Citation Nr: 1335014 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 10-21 340 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to an initial disability rating in excess of 10 percent for a thoracic strain. 3. Entitlement to an initial disability rating in excess of 10 percent for cervical disc disease prior to July 25, 2011, and in excess of 30 percent since. 4. Entitlement to a total disability rating based on individual unemployability due to a service-connected disability (TDIU). REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran had active military service from February to June 2001 and from August 2004 to January 2006. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a December 2008 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, which granted service connection for PTSD and assigned a 10 percent disability rating, effective June 9, 2008. The Veteran submitted a Notice of Disagreement (NOD) with this determination in January 2009. In an April 2010 rating decision, the RO increased the Veteran's disability rating for PTSD to 30 percent, effective June 9, 2008. He subsequently perfected his appeal in May 2010. Additionally, these matters come before the Board on appeal from a May 2009 rating decision, which granted service connection for cervical disc disease and assigned a 10 percent disability rating, and a thoracic strain and assigned a noncompensable disability rating, both effective January 5, 2009. The Veteran submitted a NOD with these determinations in September 2009, and perfected his appeal in May 2010. Subsequently, in a September 2011 rating decision, the RO increased the Veteran's disability rating for cervical disc disease to 30 percent, effective July 25, 2011. Additionally, in a February 2013 rating decision, the RO increased the Veteran's thoracic strain to 10 percent, effective January 5, 2009. Additionally, the Veteran was granted service-connection for radiculopathy of the right and left upper extremities and assigned separate 20 percent disability ratings, effective September 28, 2010. In a July 2012 statement, the Veteran noted that he was having many neck problems, which caused him to miss too many days of work. He further stated that as a result, after September 30, 2011, he would no longer be employed. Additionally, he also reported that his neck wasn't the only wound he received in Iraq that prevented him from working; his severe headaches did as well. The Board interprets this statement as raising a claim for total disability rating based on individual unemployability due to service-connected disabilities. The RO has not expressly developed or adjudicated that issue. Nevertheless, a TDIU claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. See Rice v. Shinseki, 22 Vet. App. 447 (2009). When, as here, evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for TDIU will be considered part of the claim for benefits for the underlying disability. Here, the Veteran raised the issue of entitlement to TDIU while challenging the rating for cervical disc disease, a thoracic strain, and PTSD. Therefore, his TDIU claim is part of the increased rating claims for cervical disc disease, a thoracic strain, and PTSD, and the Board has jurisdiction over these issues. The Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the above claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The issues of entitlement to initial disability rating in excess of 10 percent for cervical disc disease prior to July 25, 2011, and in excess of 30 percent since and a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the pendency of this appeal, the Veteran's PTSD has been productive of occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, and mood, due to such symptoms as suicidal ideation, near-continuous depression, impaired impulse control, and difficulty adapting to stressful circumstances; but total occupational and social impairment is not shown. 2. The Veteran's thoracic strain has been manifested by flexion greater than 60 degrees but not greater than 85, but has not been manifested by muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour, a combined range of motion of the thoracolumbar spine not greater than 120 degrees, or incapacitating episodes lasting at least 2 weeks but less than 4 weeks in a 12 month period. 3. The competent and probative medical evidence of record does not show that the Veteran's service-connected thoracic spine disability and PTSD are so exceptional or unusual that referral for extraschedular consideration by designated authority is required. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002 and Supp. 2012); 38 C.F.R. § 4.130; Diagnostic Code (DC) 9411 (2012). 2. The criteria for an initial disability rating in excess of 10 percent for a thoracic strain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp 2012); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.40-4.46, 4.71a, Diagnostic Code 5237 (2012). 3. Application of the extraschedular rating provisions are not warranted in this case. 38 C.F.R. § 3.321(b) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 U.S.C.A. §§ 3.102, 3.156(a), 3.159 and 3.326(a). 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); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran's claim arises from his disagreement with the initial evaluations assigned following the grant of service connection for his claimed thoracic spine condition and PTSD. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), Goodwin v. Peake, 22 Vet. App. 128, 134 (2008), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is required for these claims. VA must also make reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate the claim for the benefit sought unless no reasonable possibility exists that such assistance would aid in substantiating the claim. This duty includes assisting with the procurement of relevant records, including pertinent treatment records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The VA has also done everything reasonably possible to assist the Veteran with respect to his claim for benefits, such as obtaining private and VA medical records, and providing the Veteran with VA examinations in July 2008, March 2009, March 2010, July 2011, September 2012, and October 2012. As the Veteran has not indicated that he has received additional treatment for the issues on appeal, the Board thus concludes that there are no additional treatment records outstanding with respect to these claims. Consequently, the duty to notify and assist has been satisfied as to the claims now being finally decided on appeal. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Initial Increased Ratings Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2012). Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § Part 4 (2012). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2012). In Fenderson v. West, 12 Vet. App 119 (1999), the Court emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case (such as this one) in which the Veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been recognized as service-connected. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim-a practice known as "staged rating." Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided. 38 C.F.R. § 4.14. It is possible, however, for a Veteran to have separate and distinct manifestations attributable to the same injury, which would permit a rating under several diagnostic codes. The critical element permitting the assignment of multiple ratings under several diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Board has reviewed all of the evidence in the Veteran's claims file, including his VA treatment records, private treatment records, VA examination reports, and statements submitted in support of his claim. In this regard, the Board notes that, although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, all of the extensive evidence of record. Indeed, it has been held that while the Board must review the entire record, it need not discuss each piece of evidence in rendering a decision. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007); Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board's analysis will focus specifically on the evidence that is needed to substantiate the Veteran's claims for increased disability ratings for his thoracic spine condition and PTSD. A. PTSD The Veteran was initially assigned a 10 percent disability rating for PTSD, effective June 9, 2008, in accordance with the criteria set forth in the Schedule for Rating Disabilities, 38 C.F.R. Part 4, Diagnostic Code 9411 (2012). Subsequently, the Veteran's disability rating for PTSD was increased to 30 percent, effective June 9, 2008. Under the General Rating Formula for Mental Disorders, a 30 percent evaluation is provided 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). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 50 percent rating is warranted if it is productive of 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 PTSD when the psychiatric condition produces occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned when there is total occupational or social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place, memory loss for names of close relatives, own occupation, or own name. Id. The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV)). Scores ranging from 61 to 70 illustrate 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 indicate that the individual is functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 illustrate more 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). The GAF score is only one factor to be considered in ascertaining the degree of impairment caused by the Veteran's psychiatric illness. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Turning to the evidence of record, the Veteran submitted lay statements detailing his PTSD symptoms. A June 2008 statement from his wife noted that the Veteran's personality changed greatly after returning from Iraq. She reported nightmares that he would not discuss with her or anyone else. He had horrible road rage that was so bad that she would not ride in a car with him while he was driving. She felt it was not safe for her or their children. She also reported that he became very abusive toward their dog, however, he had never hurt her or their son. When he got upset, she did not argue with him because that caused him to break things in their home. A statement from the Veteran's mother noted that he had been very depressed and distant from everyone since his return from Iraq. He had a lot of anger issues and was on edge all the time. In a June 2008 statement, the Veteran reported that he found no pleasure in anything anymore. H resorted to drinking and would get angry too fast. He reported that he was hounded daily for what happened to him in Iraq. He felt guilt that others died and he didn't. He reported much resentment and anger, along with depression. He lost 10 pounds in the last month. His son was the only reason he wanted to work through this. The Veteran submitted a June 2008 letter from his private physician who treated him in outpatient psychotherapy. The Veteran presented with concerns about intense anger affecting his well-being and his family. He was deployed to Iraq where he and his fellow soldiers were wounded. He indicated symptoms consistent with a DSM-IV diagnosis of PTSD. Specifically, he complained of dreams of death, nightmares, exaggerated startle response, nervousness, anger, emotional detachment from previous activities and people, appetite disturbance and loss of weight, guilt, and depression. Additionally, he reported an increased consumption of alcohol. He indicated he began Cymbalta in early May. He still got intensely angry, was depressed and anxious, but experienced some "calm, especially early in the morning." He indicated that his son and wife's current pregnancy as reasons for living. The physician also provided the Veteran's psychiatric treatment records. The May 2008 intake evaluation noted the Veteran's affect to be blunted. He also reported assaultive/homicidal ideation. His concentration was also noted to be impaired. The records further showed that the Veteran's form of thought was intact, memory was intact, and affect was appropriate. Additionally, his speech was normal or loud. His mood was described as depressed, anxious, angry, and/or irritable. Additionally, his thought content was appropriate and sometimes paranoid, stating he was "on guard" all the time, but with no history of OCD. The Veteran was afforded a PTSD VA examination in July 2008. Upon examination, the Veteran's PTSD symptoms included sleep difficulties, nightmares on a daily basis, crying which he hid from his family, and flashbacks. He stated that he should have died many times, and felt guilty. He also reported avoidance behavior, such as avoiding crowded areas. He was constantly on guard and had a startle response. He reported bedwetting two times a month. Additionally, he reported having general anger and slept with guns under his bed at night for six months. He also stated that his personality had changed. The examiner noted that the Veteran lost his thought process while telling a story, had poor eye contact, and drifted off to a quiet silent moment. Further, he reported that his boss told him that his quality of work had gone down and he missed work three times per month. He said that he had a great job and he didn't want to lose it, but he couldn't function properly. The examiner noted that dysphoria, intrusive thoughts and startle response affected his job functioning. The Veteran came home from work and drank alcohol, and was unable to do regular chores at home. He was able to bathe, eat, keep follow-up appointments, take medication, and attend psychiatric appointments. The Veteran reported no difficulty in his thought processes and communication. The Veteran was tense, anxious, and cooperative, with good eye contact. He had fleeting and helpless suicidal ideas, with no plan or previous attempts. He had no history of homicidal ideas, auditory or visual hallucinations, paranoid thoughts, delusions, or grandiosity. He was alert and oriented, and his judgment and insight were good. The examiner diagnosed the Veteran with PTSD of moderate degree and alcohol abuse, with a GAF score of 65. Regarding occupational dysfunction, the Veteran's PTSD signs and symptoms were affecting him to a moderate degree in holding a full time job. However, it was a temporary disability and should resolve as time passes. He will be able to work in a compassionate working environment (i.e. understand his PTSD). The Veteran submitted an additional January 2009 statement from a co-worker. He noticed the Veteran's ability to work had deteriorated immensely, and he always seemed depressed and anxious. He noted that they had reports of upset customers directed towards the Veteran. He could not be around loud noises and appeared as though he did not want to be at work. He had been late and wanted to leave early often. He noted that the Veteran's future as an employee on the current contract was in question. Additionally, other installation managers noticed his erratic behavior as well. The Veteran was afforded another PTSD VA examination in March 2010. The Veteran met the current criteria for PTSD and reported symptoms of re-experiencing, avoidance, and increased arousal. He indicated that he engaged in isolation, had negative thoughts, had limited interaction with others including his immediate family, and had depression that he related to PTSD. The Veteran also engaged in substance abuse with misuse of Ultram, Darvocet, Percocet, and other medications in an effort to cope with PTSD symptoms. His symptoms occurred on a daily basis and were severe. The examiner noted changes in the Veteran's psychosocial functioning since the last examination, to include a lack of will to do anything, missing more time from work, and lack of regard for anything or anyone. The Veteran was currently employed; however, he was in jeopardy of losing his job due to continued absenteeism and tardiness. He indicated that his attitude at work had been negative and confrontational, which was also causing problems at the workplace. He stated that his quality of marriage was fair and he felt disconnected from his children due to his physical and psychiatric symptoms. He also indicated that at times he would yell at inanimate objects when he was alone. He stated that there were times when he sought confrontations and was noted to be angry and rude towards others; however, he had not had any physical altercations with anyone. He did not have any suicide attempts. He was able to maintain hygiene and grooming. He stated that his sleep had decreased, increased nervousness and anxiety, and he was fearful of the future. The Veteran stated that he felt completely helpless and fearful of what will happen if he became hospitalized as this would possibly cause him to lose his job and not be able to support his family. Upon examination, he was alert and oriented. At the examination he was tense, but cooperative. His psychomotor activity was agitated. Communication was within normal limits. Speech was normal in volume and content at a mildly accelerated rate. He had good eye contact and a mildly depressed mood, with a constricted affect. He did not have suicidal or homicidal ideations, hallucinations, or delusions. His memory, insight, and judgment were within normal limits. The Veteran was diagnosed with PTSD and substance abuse. His GAF score of 55 reflected serious impairment in industrial and social functioning. His prognosis for improvement was fair if he received consistent treatment with appropriate psychotropic medications as well as psychotherapy. The Veteran was afforded another PTSD examination in September 2012. The Veteran was noted to have occupational and social impairment due to mild or transient symptoms, which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran's family life was distant and social life was nonexistent. He worked at camp Shelby as a clerk. He would become anxious in crowds and liked being by himself, which affected his desire to work. His sleep was poor and he had nightmares nightly of dying in Iraq. He was noted to have anorexia and weight loss. He did not take pleasure in anything. He may become emotional and cry when he is alone, but was not suicidal. He was noted to have anxiety. The Veteran's PTSD symptoms included recurrent and distressing recollections, recurrent distressing dreams of the event markedly diminished interest or participation in significant activities, restrict range of affect, difficulty falling or staying asleep, and irritability or outbursts of anger. The PTSD symptoms described above cause clinically significant distress or impairment in social, occupations, or other important areas of functioning. Additionally, treatment records show that the Veteran was receiving mental health treatment at the VA. The records show treatment for anxiety, insomnia, nightmares, and sleep pattern disturbance. In October 2010 note, the Veteran reported significant improvement since taking medication. He reported better sleep and interactions with his family. After a review of the evidence of record, the Board finds that the Veteran's PTSD symptoms have been found to display the criteria contemplated by a 70 percent rating under DC 9411. His PTSD has been productive of occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, and mood, due to such symptoms as suicidal ideation, near-continuous depression, impaired impulse control, and difficulty adapting to stressful circumstances (including work or a work like setting), and the inability to establish and maintain effective relationships. The Veteran's private treating therapist noted that the Veteran's PTSD symptoms included dreams of death, nightmares, exaggerated startle response, nervousness, anger, emotional detachment from previous activities and people, appetite disturbance and loss of weight, guilt, and depression. Lay statements from the Veteran's family showed that he was very depressed, distant from the family, had anger issues, and was on edge all the time. The Veteran reported that he found no pleasure in anything anymore and resorted to drinking. Private treatment records also showed that he reported assaultive/homicidal ideation. His concentration was also noted to be impaired. Additionally, his thought content was appropriate and sometimes paranoid, stating he was "on guard" all the time, but with no history of OCD. He also reported avoidance behavior, such as avoiding crowded areas. Further, he reported that his boss told him that his quality of work had gone down. The VA examiner noted that dysphoria, intrusive thoughts, and startle response affected his job functioning. In a January 2009 statement, the Veteran's coworker noted that they had reports of upset customers directed towards the Veteran. He could not be around loud noises and appeared as though he did not want to be at work. The March 2010 examiner noted worsening symptoms, such as not having the will to do anything, missing more time from work, and lack of regard for anything or anyone. He indicated that his attitude at work had been negative and confrontational, which was also causing problems at the workplace. He stated that his quality of marriage was fair and he felt disconnected from his children due to his physical and psychiatric symptoms. Furthermore, while an examiner's classification of the level of a psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage disability rating to be assigned (38 C.F.R. § 4.126), it is notable that throughout the period of appeal, the Veteran's GAF score ranged from 55 to 65, which is indicative of serious, but not total, occupational and social impairment. Specifically, the March 2010 VA examiner stated that the Veteran's GAF score of 55 reflected serious impairment in industrial and social functioning. In the view of the Board, the GAF score is consistent with the Veteran's PTSD symptomatology and the assignment of a 70 percent rating. Although not all of the enumerated symptoms recited for the 70 percent rating are shown, the Board nonetheless finds that the severity of the Veteran's PTSD symptoms and the significant effect of these symptoms on his social and work situation justify assigning a higher disability rating of 70 percent throughout the entire period of appeal. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Veteran has had significant PTSD symptoms since his service connection claim was granted, and has continued to receive therapy for this disability. Therefore, it is reasonable to conclude that the PTSD symptoms have not changed over the years since service. The Board has considered staged ratings under Hart v. Mansfield, 21 Vet. App. 505 (2007), but concludes that they are not warranted. While he meets the criteria for a 70 percent rating, the Board has determined that he does not meet the criteria for the next higher 100 percent rating, as his PTSD symptomatology does not reveal total occupational and social impairment. The records show that the Veteran retains the ability to maintain daily tasks. Specifically, the July 2008 VA examiner noted that he was able to bathe, eat, keep follow-up appointments, take medication, and attend psychiatric appointments. The Veteran reported no difficulty in his thought processes and communication. The Veteran was tense, anxious, and cooperative, with good eye contact. Additionally, he had no history auditory or visual hallucinations, paranoid thoughts, delusions, or grandiosity. He was alert and oriented, and his judgment and insight were good. The March 2010 VA examiner noted that he was able to maintain hygiene and grooming. Additionally, at the examination his speech was normal in volume and content, at a mildly accelerated rate. Additionally, he was not shown to have any delusions, hallucinations, and inappropriate behavior. Although he reported suicidal thoughts, he denied intent or plan. Additionally, while his wife reported that he was confrontational and abusive toward their dog, he had never been abusive to her or their son. Lastly, the September 2012 VA examiner noted that the Veteran was capable of managing his financial affairs. Such findings do not warrant a 100 percent evaluation when all the other manifestations are considered. See Mauerhan, 16 Vet. App. at 443. The Board acknowledges the Veteran's complaints regarding his PTSD symptoms and notes that the Veteran is competent to make these assertions. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that lay testimony is competent to establish the presence of observable symptomatology); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Competent testimony is limited to that which the witness has actually observed and is within the realm of his personal knowledge; such knowledge comes to a witness through use of his senses-that which is heard, felt, seen, smelled, or tasted. Layno v. Brown, 6 Vet. App. 465 (1994). The Board also accepts the credibility of the Veteran's assertions concerning the impairment associated with his PTSD. In fact, the Veteran's subjective complaints have been considered in determining the present 70 percent rating for his PTSD. All reasonable doubt has been resolved in favor of the Veteran in making this decision. The evidence is for the assignment of a higher 70 percent rating throughout the entire period of appeal for the Veteran's PTSD. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To the extent that the Veteran has contended that his PTSD is more severely impaired than the rating assigned, the preponderance of the evidence is against the claim; and the benefit of the doubt doctrine is not applicable. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Thoracic Spine The Veteran's thoracic strain was assigned a 10 percent disability rating effective January 5, 2009, in accordance with the criteria set forth in the Schedule for Rating Disabilities, 38 C.F.R. Part 4.71a, Diagnostic Code (DC) under DC 5237. Diagnostic Code 5235 (vertebral fracture or dislocation), Diagnostic Code 5236 (sacroiliac injury and weakness), Diagnostic Code 5237 (lumbosacral or cervical strain), Diagnostic Code 5238 (spinal stenosis), Diagnostic Code 5239 (spondylolisthesis or segmental instability), Diagnostic Code 5240 (ankylosing spondylitis), Diagnostic Code 5241 (spinal fusion), Diagnostic Code 5242 (degenerative arthritis of the spine (see also Diagnostic Code 5003)); Diagnostic Code 5243 (intervertebral disc syndrome) are evaluated under the following General Formula for Rating Diseases and Injuries of the Spine (unless intervertebral disc syndrome is alternatively evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes): With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease: A 10 percent rating requires forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine not greater than 120 degrees but not greater than 265; or, combined range of motion of the cervical spine greater than 170 degrees, but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating requires forward flexion of the thoracolumbar greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, combined range of motion of the cervical spine greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating requires evidence of forward flexion of the cervical spine to 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating requires evidence of unfavourable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation will be assigned with evidence of unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating requires evidence of unfavorable ankylosis of the entire spine. Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion is 0 to 30 degrees, and left and right lateral rotation is 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion for the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (0 degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (in effect since September 26, 2003). Intervertebral disc syndrome (preoperatively or postoperatively) will be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. According to the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes: A 10 percent rating requires evidence of incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating requires evidence of incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating requires evidence of incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating requires evidence of incapacitating episodes having a total duration of at least six weeks during the past 12 months. Note 1: For purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note 2: If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment will be evaluated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (in effect from September 26, 2003). The Veteran contends that he is entitled to a disability rating in excess of 10 percent for his service-connected thoracic strain. Turning to the evidence of record, the Veteran was seeking private treatment for his thoracic spine disability. The Veteran underwent a MRI of the thoracic spine in November 2008. The MRI was essentially normal, showing mild multilevel endplate disease from T8-T9 through L1-L2, without significant spinal or foraminal stenosis. Further, the Veteran underwent physical therapy for cervical spine and low back pain, tingling, and numbness through his body and upper extremities. The Veteran was afforded a spine VA examination in March 2009. The Veteran reported persistent neck and back pain afterwards. Most of the pain was in his neck, and the upper back was more symptomatic than the lower back. The neck pain was said to be constant, but varied in severity, and the back was intermittent. He reported pain with activities, such as lifting. He sometimes had pain radiating down his arms and some generalized numbness and tingling in the past. This had improved to some extent. He reported flare-ups of pain occurring once every three to four weeks. Precipitating factors were unknown. Duration was for three to four hours and relieved by rest and medications. These flare-ups primarily involved the neck, but may also involve the back. He had no prescribed bed rest in the past year. Regarding the effects on his occupation, he was doing office-type work, and his neck and back did not keep him from performing his job duties. He had to call in or leave work on occasion secondary to flare-ups and neck pain. He was also independent in his activities of daily living. Upon examination, he was walking with a normal gate and used no assistive devices. Examination of the back revealed that that Veteran was able to stand erect. Range of motion (ROM) testing of the thoracic spine showed flexion of 105 degrees and extension of 0 to 30 degrees. Additionally, there was 0 to 30 degrees of right and left lateral bending, and 0 to 35 degrees of right and left lateral rotation. There was pain at the endpoint of right and left lateral flexion. There was no other objective evidence of pain on motion, spasm, or tenderness. There was also no additional limitation of motion after repetitive motion testing. The examiner diagnosed the Veteran with a thoracic strain. Regarding the DeLuca provision, there was no additional limitation of motion after three repetitive motions. Additional limitation of functioning during a flare-up due to pain, expressed in terms of additional limitation of motion in degrees, could not be determined without resort to speculation. Regarding functionality, the Veteran was independent in his activities of daily living and was gainfully employed. The Veteran was afforded another thoracic spine VA examination in October 2012. The Veteran was noted to have a thoracic strain. The Veteran reported upper back pain all day and weeklong. At its worst, the pain was 10 out of 10 in severity. This occurred about every two to three days. He missed work a lot due to the pain, and was made worse by everyday activities. Thoracic spine ranges of motion were forward flexion of 70 degrees, with no objective evidence of painful motion; extension ending at 20 degrees, with no objective evidence of painful motion; right lateral flexion ending at 20 degrees, with no objective evidence of painful motion; left lateral flexion ending at 20 degrees, with no objective evidence of painful motion; right lateral rotation ending at 30 degrees or greater, with no objective evidence of painful motion; and left lateral rotation ending at 30 degrees or greater, with no objective evidence of painful motion. The Veteran did not have additional limitation in ROM of the thoracic spine following repetitive-use testing, but had functional loss and/or functional impairment of the thoracic spine, to include less movement than normal and pain on movement. The Veteran had localized tenderness or pain to palpation for joints/soft tissue and guarding and/or muscle spasm of the cervical spine, including guarding and/or muscle spasm was present, but did not result in abnormal gait or spinal contour. The Veteran had normal muscle strength, reflexes, and sensory testing. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy or other neurological disabilities. He did not have IVDS of the thoracolumbar spine or use an assistive device. X-rays of the thoracic spine showed mild thoracic spasm, but otherwise within normal limits. Lastly, the Veteran's thoracic spine condition did not impact his ability to work. The preponderance of the above evidence demonstrates that the Veteran is not entitled to a disability evaluation in excess of 10 percent for his thoracic strain. As already noted, the next-higher disability evaluation of 20 percent requires forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gain or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. According to the March 2009 and October 2012 VA examinations, the Veteran was capable of forward flexion to no less than 70 degrees. Additionally, the combined range of motion of the thoracolumbar spine was no less than 190 degrees, which is greater than the 120 degrees or less requirement needed for a 20 percent rating. The October 2012 VA examiner noted that the Veteran had localized tenderness or pain to palpation for joints/soft tissue and guarding and/or muscle spasm of the cervical spine, including guarding and/or muscle spasm was present, but did not result in abnormal gait or spinal contour. Therefore, the preponderance of the evidence demonstrates that the Veteran has not suffered from the necessary criteria needed for a 20 percent rating at any time during the period of appeal. When applying the DeLuca criteria to the Veteran's claim, the preponderance of the evidence of record still demonstrates that he is not entitled to a disability evaluation in excess of 10 percent. At the March 2009 VA examination, there was no objective evidence of pain on motion, spasm, or tenderness. Additionally, the examiner stated that regarding the DeLuca provision, there was no additional limitation of motion after three repetitive motions. At the October 2012 VA examination, the VA examiners stated that the Veteran's thoracic spine condition did not impact his ability to work or activities of daily living. Additionally, the Veteran did not have additional limitation in ROM of the thoracic spine following repetitive-use testing, but had functional loss and/or functional impairment of the thoracic spine, to include less movement than normal and pain on movement. While these symptoms certainly indicate a worsening of the Veteran's symptomatology, they do not demonstrate that the Veteran's overall disability rating has been more appropriately characterized as 20 percent disabling at any time during the appeal period. Therefore, even though the Veteran experienced pain upon movement, this evidence alone does not demonstrate an overall functional impairment equal to a 20 percent disability evaluation. This evidence, considered in totality, demonstrates that a 10 percent disability rating is appropriate for the Veteran's thoracic strain. The Board has also considered whether a higher disability rating would be warranted based on the Formula for Rating Intervertebral Disc Syndrome. Under this formula, a 20 percent rating is warranted when there is evidence of incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. 38 C.F.R. § 4.71a. For purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). At the March 2009 VA examination, the Veteran reported flare-ups for his back condition, but also reported that he was not prescribed bed rest in the past year. Under this Diagnostic Code, an incident is not considered to be an incapacitating episode unless bed rest is prescribed. Additionally, the October 2012 VA examiner noted that the Veteran did not have IVDS of the thoracolumbar spine. The record contains no additional evidence suggesting that the Veteran has suffered from incapacitating episodes totalling at least two weeks but less than four weeks in the past 12 months due to IVDS. As such, a higher disability evaluation based on IVDS is not warranted. Under the schedular criteria, in addition to considering the orthopedic manifestations of a back disability, consideration must be given to any objective neurologic abnormalities associated with the back disability, which are to be evaluated separately under an appropriate diagnostic code. See Note (1) of the 'General Rating Formula for Disease and Injuries of the Spine.' Such neurologic abnormalities include, but are not limited to, bowel or bladder impairment. Id. The Board notes that the Veteran has been assigned two separate 20 percent disability ratings for radiculopathy of the right and left upper extremities, secondary to his service-connected cervical spine disability. The November 2008 thoracic spine MRI was essentially normal, showing mild multilevel endplate disease from T8-T9 through L1-L2, without significant spinal or foraminal stenosis. Additionally, the October 2012 VA examiner noted that the Veteran had normal muscle strength, reflexes, and sensory testing. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy or other neurological disabilities. Therefore, the Veteran has not been shown to manifest any additional neurological abnormalities associated with his thoracic strain. As such, a separate disability evaluation based on neurological abnormalities is not warranted. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to a disability rating in excess of 10 percent for a thoracic strain must be denied. III. Extraschedular Consideration The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or 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 RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 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 C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's service-connected thoracic spine strain include pain and limitation of motion. Additionally, the Veteran's service-connected PTSD symptoms have been productive of occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, and mood, due to such symptoms as suicidal ideation, near-continuous depression, impaired impulse control, difficulty adapting to stressful circumstances, and the inability to establish and maintain effective relationships. However, these symptoms of the Veteran's thoracic spine and PTSD are not shown to cause any impairment that is not already contemplated by the rating criteria, and the Board finds that the rating criteria reasonably describes his disabilities. See 38 C.F.R. § 4.71a, DCs 5235-5243; 38 C.F.R. § 4.130, DC 9411. For this reason, referral for consideration of an extraschedular rating is not warranted for these claims. ORDER Entitlement to an initial disability rating of 70 percent, but no higher, for PTSD is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to an initial disability rating in excess of 10 percent for a thoracic strain is denied. REMAND A review of the record discloses further development is necessary prior to the adjudication of the Veteran's claims of entitlement to initial disability rating in excess of 10 percent for cervical disc disease prior to July 25, 2011, and in excess of 30 percent since, and a TDIU. A. Cervical Spine The Veteran was afforded a cervical spine VA examination in September 2012. Upon examination, the Veteran was noted to have intervertebral disc syndrome, with incapacitating episodes over the last 12 months due to this condition. However, the examiner failed to state the number of incapacitating episodes the Veteran experienced in the past twelve months, which is necessary to rate the Veteran's cervical spine condition based on the criteria set forth under DC 5243. Accordingly, because the September 2012 VA examiner did not address all of the pertinent manifestations of the Veteran's IVDS of the cervical spine, the examination report is insufficient for rating purposes. See Massey v. Brown, 7 Vet. App. 204, 208 (1994) (holding that a VA examination must contain reference to the pertinent criteria to be adequate). As such, this matter must be remanded in order to obtain a VA addendum opinion addressing the Veteran's IVDS, pursuant to the appropriate diagnostic code. B. TDIU The Veteran claims that his service-connected disabilities have rendered him unemployable. VA regulations provide for a TDIU rating when the schedular rating is less than total, where it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 4.16(a). The Veteran is service connected for PTSD and assigned a 70 percent disability rating (noted above); post-concussion migraine headaches and assigned a 30 percent rating; cervical disc disease and assigned a 30 percent rating; meniscus derangement of the right knee and assigned a 10 percent disability rating; tinnitus and assigned a 10 percent disability rating; thoracic strain and assigned a 10 percent disability rating; and radiculopathy of the left and right upper extremity and assigned separate 20 percent disability ratings. The Veteran's combined disability ratings has been 70 percent as of January 5, 2009. Accordingly, the Veteran has at least one disability that is ratable at 40 percent or more (PTSD) and there are sufficient additional service-connected disabilities to bring the combined rating to 70 percent, and, thus, the percentage criteria of 38 C.F.R. § 4.16(a) is met. The remaining question therefore is whether the Veteran was unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. A January 2009 statement from the Veteran's co-worker noted that due to the Veteran's PTSD symptoms the Veteran's future as an employee on the current contract was in question. In a July 2012 statement, the Veteran noted that he was having many neck problems, which caused him to miss too many days of work. He further stated that as a result, after September 30, 2011, he would no longer be employed. Additionally, he also reported that his neck wasn't the only wound received in Iraq that prevented him from working; his severe headaches did as well. However, at the most recent September 2012 PTSD VA examination, noted that the Veteran worked at camp Shelby as a clerk. It is unclear to the Board whether the Veteran's multiple service-connected disabilities have rendered him unemployable. As the Veteran has not yet undergone a VA examination with respect to his TDIU claim, the Board finds that, on remand, he should be afforded a VA examination and opinion to ascertain the impact of his service-connected disabilities on his employability. Friscia v. Brown, 7 Vet. App. 294 (1995) (VA has a duty to supplement the record by obtaining an examination that includes an opinion as to the effect of the Veteran's service-connected disabilities on his ability to secure or follow a substantially gainful occupation). Accordingly, the case is REMANDED for the following action: 1) Ensure that the Veteran's VA treatment records are up to date. 2) The claims file and a copy of this remand should be returned to the VA examiner who conducted the September 2012 VA examination for an addendum to this examination report. If, and only if, this VA clinician is unavailable, then forward the claims file and a copy of this remand to another appropriate VA clinician for his or her review. The examiner should document the number of weeks, if any, during the past 12 months, that the Veteran has had intervertebral disc syndrome with "incapacitating episodes," defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. If the examiner finds that an opinion cannot be rendered without examining the Veteran, then schedule the Veteran for a new VA examination. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached. 3) The Veteran should be scheduled for a VA examination to evaluate the impact of his service-connected disabilities on his employability. The claims folder and a copy of this remand must be reviewed by the examiner in conjunction with the examination and the review should be noted in the examination report. The examiner should opine as to whether the Veteran's service-connected disability (PTSD, post-concussion migraine headaches, cervical disc disease, meniscus derangement of the right knee, tinnitus, thoracic strain, and radiculopathy of the left and right upper extremity) separately or collectively, render him unable to secure or follow a substantially gainful occupation. Consideration may be given to the Veteran's level of education, special training, and previous work experience when arriving at this conclusion, but factors such as age or impairment caused by nonservice-connected disabilities are not to be considered. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 4) Thereafter, the AMC/RO must review the claims file to ensure that the foregoing requested development has been completed. In particular, review the requested medical opinions to ensure that it is responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 5) Following the completion of the foregoing, and after undertaking any other development it deems necessary, the AMC should readjudicate the Veteran's claims. If a claim remains denied, the AMC should then provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs