Citation Nr: 1338375 Decision Date: 11/22/13 Archive Date: 12/06/13 DOCKET NO. 09-10 365 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to an evaluation in excess of 50 percent for posttraumatic stress disorder. 2. Whether new and material evidence has been received to reopen a claim for service connection of bilateral hearing loss. 3. Whether new and material evidence has been received to reopen a claim for benefits under 38 U.S.C.A. § 1151 for tinnitus. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Joseph R. Keselyak, Counsel INTRODUCTION The Veteran served on active duty from October 1961 to May 1965. This matter comes to the Board of Veterans' Appeals (Board) from an April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Manchester, New Hampshire. Per the Veteran's request, a Central Office Board hearing was scheduled for September 24, 2013, and the appellant failed to appear. The appellant has not filed a motion for a new hearing. Accordingly, the case will be processed as though the request for a hearing has been withdrawn. See 38 C.F.R. § 20.704(d) (2013). The issues of whether new and material evidence has been received to reopen a claim of entitlement to service connection for tinnitus, to include as secondary to PTSD (apart from the 38 U.S.C.A. § 1151 claim) and entitlement to service connection for otitis have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issues of whether new and material evidence has been received to reopen a claim for service connection of bilateral hearing loss and whether new and material evidence has been received to reopen a claim for benefits under 38 U.S.C.A. § 1151 for tinnitus 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. During the entire length of the appeal, the Veteran's PTSD has resulted in occupational and social impairment, with deficiencies in most areas, due to frequent suicidal ideation, near-continuous panic and depression, unprovoked irritability, difficulty in adapting to stressful circumstances, particularly in a work-like setting, and inability to establish and maintain effective relationships. He has not been shown, however, to have total occupational and social impairment. 2. The lay and medical evidence of record fails to demonstrate such an exceptional disability picture that the available 70 percent schedular evaluation for the Veteran's service-connected PTSD is inadequate. CONCLUSION OF LAW The criteria for the assignment of a disability rating of 70 percent for service-connected PTSD, but no greater, are met, and there is no evidence to warrant referral for consideration of a higher rating on an extraschedular basis. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(b), 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. In the notice, VA will inform the claimant which information and evidence, if any, that the claimant is to provide to VA and which information and evidence, if any, that VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159 (2011); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Notice should also address the rating criteria and effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided the appellant pre-adjudication notice by letters dated in July and November 2007. VA has obtained the Veteran's service treatment records, VA medical records, Social Security Administration (SSA) records, assisted the Veteran in obtaining evidence, afforded the Veteran a physical examination, and obtained a medical opinion as to the severity of his PTSD. All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. The United States Court of Appeals for Veterans Claims (hereinafter "the Court") has held that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examination obtained in this case is adequate. It is predicated on a substantial review of the record and medical findings and considers the Veteran's complaints, symptoms and history. As the examination report ultimately provides sufficient information such that the Board can render an informed determination, it is adequate. Notably, there are also numerous VA records present that pertain to the extent and severity of the Veteran's psychiatric disability, as well. Accordingly, VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue addressed in this decision has been met. 38 C.F.R. § 3.159(c)(4). The Board notes that the Veteran's representative has requested that he be afforded a new VA examination to address the severity of his service-connected PTSD. See February 2013 argument. He was last afforded a VA examination to address his claim in February 2008. When it is asserted that the severity of a service-connected disability has increased since the most recent rating examination, an additional examination is appropriate. See Caffrey v. Brown, 6 Vet. App. 377 (1995); Green v. Derwinski, 1 Vet. App. 121 (1991). Nonetheless, the Board is not required to remand an appealed disability benefit claim solely because of the passage of time since an otherwise adequate examination report was prepared. VAOPGCPREC 11-95 (April 7, 1995). The Veteran's representative does not allege that the Veteran's PTSD has increased in severity since the February 2008 VA examination or that this examination was inadequate, but rather that the passage of time since his last VA examination warrants a new examination. Thus, the Board does not find that a remand for further examination is proper. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Laws and Regulations Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. The VA schedule of ratings will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). 38 C.F.R. § 3.321(b)(1) provides that, in exceptional circumstances, where the schedular evaluations are found to be inadequate, the veteran may be awarded a rating higher than that encompassed by the schedular criteria. According to the regulation, an extraschedular disability rating is warranted upon a finding that "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 would render impractical the application of the regular schedular standards." Id. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. See 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. See 38 C.F.R. § 4.2 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In addition, an appeal from the initial assignment of a disability rating requires consideration of the entire time period involved, and contemplates "staged ratings" where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). However, "staged ratings" are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating a mental disorder, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of examination. 38 C.F.R. § 4.126(a). The general rating criteria used for evaluation of the Veteran's PTSD provides a 100 percent evaluation for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). The Veteran's disability is currently rated at 50 percent. A 50 percent rating is warranted where the disorder is manifested by 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A higher, 70 percent rating is warranted where the disorder is manifested by 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. Furthermore, with specific regard to the 70 percent rating, such rating "requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). The maximum 100 percent disability rating requires total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. It is noted that the "such symptoms as" language of the diagnostic code listed above means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. A Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A GAF of 21-30 indicates behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g. sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g. stays in bed all day; no job, home, or friends.). A GAF score of 31-40 contemplates some impairment in reality testing or communications (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41-50 illustrates "[s]erious 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 score of 51-60 represents "[m]oderate 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)." A score of 61-70 illustrates "[s]ome 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, has some meaningful interpersonal relationships." Id. The GAF scores, however, assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the evaluation issue; rather, they 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). In claims for VA benefits, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. 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(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Facts and Analysis A review of the record discloses an August 2006 VA mental health note pertaining to a psychotherapy session for treatment of depression/anxiety. At this time, the Veteran reported that he was doing well, generally sleeping OK and eating OK. He had been taking increased lorazepam per doctors ordered. He was alert and oriented to time, place and person. He had no suicidal/homicidal ideation or psychosis. His thoughts were coherent and goal-oriented. "Stable" was assessed. Of record is a November 2006 VA mental health note, documenting a 20 minute psychotherapy session relating to PTSD and reducing depression. The note documents that the Veteran was "more depressed, more reclusive" and had somewhat less energy. Decreased concentration was also noted. His Wellbutrin was increased in dosage and he was noted as "will be trying to get out more." He was alert and oriented times three, and had no suicidal intent, homicidal intent or psychosis. His thoughts were coherent and goal-oriented. Increased depression was assessed. A February 2007 VA mental health record documents ongoing psychotherapy for "anxiety/depression" and with the goal of reducing depression. At this time, the Veteran reported doing better after the Wellbutrin increase without side effects, and that he was feeling generally better in terms of mood. He was alert and oriented times three. He had and had no suicidal intent, homicidal intent or psychosis. He had a less depressed mood and affect. A June 2007 VA mental health treatment record reflects a 20 minute psychotherapy session for treatment of depression and anxiety, with a goal of reducing the same. At this time, the Veteran reported continued problems with sleeping, anxiety and depression. He was alert and oriented times three. He had no suicidal intent, homicidal intent or psychosis. His thoughts were clear and goal-oriented. He was assessed as stable and with fairly chronic symptoms. He was assigned a GAF score of 55 and had a positive PTSD screen. In December 2007, the Veteran was again seen for VA psychotherapy, with the goal of "maintain wellness." At this time the Veteran complained of more nightmares. The addition of Celexa as a medication was discussed. The Veteran was alert and oriented times three. His thoughts were coherent and goal-oriented. PTSD, worsened was assessed. A GAF score of 60 was assigned. The Veteran filed his claim for an increased evaluation of PTSD in July 2007. In February 2008, he was afforded a VA examination to address the severity of his condition. At the time of the examination, the Veteran complained of insomnia, nightmares, intrusive thoughts and loss of concentration. He spent most of his days playing card games on the computer, and did not do any cooking, cleaning or grocery shopping. He had his driver's license, but did not drive due to physical problems. He had not had any legal problems since his last examination in 2005. He was noted as not working due to cardiac troubles. He was in his second marriage, and had been so married for 35 years. He described his relationship as "tense because [he] yelled at [his wife] a lot." There was a total of 7 children between him and his wife, but he did not speak to any of them. He had no friends or family with whom he socialized. His only hobby was "the computer." He did not use alcohol or drugs. He had not assaulted anyone or attempted suicide since his last VA examination in 2005. Mental status showed that the Veteran's speech was slow, hesitant and monotonous. His mood was depressed, anxious and irritable. His affect was appropriate to his mood. There were no indications of depersonalization, but there was evidence of derealization. He denied hallucinations or illusions. His though process tended to be circumstantial, but he was easily directed to the topic at hand. There were no obsessions, although he was preoccupied with his failing health. There were no delusions. He had a suicidal ideation of a passive nature, but no homicidal ideation. He was oriented times 3 and functioned in the average range of intelligence. There were mild problems with attention and concentration resulting in mild short-term memory problems. Long-term memory appeared to be intact. His ability for abstract and insightful thinking was in the low-average range. Commonsense reasoning and judgment, as well as moral and ethical thinking, were also within normal limits. The Veteran also reported getting about 5 to 6 hours of sleep each night, which was sometimes "good," but at other times described as "sometimes my brain's awake all night." He was noted as suffering from sleep apnea. His appetite was decreased and his energy level was "very low." His temper was "very bad" and he related feeling depressed and anxious "all of the time." In terms of PTSD, the Veteran reported intrusive memories, as well as nightmares and night sweats. He reported concern over safety. He did not trust people, could not get close to them and could not tolerate crowds. He had an exaggerated startle response. Examination resulted in assessments of PTSD, mood disorder with depressive features due to service-connected multiple medical problems and anxiety disorder with generalized anxiety due to service-connected multiple medical problems. The examiner assessed a GAF score of 45, noting that the GAF score was in the "serious symptoms" range. The examiner explained that this was because he could not keep a job, had no friends and was even in a bad relationship with his own children. The examiner noted that the Veteran "cannot be around other people." He was found able to manage his VA benefits. In summary, the examiner concluded that the Veteran's symptoms were of a serious nature with ongoing frequency. They related that the Veteran's symptoms "seriously affect his employment function and seriously affect his social functioning." The examiner explained that the Veteran had no impairment of thought process or communication and was able to maintain personal hygiene and his daily responsibilities. They concluded that the Veteran's PTSD symptoms resulted in deficiencies in work, family relations, judgment, thinking and mood, which required continuous medication. The examiner emphasized that the Veteran "just cannot interact with people appropriately and he does not feel comfortable being around other people." A June 2008 VA mental health note documents that the Veteran was doing fairly well with an "upbeat attitude." Sleeping, eating, mood and energy were described as "all good." He denied any other problems with anxiety and reported that he was "holding [his] own." He was then taking Wellbutrin, but not Celexa, as he felt that it made his anxiety worse. He reported no anxiety, and that it was in "good check" A GAF score of 65 was assessed. He was alert and his affect was not depressed or anxious. He was well-groomed and made good eye contact. His speech was spontaneous and well-articulated. He denied any other overt problems, as well as suicidal/homicidal ideation. He had no psychosis. He was assessed as remaining stable, with good control of anxiety and depression. A September 2008 VA mental health note documents a complaint of increased anxiety. He was then alerted and oriented times three. His thoughts were coherent and goal-oriented. He had no suicidal ideations or thoughts of harming others. He had some anxious affect. Significant anxiety was assessed. His medication was changed and he was assigned a GAF score of 65. An October 2008 VA mental health note reflects continued psychotherapy for anxiety, with the goal of reducing the same. The Veteran was then noted as doing well and that he felt that he was eating and sleeping better. He was alerted and oriented times three. His thoughts were coherent and goal-oriented. He had no suicidal ideation or any thoughts of harming others. His affect was not anxious and his mood was good. Of record is a January 2009 VA mental health note pertaining to psychotherapy. The note documents that the Veteran reported "hanging in there pretty well," and minimal sleep disturbance. He related that his "wife is not complaining," so that must mean he was doing "OK." He was alerted and oriented times three. His thoughts were coherent. He was goal-oriented. He had no suicidal/homicidal ideations, or thoughts of harming others. He was relaxed and well-groomed. Stable depression and stable PTSD were assessed. He was assigned a GAF score of 63. In a March 2009 statement, the Veteran asserted that a higher evaluation was warranted for his PTSD. In the statement, he related that he had almost no short term memory and did not talk to anyone but for his doctors. He noted that he had trouble keeping any thoughts in his brain and often lost track of the subject of a conversation. He noted that a doctor had told him that he could "never" go back to work, and that he was entirely dependent on his wife, including as due to being unsteady on his feet. An April 2009 VA mental health note documents treatment for depressive disorder and PTSD by history. At this time, the Veteran related that he had been doing well. He reported good control of sleep and depressive feelings, without any sustained depression or anxiety. He reported no suicidal ideation and no over symptoms of hypervigilance. He reported having nightmares "very rarely." He was alert and oriented times three. He had no suicidal thoughts or thoughts of harming others. He had good eye contact and was well-groomed. In June 2009, the Veteran was again seen for VA mental health treatment, particularly for treatment of depression. At this time, the Veteran reported doing well and that he felt better physically and emotionally with the warmer weather, but generally had no depression. His eating, mood, energy and concentration were all "OK." He denied any neurovegetative symptoms of depression and that reported that he felt relatively free from anxiety. He was alert and oriented times three. He was coherent and had good eye contact. His mood and affect were not depressed. He was cooperative and well-groomed. He had no suicidal ideations or thoughts of harming others. "Doing very well" and "good control of both PTSD" symptoms, as well as "no depression" were assessed. The Veteran was assigned a GAF score of 65. A February 2010 VA mental health note documents a complaint that the Veteran had been feeling more irritable lately and that he would "get frustrated really easily." He questioned whether it was necessary to increase his bupropion medication. On objective examination, he was somewhat tense and irritable, but able to communicate needs effectively and appropriately. He denied suicidal and homicidal ideation. A depression screen was negative and the Veteran was assigned a GAF score of 60. In March 2010, the Veteran was again seen by VA mental health. At this time, he related that he was feeling quite a bit better since the last increase in bupropion. He was much calmer and less irritable. He described having some significant stress in the past 2 months related to health and family issues. Objective examination showed no acute mental status findings. He denied suicidal and homicidal ideations. Of record is a December 2010 VA mental health note pertaining to treatment of PTSD. The note documents that the Veteran reported that things were "about the same" and that he had recently bought a new townhouse. The Veteran reported that he liked the new townhouse as it was more spacious. He was then notably living with his wife and 2 of their teenaged grandsons. He still had flares of irritability, hypervigilance and poor sleep, but not as frequently or as intensely as before. Objective findings remained unchanged since the last examination. He was assigned a GAF score of 60. In March 2011, the Veteran was again seen for VA mental health treatment for PTSD. At this time, he reported that he was doing "OK," and in fact a little better since a change in his living arrangements. In particular, the Veteran had not been getting along well with his wife, so he moved next door to his daughter's house and this was "working out quite a bit better." He denied any significant signs and symptoms of depression and anxiety. It was noted, however, that a recent depression screening had indicated that the Veteran felt that he would be better off dead. He then, however, denied any suicidal ideation or other safety issues. It was noted that he had had a suicide attempt in the early 1990s, but not any significant suicidal ideation since then. Objective examination showed that he had no acute mental status findings or any changes since the last visit. PTSD continued to be assessed and the Veteran was assigned a GAF score of 63. A June 2011 VA mental health note relates to treatment of PTSD, with the goal of mood stability. At this time, mood-wise, the Veteran reported that he was essentially stable. He denied any significant symptoms of anxiety or depression and related that he was sleeping better with his medications. He was still concerned about memory loss and troubles with word finding. Objective examination showed no change from last visit and no acute mental status findings. The Veteran denied suicidal/homicidal intent. No new psychological concerns and "moods essentially fairly stable," with no changes were assessed. He was assigned a GAF score of 62. A September 2011 VA mental health record documents treatment for PTSD and that at this time the Veteran reported feeling a lot of relief recently due to a VA service connection award and the payment of a very large sum of back pay. Objective evidence showed no acute mental status findings. The Veteran denied suicidal/homicidal ideation. No new psychological concerns or problems were assessed at this time. A December 2011 VA mental health note refers to treatment for PTSD. At this time, the Veteran reported that he was doing well and that he and his wife were contemplating taking a vacation to Hawaii. The Veteran expressed excitement over this prospect. Objective examination showed no acute mental status findings and that the Veteran denied suicidal/homicidal ideation. An April 2012 mental health note reflects psychotherapy for PTSD. At this time, the Veteran and his wife related their concerns with memory and concerns over dementia. Objective examination showed no changes since the last visit. The Veteran denied suicidal/homicidal ideation. Modification of medication was discussed. A July 2012 VA mental health note documents continued treatment for PTSD, with a goal of decreased anxiety and improved mood. At this time, the Veteran's wife appeared with him. She reported that the Veteran was laughing more and enjoying time with her better than before he had started bupropion. Concerns over memory were noted, but there were no acute mental status findings. The Veteran then denied suicidal/homicidal ideation. An August 2012 VA primary care note documents good judgment and fair insight. It also discloses that the Veteran was then alert and oriented times three, with good recent and remote memory, as well as an assessment of stable depression. A November 2012 VA mental health note pertains to psychotherapy for PTSD, with a treatment goal of minimal to no symptoms of PTSD to interfere with daily functions. At this time, the Veteran denied any new psychiatric concerns and reported "ups and downs," that he reported he could mostly cope with. He then described a lot of disagreements with his wife, mostly dealing with financial management issues and other daily household conflicts. Marriage counseling was then suggested. Objective examination showed no changes since his last visit and the Veteran denied suicidal/homicidal ideation. Resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's PTSD warrants an increased rating of 70 percent. Specifically, it has resulted in occupational and social impairment, with deficiencies in most areas, due to near-continuous panic and depression, unprovoked irritability, difficulty in adapting to stressful circumstances and inability to establish and maintain effective relationships. It is particularly salient to the Board that the Veteran's GAF scores have ranged from 45 to 65, with a low GAF score of 45. The Board is cognizant that the GAF scores have largely ranged in the 60s, particularly after his February 2008 VA examination. However, GAF scores, like an examiner's assessment of the severity of a condition, are not dispositive of the evaluation issue; rather, they 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). A review of the record discloses that the Veteran has few friends and has tended to isolate himself, with extreme reliance upon his wife, with whom he has frequent conflicts and has even resided apart from during the course of the present claim. Despite the fluctuations in the Veteran's mood, the evidence shows near-continuous anxiety and depression, and his low GAF score of 45, viewed in light of these facts, indicates predominately moderate to serious symptoms associated with PTSD. Richard, supra. Accordingly, the Board finds that the Veteran's symptoms more closely approximate a 70 percent rating for PTSD, throughout the course of the present claim and appeal. Hart, supra. However, although an increased rating of 70 percent is warranted, the evidence of record does not reflect symptomatology of PTSD that would meet the criteria for an even higher rating of 100 percent. Although the evidence demonstrates a significant degree of occupational and social impairment due to PTSD, it does not show total occupational and total 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, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Indeed, the Veteran has been able to maintain some interpersonal relationships, particularly with his wife and close family. A review of the record saliently shows that he stopped working and was awarded SSA benefits due to heart problems. In short, there is simply no evidence to support an increased rating of 100 percent. Even considering that the Veteran's disability has resulted in significant occupational and social impairment, his PTSD has not been shown to result in total social impairment. As such, a rating in excess of 70 percent under Diagnostic Code 9411 is not warranted for any time during the course of the present claim and appeal. Hart, supra. In reaching the above-stated conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against awarding a disability rating in excess of 70 percent, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2013); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Extraschedular Consideration According to the regulation, an extraschedular disability rating is warranted based upon a finding that 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 would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2013). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. It is appropriate to consider extraschedular referral on a "disability-by-disability" basis. Johnson v. Shinseki, 26 Vet. App. 237 (2013). With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected condition is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The criteria particularly contemplate his specific symptoms and the condition's social and industrial impairment. The Board further observes that, even if the available schedular evaluation for his disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required frequent, or any, hospitalizations for his PTSD. Additionally, there is not shown to be evidence of marked interference with employment due to this disability not contemplated by his 70 percent rating. Moreover, there is no evidence in the medical records of an exceptional or unusual clinical picture. In short, there is nothing in the record to indicate that the service-connected disability on appeal causes impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Entitlement to an initial evaluation of 70 percent, but no greater, for PTSD is granted, subject to the laws and regulations governing the award of monetary benefits. REMAND The Board notes that a decision by the Court pertains to attempts to reopen claims subject to prior final denials. In Kent v. Nicholson, 20 Vet. App. 1 (2006), the Court determined that the Veterans Claims Assistance Act (VCAA) requires VA to notify a claimant of the evidence and information that is necessary to reopen the claim and that VA must notify the claimant of the evidence and information that is necessary to establish entitlement to the underlying claim for the benefit sought by the claimant. The Court also found that, in order to satisfy the legislative intent underlying the VCAA notice requirement to provide claimants with a meaningful opportunity to participate in the adjudication of their claims, the VCAA requires, in the context of a claim to reopen, the Secretary to look at the bases for the denial in the prior decision and respond with a notice letter that describes what evidence would be necessary to substantiate that element or elements required to establish service connection that were found insufficient in the previous denial. In a November 2007 letter, the RO informed the Veteran that his claim for hearing loss and benefits under 38 U.S.C.A. § 1151 for tinnitus were last denied in a December 2005 rating decision on the grounds that "no new and material evidence" had been received. The letter did not provide the Veteran with any substance regarding the bases for the previous denials and incorrectly indicated that the 38 U.S.C.A. § 1151 claim for tinnitus was denied in the December 2005 rating decision. This claim was last denied in a May 1999 Board decision. A review of the record documents that the application to reopen the claim for entitlement to service connection for hearing loss was denied on the grounds that new and material evidence had not been received showing aggravation of hearing loss that pre-existed service and that the 38 U.S.C.A. § 1151 claim for tinnitus was denied on the grounds that the evidence did not establish an additional disability caused by VA treatment. Upon remand, the Veteran should be provided adequate Kent notice and invited to substantiate the applications to reopen. Accordingly, the case is REMANDED for the following action: 1. Take appropriate action to comply with Kent v. Nicholson, 20 Vet. App. 1 (2006), to include furnishing the Veteran with a letter informing him of the evidence and information that is necessary to reopen the claims for service connection of bilateral hearing loss and for benefits for tinnitus under the provisions of 38 U.S.C.A. § 1151 remanded herein, and that also asks the Veteran to provide VA any evidence in his possession that might substantiate his claims. The notice should inform the Veteran that his claim for service connection of bilateral hearing loss was last denied in a December 2005 rating decision on the grounds that the evidence did not establish that pre-existing hearing loss was aggravated in service. The notice should also inform him that his claim for entitlement to benefits for tinnitus under 38 U.S.C.A. § 1151 was last denied by the Board in May 1999 on the grounds that the evidence did not establish that VA care resulted in this additional disability. The notice should also inform the Veteran of the standards of establishing service connection for a pre-existing disability, as well as the standards for substantiating a claim under 38 U.S.C.A. § 1151. 2. After the development requested above has been completed to the extent possible, review the record and readjudicate the Veteran's claims. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a Supplemental Statement of the Case (SSOC) and given the opportunity to respond thereto before this case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs