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (noting that diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities under the rating schedule). Hyperlipidemia is "a general term for elevated concentrations of any or all of the lipids in the plasma, such as hypertriglyceridemia, hypercholesterolemia, and so on." Dorland's Illustrated Medical Dictionary 883 (30th ed. 2003). In this case, the Veteran has identified no evidence of a current disability manifested by high cholesterol. In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). As elevated cholesterol does not constitute a disability, service connection for high cholesterol cannot be awarded, regardless of whether the Veteran has the claimed findings of hyperlipidemia, elevated triglycerides, or elevated cholesterol. A symptom or a finding, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a "disability" for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). The Court consistently has held that, under the law, a "determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). This principle has been repeatedly reaffirmed by the Federal Circuit Court, which has stated that "a veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the veteran's service and the disability." Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of 38 U.S.C.A. §§ 1110 and 1131 as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and, therefore, the decision based on that interpretation must be affirmed). For the reasons expressed above, the Board finds that a preponderance of the evidence is against the Veteran's claim of entitlement to service connection for high cholesterol, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Evaluation of PTSD Disability evaluations are determined by the application of a schedule of ratings, which is based on average industrial impairment. 38 U.S.C.A. § 1155. A proper rating of the Veteran's disability contemplates its history, 38 C.F.R. § 4.1, and must be considered from the point of view of a Veteran working or seeking work. 38 C.F.R. § 4.2. 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. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Under the rating criteria of 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013), a 100 percent evaluation is provided for PTSD 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; memory loss for names of close relatives, own occupation, or own name. A 70 percent evaluation is provided 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; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance or hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Furthermore, with specific regard to the 70 percent rating, such rating "requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013) (emphasis added). A 50 percent evaluation is appropriate where there is reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 30 percent disability rating is appropriate where the evidence shows that PTSD is productive of occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (i.e., forgetting names, directions, and recent events), warrants a 30 percent disability evaluation. It is noted that the "such symptoms as" language of the diagnostic code listed above means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court also pointed out in that case, the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet.App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical 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; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). VA treatment records reflect that the Veteran was psychiatrically hospitalized from June 28 to July 2, 2007. On admission, the diagnoses were mood disorder, substance abuse (crystal methamphetamine) and nicotine dependence. The Veteran's global assessment of functioning (GAF) score on admission was noted to be 33, and it was 53 on discharge. The Veteran underwent VA examination in August 2007. His history was reviewed. He reported that he was married and separated, and that he had two children with whom he had good relationships. He denied a history of suicide attempts and violence. He denied alcohol use. On mental status examination, the Veteran was clean and neatly groomed. He was cooperative and friendly. Psychomotor activity was unremarkable, though speech was slow. Mood was depressed, and affect was normal. He could perform serial sevens and spell a word forward and backward. He was oriented. His thought process and content was unremarkable. With respect to judgment and insight, the Veteran understood the outcome of his behavior and understood that he had a problem. Regarding sleep impairment, the Veteran reported that he slept well with medication. There was no inappropriate, obsessive, or ritualistic behavior. There were no homicidal or suicidal thoughts. Impulse control was good. Memory was normal. The examiner noted that the Veteran had persistent re-experiencing of traumatic events, avoidance of stimuli associated with the trauma and numbing of general responsiveness, and increased arousal that caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The examiner indicated that the Veteran's symptoms were frequent, chronic, and moderate, and that there had been no periods of remission since the Veteran's return from Iraq. He assigned a GAF score of 60, indicative of moderate symptoms. He noted that there was moderate impairment in functional status and quality of life due to PTSD. He stated that there was reduced reliability and productivity due to PTSD symptoms, noting that such reduction was due to hyper vigilance and exaggerated startle response. The Veteran was again hospitalized from June to July 2008. Diagnoses were noted to be amphetamine dependence, PTSD, and tobacco use disorder. The discharge summary notes that the Veteran's GAF on admission was 45, and that it was 50 on discharge. The records pertaining to this hospitalization indicate that the Veteran received treatment for his substance abuse and mental disorder. During that time, he received numerous demerits and one verbal warning, and was placed on graduated sanctions for a positive urine screen and possession of contraband. He was discharged from programming for multiple program rule violations. The Veteran was evaluated for SSA purposes in December 2008. The Veteran reported that he participated in a VA drug rehabilitation program in July 2008. He indicated that his sleep was disturbed by severe anxiety. The Veteran's wife stated that he was very emotional and angry. On mental status examination, the Veteran was appropriately dressed and his grooming was good. The Veteran was cooperative, pleasant, interested, and could concentrate. Orientation was good. Thought processes and speech were appropriate. There were no loose associations or confusion. Mood was depressed and the Veteran was noted to cry easily. Affect was appropriate. He stated that he heard voices regularly. He admitted to suicidal ideation and stated that he had overdosed on two occasions. He denied homicidal ideation. He was able to perform serial sevens and could count back from the number 20. He repeated three common words immediately but could recall only one after two or three minutes. The examiner concluded that the Veteran could perform basic daily activities. He noted that the Veteran's behavior and appearance were good. He indicated that his ability to relate to others was somewhat affected. He noted that the Veteran could concentrate and was persistent. He also noted that the Veteran adapted well to the changing conditions of the evaluation, but that he would probably have difficulty with total independent functioning. He concluded that the Veteran's ability to meet the demands of competitive employment was affected by his psychiatric symptoms. On VA examination in March 2010, the Veteran's history was reviewed. He denied any current social relationships. He indicated that activities and leisure pursuits were limited to watching television. He stated that he was married and separated. He denied a history of suicide attempts and violence, as well as alcohol use. He noted that he had a history of drug dependence but that he had been clean for over one year. On mental status examination, the Veteran's psychomotor activity was lethargic. His speech was clear. He was cooperative and friendly. His affect was normal, and his mood was depressed. Attention was intact, and the Veteran was able to perform serial sevens and spell a word forward and backward. He was oriented. His thought process and content was unremarkable. There were no delusions. With respect to judgment and insight, the examiner noted that the Veteran knew the outcome of his behavior and understood that he had a problem. The Veteran reported that he got three to four hours of sleep per night, causing exhaustion that interfered with his daytime activities. No inappropriate, obsessive, or ritualistic behavior was documented. The Veteran denied delusions, hallucinations, and panic attacks. The examiner noted that he was able to maintain his personal hygiene, and that there was no problem with activities of daily living. Memory was normal. With respect to PTSD symptoms, the examiner noted that the Veteran had recurrent distressing dreams, that he was avoidant of activities, places, or people that aroused recollections of the trauma, that he had markedly diminished interest in participation in significant activities, and that he felt detached from others. He also noted that the Veteran had difficulty falling and staying asleep, experienced irritability, was hypervigilant, and had an exaggerated startle response. He concluded that the Veteran's symptoms were frequent, chronic, and moderate. He further noted that there had been no periods of remission since the Veteran's last VA examination. The Veteran was noted to be unemployed, reporting that his employer considered him to be a liability on the job; however, the examiner also indicated that the Veteran did not contend that his unemployment was due to his mental disorder's effects. The diagnosis was PTSD. The examiner assigned a GAF score of 60. He indicated that the Veteran had moderate impairment in functional status and quality of life due to PTSD. He further stated that the Veteran's substance abuse had its onset after PSTD and was clearly a means of coping with the PSTD symptoms. He stated that there was reduced reliability and productivity due to PTSD symptoms, noting that such reduction was due to sleep disturbance, avoidance behaviors, hyper vigilance, and irritability. Upon careful consideration of the evidence pertaining to this claim the Board has determined that for the entire appellate period, an evaluation of 50 percent is warranted for the Veteran's PTSD. The Board acknowledges that evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. If the evidence demonstrates that a claimant 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. Mauerhan v. Principi, 16 Vet. App. 436 (1992). In this case, the Board observes that the Veteran's reported symptoms include sleep disturbance, depressed mood, irritability and anger, hyper arousal, and avoidance. Moreover, the Board accepts that the Veteran's PTSD impacts his personal relationships. There is mildly impaired recent memory. In essence, the evidence reflects symptoms that are best contemplated by the criteria for a 50 percent evaluation. The Board has also determined that an evaluation in excess of 50 percent is not warranted, specifically because the evidence does not demonstrate deficiencies in most areas referenced in the higher rating category, or similar manifestations on par with those symptoms. There has been no demonstration of symptoms such as obsessive rituals interfering with routine activities; intractable panic or depression to the extent that if affects the Veteran's ability to function independently, appropriately and effectively; speech disturbance; or spatial disorientation. No deficiencies in judgment and insight have been documented. The Veteran's hygiene has been noted to be good, and examiners have stated that there is little to no impact on daily activities. No impairment of impulse control has been recorded, although the Veteran and his wife do endorse difficulty with anger. While there has reportedly been an impact on the Veteran's interpersonal functioning with regard to his wife, the record does not reflect the inability to maintain relationships as contemplated by the diagnostic criteria for the higher rating. In that regard, the Veteran reports good relationships with his children. The Board observes that in cases where the original rating assigned is appealed, consideration must be given to whether a higher rating is warranted at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). In considering whether staged ratings are appropriate, the Board acknowledges that VA records include a GAF score of 33 on hospital admission in June 2007; however, within days the Veteran's GAF score was 53 on discharge, more in line with the remainder of the evidence and the typical functioning of the Veteran. Similarly, while the Veteran's GAF score on hospital admission in June 2008 was 45, and it was 50 on discharge. The Board observes that this hospitalization was for a period of more than 21 days, and that the Veteran was therefore assigned a 100 percent evaluation for this period. Thus, his rating contemplates the hospitalization. Otherwise, GAF scores assigned by VA examiners in 2007 and 2010 were 60, evidencing moderate symptoms. The Board additionally notes that a GAF score does not automatically equate to any particular percentage in the Rating Schedule. Rather, it is but one factor to be considered in conjunction with all the other evidence of record. 38 C.F.R. §§ 4.2, 4.6. The Board also notes that in the context of the December 2008 examination by the Social Security Administration, the Veteran reported his July 2008 VA hospitalization, and also noted that he sometimes heard voices and contemplated suicide, referencing two near overdoses. The treatment records from the VA hospitalization, however, clarify that while he had some thoughts of death, he had no overt suicidal ideation. He also denied auditory hallucinations and delusions. Thus, while the Veteran is noted on this one occasion of having experienced suicidal thoughts when at the height of his drug use, when considered with the remainder of his symptoms as described above, to include his prior and subsequent denials of suicidal ideation and hallucinations, the Board finds that the Veteran's level of psychiatric impairment does not more nearly approximate the 70 percent rating criteria; rather, his disability picture more nearly approximates occupational and social impairment with reduced reliability and productivity. Since the Veteran has been diagnosed as having psychiatric conditions in addition to the service-connected PTSD and the symptoms attributable to other psychiatric conditions have not been disassociated from his service-connected disorder, the Board has considered all psychiatric symptoms in reaching the above conclusion. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). In summary, the Veteran's disability picture more nearly approximates the criteria for a schedular evaluation of 50 percent, but no higher. As such, the Board concludes that a 50 percent evaluation for the Veteran's PTSD for the entire period on appeal is appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999). Extraschedular Consideration The Board has also considered whether the Veteran's PTSD presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's service-connected PTSD with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. In particular, the Veteran's symptoms as described in detail above are specifically contemplated by the rating criteria. Consequently, the Board has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Finally, where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). TDIU may be a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran retired for nonservice-connected reasons and has not alleged that he is unemployable due to his psychiatric disorder. Moreover, there is no evidence of unemployability, accordingly, TDIU is not raised by the record. ORDER Entitlement to service connection for high cholesterol is denied. Entitlement to an initial evaluation of 50 percent for PTSD is granted, subject to the laws and regulations controlling the award of monetary benefits. (CONTINUED ON NEXT PAGE) REMAND As noted above, the Veteran was a member of the Alabama National Guard from 1990, and had active service from March 2003 to April 2004. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). With specific regard to National Guard and Reserve service, service connection may be granted for disability resulting from either disease or injury incurred in, or aggravated while performing, active duty for training (ACDUTRA). With respect to time periods of inactive duty training (INACDUTRA), service connection may only be granted for injury so incurred or aggravated. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131 (West 2002). Where a Veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and hypertension becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101 , 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). Presumptive service connection, however, is not applicable to periods of ACDUTRA. Biggins, 1 Vet. App. at 478. With regard to the Veteran's hypertension claim, the Board notes that service connection may be established if it is shown to be etiologically related to the Veteran's period of active service, if it manifested within one year of separation from active service, or if it is shown to have manifested during a period of ACDUTRA. Unfortunately, the current record does not indicate the Veteran's periods of ACDUTRA. The Board is therefore unable to make a determination as to whether hypertension was manifest during a period of ACDUTRA. An attempt must be made to verify the Veteran's periods of ACDUTRA and INACDUTRA through official sources. Additionally, given the facts noted above, the Board finds that the evidence currently of record is insufficient to resolve the claim of entitlement to service connection for hypertension and that a medical examination is warranted. Regarding the claimed eye disability, the Board notes that in a post-deployment checklist dated in March 2004, the Veteran reported that he experienced redness of his eyes with tearing during his deployment to Kuwait and Iraq. In a March 2008 report, a private provider noted that the Veteran had moderate dry eyes, reportedly worse since the Veteran's last tour of duty. The Board notes that on VA examination in September 2007, dry eyes were diagnosed; however, the examination did not provide an opinion concerning whether dry eye syndrome was related to the complaints during active duty. The Board observes that once VA provides an examination, it must be adequate or VA must notify the Veteran why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Here, the examiner did not provide an opinion with respect to the etiology of the Veteran's dry eye syndrome; thus, an addendum is required to address the issue of nexus. With respect to the claim for Wolff-Parkinson-White syndrome, claimed as irregular heartbeat, the Board notes that a June 2006 VA record indicates that an EKG report was abnormal and that Wolff Parkinson-White syndrome was noted in the comments section. At that time, the Veteran reported having had cardiac abnormalities as a newborn. He reported episodes where his heart "would run away with him" as a child, and most recently two years previously. He endorsed dyspnea on exertion. On VA examination in September 2007, Wolff-Parkinson-White was also diagnosed. The examiner did not provide an opinion with respect to the etiology of this diagnosis. The Board further observes that the AOJ denied this claim on the basis that it is a congenital defect. However, the record is unclear with respect to whether the diagnosis is congenital in nature, and if so, whether it is in fact a defect or disease. Service connection may be granted for congenital diseases, but not congenital defects. Quirin v. Shinseki, 22 Vet. App. 390, 394 (2009) (discussing VAOPGCPREC 82-90); Monroe v. Brown, 4 Vet. App. 513, 515 (1993). Because of the lack of clarity in the record with respect to this claimed disability, the Board finds that an examination is warranted to determine the nature and etiology of the claimed Wolff-Parkinson-White syndrome. Accordingly, the case is REMANDED for the following action: 1. Attempt to verify all periods of ACDUTRA and INACDUTRA for the Veteran's National Guard service, beginning in 1990. 2. If additional service is verified, all service treatment records for any periods of ACDUTRA and INACDUTRA are to be obtained from the proper authorities and associated with the claims folder. All attempts to procure records should be documented in the file. If the AOJ cannot obtain records, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. The following actions must be undertaken only after completion of the above-directed development. 3. Schedule the Veteran for a VA examination in order to determine the nature and etiology of hypertension and Wolff-Parkinson-White syndrome. The entire claims file, to include a complete copy of the REMAND, must be made available to the examiner designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented medical history and assertions. Any further indicated tests and studies should be accomplished (with all results made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. After examining the Veteran and reviewing the relevant evidence in the claims file, the examiner should address the following questions: Hypertension Whether it is it is at least as likely as not (i.e., probability of 50 percent), that hypertension: (1) had its onset in or is otherwise related to the Veteran's period of active duty from March 2003 to April 2004; (2) if it was manifested within one year after the Veteran's period of active duty; or (3) whether it was manifested during any period of ACDUTRA. Whether hypertension clearly and unmistakably preexisted the Veteran's entrance into any period of ACDUTRA; and if so, whether hypertension clearly and unmistakably did not increase in severity in service beyond the natural progress of the condition (representing a permanent worsening of such disorder). Wolff-Parkinson-White syndrome Whether Wolffe-Parkinson-White syndrome, if diagnosed, is a congenital defect or disease. If such is found to be a disease rather than a defect, whether it is at least as likely as not (50 percent or greater probability) that Wolff-Parkinson-White syndrome had its onset in or is otherwise related to the Veteran's period of active duty from March 2003 to April 2004. If such is found to be a disease rather than a defect, whether Wolff-Parkinson-White syndrome clearly and unmistakably preexisted the Veteran's entrance into any period of active service or ACDUTRA; and if so, whether it clearly and unmistakably did not increase in severity in service beyond the natural progress of the condition (representing a permanent worsening of such disorder). The underlying reasons for the opinions expressed must be included. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. If the examiner is unable to offer any of the requested opinions, it is essential that she offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 4. Forward the Veteran's claims file the examiner who conducted the September 2007 VA eye examination (or suitable substitute if necessary) to determine the nature and etiology of the Veteran's currently present eye disability. The entire claims file, to include a complete copy of the REMAND, must be made available to the examiner, and the report should include discussion of the Veteran's documented medical history and assertions. If further examination is deemed necessary by a medical professional in order to answer the following questions, then such should be scheduled. The examiner is asked to provide an opinion with respect to whether it is at least as likely as not (i.e., probability of 50 percent), that the Veteran's current eye disability is related to any disease or injury during active service, or a period of ACDUTRA, or an injury during a period of INACDUTRA. A discussion of the complete rationale for all opinions expressed should be included in the examination report, to include reference to pertinent evidence where appropriate. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. If the examiner is unable to offer any of the requested opinions, it is essential that she offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 5. Then, readjudicate the claims on appeal, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The law requires that all claims that are remanded by the Board of Veterans' Appeals for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs