Citation Nr: 1333429 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 10-05 147 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for chloracne, claimed as due to herbicide exposure. 2. Entitlement to service connection for tinnitus, to include as secondary to ischemic heart disease and/or posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for hepatitis C, to include a liver transplant. 5. Entitlement to service connection for a skin disorder, to include a rash and benign tumors of the face and back, claimed as due to herbicide exposure. 6. Entitlement to service connection for a right knee disorder. 7. Entitlement to an initial rating in excess of 30 percent for PTSD. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A.M. Ivory, Counsel INTRODUCTION The Veteran had active military service from October 1969 to November 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. Regarding the Veteran's claim for service connection for a skin disorder, the Board notes that he originally filed separate claims for service connection for a rash and benign tumors of the face and back. However, the Board has a duty to identify the benefit being sought on appeal by applying a "sympathetic reading" to a lay person's pleadings with attention focused upon the symptoms and/or symptoms the claimant is attempting to service connect, regardless of the phraseology utilized by the claimant or the RO. Brokowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009). Therefore, the Board has recharacterized the issue as a skin disorder, to include a rash and benign tumors of the face and back, as listed on the title page. The Board notes that chloracne is also a skin disorder; however, as a different disposition is reached herein with respect to such issue, it has been listed separately on the title page. The Veteran testified before a Decision Review Officer (DRO) at the RO in May 2010. A copy of the hearing transcript is of record. 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 reveals additional VA treatment records dated through September 2012, which were considered in the October 2012 supplemental statement of the case, and an August 2013 Appellant's Brief submitted by the Veteran's representative. The issues of entitlement to service connection for bilateral hearing loss, tinnitus, hepatitis C, a skin disorder, and a right knee disorder are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. For the entire appeal period, the Veteran does not have a current diagnosis of chloracne. 2. For the entire appeal period, the Veteran's PTSD is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks as a result of insomnia and sleep problems, lack of motivation, anhedonia, recurrent depression, mild anxiety, occasional panic attacks, nightmares, intrusive memories, flashbacks, and avoidance of crowds, without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment CONCLUSIONS OF LAW 1. The criteria for service connection for chloracne have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 2. The criteria for an initial rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2012). 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 agency of original jurisdiction (AOJ) decision on the claim for VA benefits. Relevant to the Veteran's claims herein decided, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, an October 2006 letter and a December 2007 letter, all sent prior to the initial unfavorable decision issued in July 2008, advised the Veteran of the evidence and information necessary to substantiate his service connection claims as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letters advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Additionally, pertaining to his initial rating claim, the Board observes that the Veteran has appealed with respect to the propriety of the initially assigned rating for his PTSD from the original grant of service connection. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claim for service connection for PTSD was granted and an initial rating was assigned in the July 2008 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Relevant to the duty to assist, the Veteran's service treatment records, post-service VA and private treatment records, and records from the Social Security Administration (SSA) have been obtained and considered. The Board notes that, in October 2009, the RO issued a Memorandum making a formal finding of unavailability of medical records, surgical records, hospital clinical records, nurses' notes, and outpatient treatment records from the VA Medical Center in Indianapolis for August 1984. The RO noted all of the efforts that were made to obtain such records, and concluded that such records are unavailable and further attempts to obtain them would be futile. In an October 2009 letter, the Veteran was advised of such efforts as well as the finding of unavailability, and was invited to submit the records himself. To date, he has not done so. Additionally, in August 2012, the RO issued another Memorandum making a formal finding of unavailability of Baltimore VA Medical Center treatment records dated from December 1978 to May 1981. The RO noted all of the efforts that were made to obtain such records, and concluded that such records are unavailable and further attempts to obtain them would be futile. In an August 2012 letter, the Veteran was advised of such efforts as well as the finding of unavailability, and was invited to submit the records himself. To date, he has not done so. The Board further notes that, while the Veteran has reported treatment through his employer, Naval Avionics Center primarily for his hearing loss and tinnitus in May 2007. The RO attempted to obtain such records from Naval Air Warfare Center Naval Avionics in April 2008, but such was sent to an incorrect address. In June 2012, RO personnel contacted Raytheon, which was formally known as the Naval Air Warfare Center, and was provided with a fax number. As such, in a June 2012 letter, the Veteran was advised that the RO had previously requested records from the Naval Air Warfare Center, which was now known as Raytheon, but such was returned due to an invalid address. The RO requested that the Veteran fill out an updated authorization form with the correct address. He was also provided with the phone number of Raytheon. However, the Veteran did not complete an appropriate authorization form to allow VA to obtain any records from such facility. The Board emphasizes that "the duty to assist is not always a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, the Board finds that VA has satisfied its duty to assist in this regard. Also, at the July 2012 VA examination, the Veteran reported private treatment at St. Vincent Hospital in 1985 and 1986 for his psychiatric symptoms; however, he did not provide an authorization form for VA to obtain such records. Id. Moreover, as the records pre-date the effective date of service connection for PTSD by two decades, they are not relevant to the instant claim. Therefore, there is no need to obtain them. Furthermore, the Veteran has not identified any additional, relevant records that have not been requested or obtained. As relevant to the Veteran's claim for service connection for chloracne, he was afforded a VA examination in September 2012. The Board finds that such VA examination and accompanying opinion is adequate to decide the issue as it is predicated on an interview with the Veteran; a review of the record, to include his service treatment records; and a physical examination with diagnostic testing. Such examination failed to show the presence of chloracne. Moreover, the Veteran's service and post-service treatment records are also negative for any diagnosis of chloracne. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding such issue has been met. Additionally, as pertinent to the Veteran's claim for a higher initial rating for his PTSD, he was afforded VA examinations in June 2008 and July 2012. Neither the Veteran nor his representative has alleged that such is inadequate for rating purposes. Moreover, the Board finds that the examination is adequate in order to evaluate the Veteran's service-connected PTSD as they include an interview with the Veteran, a review of the record, and a full mental status examination, addressing the relevant rating criteria. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's initial rating claim and no further examination is necessary. Additionally, in May 2010, the Veteran was provided an opportunity to set forth his contentions during a hearing before a DRO. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the DRO or Veterans Law Judge 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. Here, during the May 2010 hearing, the DRO enumerated the issues on appeal. Also, information was solicited regarding the Veteran's in-service experiences he alleges resulted in his chloracne, the type and onset of symptoms, and his contention that his military service caused such disorder. Additionally, while it was noted that the Veteran's claim for a higher initial rating for PTSD was also on appeal, the Veteran and his representative declined to present testimony regarding such issue. 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. See Bryant, 23 Vet. App. at 497. Moreover, the Veteran submitted additional evidence since the May 2010 hearing and was afforded new VA examinations for his chloracne and his PTSD in 2012. Under these circumstances, nothing gives rise to the possibility that evidence had been overlooked with regard to the Veteran's claims decided herein. As such, the Board finds that, consistent with Bryant, the DRO 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 decided herein 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 herein decided. II. Service Connection Claim Service connection may be granted 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(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this regard, as the Veteran does not have a diagnosis of a chronic disease as defined by regulation, the laws and regulations pertaining to presumptive service connection, to include on the basis of continuity of symptomatology, are inapplicable. VA regulations provide that a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period from January 9, 1962, to May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 U.S.C.A. § 1116 ; 38 C.F.R. § 3.307(a)(6)(iii). In the instant case, the Veteran's service records confirm that he served in Vietnam from April 1972 to January 1973. Certain diseases, to include chloracne, shall be service-connected if the Veteran was exposed to an herbicide agent during active service even though there is no record of such disease during service, provided that the requirements of 38 C.F.R. § 3.307(d) are satisfied. 38 C.F.R. § 3.309(e). Additionally, chloracne must have become manifest to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. 3.307(a)(6)(ii). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service treatment records as well as post-service treatment records are negative for a diagnosis of chloracne. While the Veteran is presumed to have been exposed to herbicides coincident with his service in Vietnam, the regulations specifically state that chloracne must have become manifest to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. 3.307(a)(6)(ii). In this regard, his last exposure occurred in 1973. However, there is no evidence that he manifested chloracne to a compensable degree within one year following such exposure. In this regard, his service treatment records, to include those dated subsequent to his Vietnam service, are negative for any complaints, treatment, or diagnosis referable to his skin, to include chloracne. Moreover, service connection is not warranted for chloracne on a direct basis. In this regard, the evidence fails to show that he has a current diagnosis of such disorder. Specifically, the Veteran's service treatment records and post-service treatment records of any complaints, treatment, or diagnosis referable to chloracne. Moreover, at his September 2012 VA examination, the examiner stated that the Veteran did not have a diagnosed skin disorder. Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet.App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a Veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1. See also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that a symptom, 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), vacated in part and remanded on other grounds sub. nom. Sanchez-Benitez v. Principi, 239 F. 3d 1356 (Fed. Cir. 2001). In the instant case, the probative evidence of record fails to demonstrate a current diagnosis of chloracne at any point during the appeal period. While the Board has also considered the Court's holding in Romanowsky, supra, there is also no probative evidence of a recent diagnosis of chloracne prior to the Veteran's claim. In this regard, the Board notes that the Veteran is competent to report his own symptoms or matters within his personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In addition, laypersons may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (the Board's categorical statement that 'a valid medical opinion' was required to establish nexus, and that a layperson was 'not competent' to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, matters of a medical diagnosis for disabilities not capable of lay observation, such as chloracne, are matters within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). In the instant case, the Veteran does not have the appropriate medical training and expertise to competently self-diagnose chloracne. Specifically, chloracne is a very specific type of skin disorder and, while the Veteran is competent to describe his rashes and benign tumors, he is not capable of identifying chloracne. Therefore, his lay assertions in this regard have no probative value. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) ("[s]ometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. § 1110. Thus, where, as here, the probative evidence indicates that the Veteran does not have a current diagnosis of chloracne for the entire appeal period, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer, supra. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for chloracne. As such, that doctrine is not applicable in the instant appeals, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). III. Initial Rating Claim The Veteran is currently in receipt of a 30 percent evaluation for his service-connected PTSD. He contends that such disability is more severe than as reflected by the currently assigned rating. Therefore, the Veteran claims that he is entitled to a higher initial rating for his PTSD. In addition to his PTSD, the Veteran also has a diagnosis of depressive disorder, which the June 2008 VA examiner related to his PTSD and military service. The Court has held that, when it is not possible to separate the effects of the service-connected condition from a nonservice-connected condition, 38 C.F.R. § 3.102, which requires that reasonable doubt on any issue be resolved in the Veteran's favor, clearly dictates that such signs and symptoms be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181 (1998). Therefore, as depressive disorder is part of the Veteran's PTSD, the Board has attributed all symptoms of such disorder to his service-connected PTSD. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. Fenderson v. West, 12 Vet. App. 119 (1999). The July 2008 rating decision granted the Veteran service connection for PTSD and assigned an initial 30 percent disability rating, effective August 29, 2006. The Veteran's PTSD is currently evaluated under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9411. Under such regulations, ratings are assigned according to the manifestation of particular symptoms. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase 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). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). 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). Id. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Id. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the DSM-IV, GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness". There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown , 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). July 2008, August 2008, October 2008 and April 2009 private treatment records reflect complaints of insomnia. Upon examination, the Veteran's speech was fluent. In May 2008, the Veteran reported that he had some mild short term memory issues, but his recent and remote memory were normal upon examination at such time and again in July 2008. At the Veteran's June 2008 VA examination, he reported that he felt depressed in the afternoons. He endorsed "so-so" appetite, low energy (due to/exacerbated by medical conditions), sleep problems, lack of motivation, and anhedonia. He reported that he believed he has been depressed since Vietnam. The Veteran indicated that he had been married three times. He reported that he was close to his daughter and they talk all the time; however, he had not talked to his son in 15 years. While the Veteran's first two marriages ended, he currently was married for 12 years and reported that his marriage was going great. He also indicated that he adopted his step-daughter and gets along with her. The Veteran further reported that he is close to both of his parents and talks to them or sees them every day. The Veteran indicated that he does not have any friends and hadn't made any many friends since returning from Vietnam. He stated that he did not want to get close to anyone. The Veteran reported that he used to shoot competitively but stopped because of deteriorating health and denied any current interests. He also stated that he used to get into physical altercations, but had not done so since the 1980's. The Veteran reported that he had solid marital and family relationships, but does not maintain friendships. He also stated that used to drink as a way to self medicate and as a way to sleep but stopped drinking in 2006 because of his liver problems. On examination, the Veteran was clean and casually dressed. He was also restless, tense, and rubbed his hands on his legs when he discussed his in-service stressors. His speech was spontaneous, clear, and coherent and his attitude was cooperative and attentive. His affect was mildly anxious and mildly dysphoric. The Veteran was oriented to person, time, and place. His thought processes and thought content were unremarkable, it was also logical, sequential, and goal directed. He had no delusions or hallucinations and understood the outcome of his behavior. The Veteran had sleep impairment and slept on average of four to six hours. He reported difficulty initiating sleep and woke up in the middle of the night. He also had night sweats frequently. The Veteran did not have any inappropriate behavior, obsessive or ritualistic behavior, homicidal thoughts, suicidal thoughts, or episodes of violence. It was noted that he had good impulse control. The Veteran reported panic attacks that could occur a couple times as a week but then he may go a month without one. The VA examiner stated that the Veteran's symptoms mildly to moderately impaired his functioning. He further indicated that the Veteran did not have total occupational and social impairment due to PTSD signs and symptoms. While he did have deficiencies in judgment, thinking, family relations, work, or mood it was specifically stated that he did not have any deficiencies in judgment, thinking, or work. Additionally, he did have deficiencies in family because he did not maintain any friendships and deficiencies in mood because he had chronic depression and a decreased quality of life. The VA examiner stated that he did not have reduced reliability and productivity due to PTSD symptoms nor did he have occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks due to PTSD symptoms with general satisfactory functioning. The VA examiner stated that the Veteran did have transient or mild symptoms which decrease work efficiency and ability to perform occupational tasks only during period of significant stress; he maintained close family relationships with his wife, daughter, and parents but not with people outside of his family; he has been less involved with leisure activities; and worked for the same employer for 25 plus years but typically stayed to himself. A December 2009 VA treatment record reflects that, upon mental status examination, the Veteran was alert, oriented times three, and appropriate. A March 2010 private record reflects complaints of mild insomnia. Upon physical examination, the Veteran was alert and oriented, and his speech was fluent. An August 2011 VA psychology outpatient note stated that the Veteran had recurrent depression, but since medication was added, his mood improved. He enjoyed going out with his wife. He also denied current suicidal or homicidal ideation, plan, or intent. His symptoms were generally well controlled with medication, his nightmares decreased over time, and although he was still vigilant, he had some decrease in his intrusive memories that were tied to his military service. The Veteran was afforded another VA examination in July 2012. At such time, he reported complaints of depression, lack of attention, and a preference to stay by himself. He reported that he had no friends, but then indicated that he had a couple of buddies from service that he stays in touch with. The Veteran further reported flashbacks and nightmares, but indicated that such were not as vivid as they used to be. He indicated that he had nightmares a couple of times a week and sleeps four hours at a time. He reported avoidance of crowds, anger issues, and sleep issues. Upon mental status examination, the Veteran had symptoms of depressed mood, panic attacks that occurred weekly or less often, and chronic sleep impairment. No other symptoms were recorded. He reported that he retired from his job because of his liver transplant. The VA examiner stated that the Veteran had a formally diagnosed mental condition but did not have symptoms severe enough either to interfere with occupational and social functioning or to require continuous medication. Following a review of the relevant evidence of record, the Board concludes that the Veteran is not entitled to an initial rating in excess of 30 percent for his PTSD. In this regard, the Board finds that, for the entire appeal period, such disability is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks as a result of insomnia and sleep problems, lack of motivation, anhedonia, recurrent depression, mild anxiety, occasional panic attacks, nightmares, intrusive memories, flashbacks, and avoidance of crowds, without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. As indicated previously, a 50 percent rating is warranted where 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 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. Based on the evidence of record, the Board finds that the Veteran's PTSD does not result in occupational and social impairment with reduced reliability and productivity. First, the Board notes that both the June 2008 and July 2012 VA examiners indicated that the Veteran's PTSD symptomatology did not result in such impairment. Moreover, while he does have some symptomatology indicative of 50 percent rating, such does not result in occupational and social impairment with reduced reliability and productivity. Specifically, while the Veteran did report that sometimes he had panic attacks more than once a week, he also reported that he could go a month without one. The Veteran did report in June 2008 that he did not have a lot of friends and did not want to get to close people, but in July 2012 he stated that he was still friends with people from his military service. He also reported that, though he was on his third marriage, he had a good relationship with his wife and daughter, and was close to his parents. The Veteran reported that he used to get into fights, but has not done so since the 1980's. Furthermore, he has been noted to have good impulse control. His judgment was consistently found to be intact while his insight was consistently found to be present, intact, or good. Likewise, there is no evidence of impaired abstract thinking. His speech was consistently found to be fluent, goal-directed and logical. While the Veteran's affect has been variously described as mildly anxious and mildly dysphoric, it has not been noted to be flattened. Additionally, while the Veteran reported that he had some mild short term memory issues in May 2008, mental status examination at such time, and consistently thereafter, found that his recent and remote memory were normal. Therefore, the Board finds that, despite the Veteran's subjective report of mild memory, the objective evidence fails to demonstrate any impairment of short- or long-term memory. There is also no evidence that the Veteran has difficulty in understanding complex commands. He routinely denied suicidal and homicidal ideations. While the Veteran reported some flashbacks and intrusive memories, it was noted in August 2011 that they were decreasing. It was also noted that medication improved his depression. While the Veteran does have recurrent depression and was noted to be mildly anxious and dysphoric, which may be contemplated in the 50 percent criteria of disturbances of motivation and mood, the Board finds that such symptoms are not of such a frequency and severity so as to result in occupational and social impairment with reduced reliability and productivity. The Board further notes that the evidence of record reflects that the Veteran has additional symptomatology that is not enumerated in the rating criteria, to include depression, sleep disturbances, nightmares, flashbacks, intrusive thoughts, and an inability to be in crowds. See Mauerhan, supra. However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 30 percent under the General Rating Formula as they are not of such a severity or frequency to result in occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. Additionally, the Board notes that the Veteran was assigned a GAF score of 45 in June 2008, a GAF score of 45 in August 2011, a GAF score of 65 in July 2012. GAF scores of 61 to 70 are indicative of 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 generally functioning pretty well, with some meaningful interpersonal relationships. 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). A GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207(1994). Although the Veteran has been assigned a GAF score reflecting mild to serious symptoms, the Board finds that the Veteran is not entitled to a rating in excess of 30 percent for PTSD. While a GAF score of 45 represents serious symptoms or serious impairment in social, occupational or school functioning, the Board notes that the mental status examinations conducted during this period detail only mild to moderate symptoms indicative of a 30 percent rating. Therefore, as the Veteran's PTSD symptoms, as detailed previously, are contemplated by his 30 percent evaluation and, absent more severe symptoms, a higher rating is not warranted. Moreover, the Board finds that, during such time period, the Veteran's PTSD symptomatology, described above, does not more nearly approximate a 70 or 100 percent rating. While the July 2008 VA examiner stated that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood he went thoroughly through each area and stated that there was no deficiencies in judgment, thinking, or work; the only deficiencies were in family because he did not maintain friendships and mood because of his depression, both of which are contemplated in his currently assigned 30 percent rating. Moreover, he then stated that the Veteran's PTSD was manifested by occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress; the specific criteria for a 10 percent disability rating. Furthermore, the July 2012 VA examiner stated that the Veteran's PTSD was manifested by mental condition that has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication, which is the criteria for a noncompensable rating. In addition, the Board finds that the evidence fails to demonstrate primarily such symptomatology as flattened affect; impaired speech; difficulty understanding complex commands; impairment of memory, judgment, or abstract thinking; disturbances of motivation and mood; obsessional rituals; near-continuous panic or depression; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; gross impairment in thought processes or communication; delusions or hallucinations; grossly inappropriate behavior; persistent danger of hearing self or others; inability to perform activities of daily living; disorientation to time or place; or memory loss. Therefore, for the foregoing reasons, the Board finds that the Veteran is not entitled to a rating in excess of 30 percent for PTSD. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected PTSD; however, the Board finds that his symptomatology has been stable throughout the appeal. Therefore, assigning staged ratings for such disability is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b) (1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation 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 "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected PTSD with the established criteria found in the rating schedule. The Board finds that the Veteran's PTSD symptomatology is fully addressed by the rating criteria under which such disability is rated. In this regard, all of the Veteran's psychiatric symptomatology is contemplated by the rating criteria, to include those symptoms which are not specifically enumerated. See Mauerhan, supra. There are no additional symptoms of his PTSD that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the evidence does not show, and the Veteran has not alleged, that his PTSD renders him unemployable. Rather, the evidence, to include VA examination reports as well as SSA records, reflect that he retired due to liver disease, to include a liver transplant. Therefore, the Board finds that the issue of entitlement to a TDIU is not expressly raised by the Veteran or reasonably raised by the record and, consequently, further consideration of such is not necessary. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to an initial rating in excess of 30 percent for PTSD. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107. ORDER Service connection for chloracne is denied. An initial rating in excess of 30 percent for PTSD is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran was afforded a VA examination for his claim of entitlement to service connection for bilateral hearing loss in May 2008. At that time, he did not meet the standards for hearing loss for the right ear under 38 C.F.R. § 3.385. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater, or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels or greater, or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. However, he did meet the standards for hearing loss under 38 C.F.R. § 3.385 for the left ear. Additionally, the Veteran reported bilateral tinnitus that he first noticed approximately 20 years previously while working for Naval Avionics. After a review of the record, an interview with the Veteran, and an audiological examination, the examiner opined that it was less likely as not that hearing loss and tinnitus were caused by or a result of noise exposure from heavy mortar and rocket attacks during the Veteran's service in Vietnam. The examiner noted that the Veteran's service treatment records showed no evidence of hearing loss or tinnitus at his separation physical. Additionally, at the time of the VA examination, the Veteran reported that his tinnitus was first noticed twenty years previously, which was 10 years after his military service. Therefore, the examiner concluded, based on the date of reported onset of tinnitus and the service treatment records demonstrating normal hearing levels at discharge, the Veteran's current hearing loss and tinnitus are less likely as not caused by or a result of noise exposure during military service. However, the VA examiner did not comment upon the threshold shift in the Veteran's hearing during his military service. Specifically, at the time he entered service, his August 1969 enlistment examination revealed the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT -5 -5 -5 - -5 LEFT -5 -5 -5 - +5 At the time of his service discharge, his June 1978 examination revealed the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 5 5 5 LEFT 10 5 0 10 10 Additionally, subsequent VA treatment records indicate that the Veteran has been scheduled for more recent hearing tests. Specifically, in April 2012, it was noted that the Veteran was scheduled for a hearing test. In May 2012 it was stated that the Veteran would be scheduled for another audiology appointment after his wax build up was cleaned out, and in June 2012, it was stated that he had major wax build up in the right ear with no hearing in the right ear. However, it is unclear whether an audiology examination has been subsequently conducted. Moreover, at his May 2010 DRO hearing, the Veteran reported that his tinnitus and bilateral hearing loss first began during his military service coincident with his duties on the flight line. Finally, in May 2012 the Veteran reported at an audiology appointment that he had constant bilateral buzzing for the past year that he attributed to new medication. He also reported that 10 years ago he had tinnitus for one week that he attributed to stress. As the Veteran is service-connected for ischemic heart disease and PTSD, it is unclear whether medications related to treatment for such disabilities, or the stress associated with his PTSD, caused or aggravated his tinnitus. Therefore, in light of the examiner's failure to comment upon the threshold shifts during the Veteran's military service, the possibility of additional records demonstrating a diagnosis of bilateral hearing loss per VA regulations, the Veteran's new assertion that his hearing loss and tinnitus began during service, and the newly raised theories of entitlement regarding secondary service connection for tinnitus, the Board finds that the Veteran should be afforded a new VA examination so as to determine the current nature and etiology of his bilateral hearing loss and tinnitus. Additionally, with respect to his tinnitus, the Veteran should also be provided VCAA notice pertaining to the secondary aspect of such claim. Regarding the Veteran's claim for service connection for hepatitis C, he asserts that he was exposed to blood during service when he cleaned up blood off of a plane and an office. While the Veteran was not diagnosed with hepatitis C during service, his June 1978 separation examination noted that he had three tattoos (he had only one on entrance) and he had unexplained weight loss as he lost 25 pounds in a two week period. He further reported that, upon his return from Vietnam, he was told that he could not donate blood. While he was afforded a VA examination in May 2008, no etiological opinion was rendered at that time. However, at a November 2009 VA examination, the examiner indicated that she could not resolve the issue of whether the Veteran's hepatitis C is related to his military service without resorting to mere speculation. At such time, the Veteran reported that, while he was in Vietnam, he had elevated liver enzyme levels and, after his return, he could not donate blood because he had hepatitis antibodies. It was also noted that he had tattoos prior to his entrance into the military and during his military service and a blood transfusion prior to 1992. The VA examiner stated that the literature indicates that a blood transfusion prior to 1992 could result in hepatitis C and so could a tattoo or a piercing in an unsafe environment. All of these factors put the Veteran at risk. She opined that the cause of the Veteran's hepatitis C was most likely multifactorial in nature and, thus, she could not resolve this issue without resorting to mere speculation. As there is no definitive opinion regarding this issue, the Board finds that the Veteran should be afforded another VA examination so as to determine the nature and etiology of his hepatitis C. Regarding the Veteran's claim for service connection for a skin disorder, to include a skin rash and tumors of the face and back, a March 2006 VA treatment note includes a past medical history for a removal of cysts from his back and the Veteran testified that he has a rash during the change of seasons. Additionally, a December 2009 VA treatment note indicated that he had lesions from shingles and a September 2012 treatment note indicated that the Veteran had a tumor on his back removed. While the September 2012 VA examiner found that the Veteran did not have a diagnosed skin disorder, the Board finds that the aforementioned evidence is sufficient to establish a current diagnosis of a skin disorder. Therefore, the Veteran should be afforded a new VA examination so as to determine the nature of his claimed rash and skin tumors, to include any residual scarring, as well as the etiology of such skin disorder(s), to include whether such are related to his in-service exposure to herbicides. Regarding the Veteran's claim for service connection for a right knee disorder, the Board observes that his service treatment records are negative for complaints, treatment, or diagnoses referable to the right knee, with the exception of a notation on his June 1978 separation examination that he broke his knee in 1967. In this regard, at his May 2010 DRO hearing, the Veteran reported that he chipped his patella during high school, but such healed. He further testified that he injured his right knee during basic training, in approximately 1970, when he slipped and fell and hit under his kneecap. The Veteran stated that, since such injury, he experienced popping of the right knee. He and his representative further argued that, as he did injure his right knee prior to service, that his military service either caused his current knee disorder or aggravated his pre-existing knee disorder. As such, the Veteran was afforded a VA examination in August 2012 where a diagnosis of right knee anterior cruciate ligament (ACL) damage was diagnosed. Following a review of the record, an interview with the Veteran, and a physical examination, the examiner opined that it was less likely than not that his diagnosed right knee disorder was related to his military service. The examiner stated that the Veteran had at least three injuries to his knee, only one of which occurred in service. He indicated that it was likely that his fall in the 1980's caused his ACL damage since that it was when it was diagnosed. He stated that he had no way of knowing whether his knee injury in service resulted in damage without documentation of such injury. However, the Board finds that a remand is necessary in order to obtain an addendum opinion regarding the nature and etiology of the Veteran's right knee disorder, to include whether he had a pre-existing disorder that was aggravated by service. Additionally, in offering an addendum opinion, the examiner should be advised that he cannot rely on the lack of contemporaneous medical records for his negative opinion. See Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (2006) (that the lack of contemporaneous medical records does not, in and of itself, render lay evidence not credible). Rather, he should consider the Veteran's report of the circumstances and type of injury he incurred (i.e., slipped and fell and hit under his kneecap). Finally, on remand, the Veteran should be given an opportunity to identify any VA or non-VA healthcare provider who treated him for his bilateral hearing loss, tinnitus, hepatitis C, skin disorder, and right knee disorder. Thereafter, any identified records not already of record, to include VA treatment records from the facility in Indianapolis, Indiana, dated from September 2012 to the present, should be obtained for consideration in the Veteran's appeal. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be provided with proper VCAA notice regarding the evidence and information necessary to substantiate his claim of entitlement to service connection for tinnitus as secondary to his service-connected ischemic heart disease and/or PTSD. 2. The Veteran should be given an opportunity to identify any VA or non-VA healthcare provider who treated him for his bilateral hearing loss, tinnitus, hepatitis C, skin disorder, and right knee disorder. After securing any necessary authorization from him, obtain all identified treatment records that are not already of record, to include VA treatment records from the Indianapolis VA Medical Center dated from September 2012 to the present. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. After obtaining all outstanding treatment records, the Veteran should be afforded an appropriate VA examination so as to determine the nature and etiology of his bilateral hearing loss and tinnitus. The entire claims file must be made available to the examiner and the examination report should include discussion of the Veteran's medical history and assertions. All appropriate tests and studies should be accomplished, including the Maryland CNC test and a puretone audiometry test, and all clinical findings should be reported in detail. (A) The examiner should indicate whether the Veteran has bilateral hearing loss and/or tinnitus. (B) If so, the examiner should offer an opinion as to whether it is at least as likely as not that the Veteran's bilateral hearing loss and /or tinnitus are related to his in-service noise exposure. In offering such opinion, the examiner should specifically comment upon the threshold shift in the Veteran's hearing acuity from his August 1969 enlistment examination to his June 1978 separation examination and the significance, if any, of such shift. The examiner should also consider the Veteran's testimony at the May 2010 DRO hearing that his hearing loss and tinnitus first began during service when he served on the flightline. (C) The examiner should also offer an opinion as to whether it is at least as likely as not that the Veteran's tinnitus is caused OR aggravated by any medication that he takes for the treatment of his ischemic heart disease and/or PTSD, and/or the stress related to his PTSD. Any opinions expressed must be accompanied by a complete rationale. 4. After obtaining all outstanding treatment records, the Veteran should be afforded an appropriate VA examination so as to determine the nature and etiology of his hepatitis C. The entire claims file must be made available to the examiner, and the examination report should include discussion of the Veteran's medical history and assertions. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner should discuss the nature, onset, and etiology of the Veteran's hepatitis C. A history of all the Veteran's potential risk factors of hepatitis C infection should be detailed in full. The examiner must list and discuss all documented and reported pre-service, in-service, and post-service risk factors. The VA examiner then must determine if it is at least likely as not that the Veteran's hepatitis C is due to his military service. In offering such opinion, the examiner should specifically discuss the two additional tattoos and the unexplained 25 pound weight loss in a 2 week period noted on the Veteran's June 1978 service separation examination (to include the results of the CBC and mono spot tests obtained in May 1978) as well as the Veteran's contentions that cleaned up other servicemembers' blood. Any opinions expressed must be accompanied by a complete rationale. 5. After obtaining all outstanding treatment records, the Veteran should be afforded an appropriate VA examination so as to determine the nature and etiology of his skin disorder, to include a rash and tumors of the face and back. The entire claims file must be made available to the examiner, and the examination report should include discussion of the Veteran's medical history and assertions. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner should discuss the nature, onset, and etiology of the Veteran's skin disorder. The VA examiner should state all skin diagnoses found to be present, to include a rash and tumors of the face and back, or any resulting scarring, from the time of his August 2006 claim to the present. In this regard, the examiner is advised that the notation in a March 2006 VA treatment note of a past medical history of removal of cysts from the back, the Veteran's testimony at his May 2010 DRO hearing that he experiences a rash during the change of seasons, a December 2009 VA treatment note indicating lesions from shingles, and a September 2012 treatment note indicating that the Veteran had a tumor on his back removed is sufficient evidence of a current diagnosis of a skin disorder during the appeal period (i.e., from August 2006 to the present). For each diagnosis, the VA examiner should offer an opinion as to whether such is at least as likely as not related to the Veteran's military service, to include his in-service exposure to herbicides. Any opinions expressed must be accompanied by a complete rationale. 6. After all outstanding records have been associated with the claims file, return the claims file to the VA examiner who conducted the Veteran's August 2012 right knee examination. The claims file and a copy of this Remand must be made available to the examiner. The examiner shall note in the examination report that the claims folder and the Remand have been reviewed. If the August 2012 VA examiner is not available, the claims file should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. (A) The examiner should identify all current diagnosis of a right knee disorder (right knee ACL damage was diagnosed in August 2012). (B) For each current diagnosis, the examiner should offer an opinion as to whether there is clear and unmistakable evidence that the disorder(s) pre-existed service. In offering such opinion, the examiner should consider the June 1978 notation that the Veteran broke his knee in 1967 (prior to service). (i) If there is clear and unmistakable evidence that the disorder(s) pre-existed service, the examiner is asked to opine as to whether there is clear and unmistakable evidence that the pre-existing disorder(s) did not undergo an increase in the underlying pathology during service. If there was an increase in the severity of the Veteran's disorder(s), the examiner should offer an opinion as to whether such increase was clearly and unmistakably due to the natural progress of the disease. (ii) If there is no clear and unmistakable evidence that any current disorder pre-existed service, then the examiner is asked whether it is at least as likely as not that the disorder is directly related to service, including the Veteran's self-described in-service injury. In offering any opinion, the examiner is advised that advised that he cannot rely on the lack of contemporaneous medical records for his negative opinion. Rather, he should consider the Veteran's report of the circumstances and type of injury he incurred (i.e., slipped and fell and hit under his kneecap). Any opinions expressed must be accompanied by a complete rationale. 7. 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. If the claims remain 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. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). _________________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs