Citation Nr: 1339345 Decision Date: 11/29/13 Archive Date: 12/13/13 DOCKET NO. 10-10 010 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for right ear hearing loss. 2. Entitlement to service connection for left ear hearing loss 3. Entitlement to service connection for tinnitus. 4. Entitlement to an initial rating (or evaluation) for posttraumatic stress disorder (PTSD) in excess of 30 percent. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from November 1967 to May 1971. This matter comes to the Board of Veterans' Appeals (Board) on appeal from October 2008 and July 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The issues currently on appeal were previously remanded by the Board in June 2012 for further evidentiary development of requesting outstanding Social Security Administration (SSA) disability records. This was accomplished, and the claims were readjudicated in a November 2012 supplemental statement of the case. For this reason, the Board concludes that that the Board's remand orders have been substantially complied with, and it may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). The June 2012 Board remand also required the RO to issue a statement of the case for the claims for service connection for a prostate disorder and an increased rating for a hiatal hernia. See Manlincon v. West, 12 Vet. App. 238 (1999). The Veteran was furnished a statement of the case for these issues in April 2013, and was informed that, to perfect an appeal, a substantive appeal needed to be filed within 60 days. The Veteran did not submit a substantive appeal as to these issues; therefore, the issues are not properly before the Board. 38 U.S.C.A. §§ 7105, 7108 (West 2002); 38 C.F.R. § 20.302(c) (1997); Roy v. Brown, 5 Vet. App. 554 (1993). FINDINGS OF FACT 1. The Veteran engaged in combat with the enemy during service. 2. The Veteran was exposed to loud noises (acoustic trauma) during service, to include during combat. 3. The Veteran's right ear hearing impairment does not meet the criteria for hearing loss disability for VA compensation purposes. 4. The Veteran has current sensorineural hearing loss in the left ear that meets the criteria for hearing loss disability for VA compensation purposes. 5. Symptoms of left ear hearing loss were chronic in service. 6. Current tinnitus is not causally or etiologically related to service, to include exposure to loud noises in service. 7. For the entire initial rating period, the Veteran's PTSD has more nearly approximated occupational and social impairment with reduced reliability and productivity due to symptoms of anxiety, anger outbursts, startled response, hypervigilance, disturbing dreams, sleep impairment, passive suicidal ideation, and a decreased ability to form and maintain social and familiar relationships. 8. For the entire initial rating period, the Veteran's PTSD has not been characterized 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: 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. The criteria for service connection for right ear hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1154(b), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2013). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for left ear hearing loss have been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1154(b), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2013). 3. The criteria for service connection for bilateral tinnitus have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 4. Resolving reasonable doubt in the Veteran's favor, the criteria for an initial disability rating of 50 percent for PTSD, but no higher, have been met for the entire initial rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In timely letters dated July 2009 and April 2008, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran and what evidence VA would obtain. The notice included provisions for disability ratings and for the effective dates of each claim. As the Board is granting service connection for left ear hearing loss, there is no need to discuss the VCAA duties as to that issue. As to a higher initial rating for PTSD, this claim arises from a disagreement with the initial rating assigned after the grant of service connection. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or address prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003; 38 C.F.R. § 3.159(b)(3)(i) (stating that there is no duty to provide VCAA notice upon receipt of a NOD). The Board is also satisfied that VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes service treatment records, VA treatment records, VA examinations, SSA disability records, and the Veteran's statements. Further, the Veteran was afforded VA medical examinations in May 2008 (audiological), June 2009 (PTSD), November 2009 (PTSD), and September 2012 (PTSD). To that end, 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 the VA opinions and findings obtained in this case are adequate. The opinions considered all of the pertinent evidence of record and provided a complete rationale for the opinions stated. As to the May 2008 VA audiological examination, the Board finds that the medical opinion regarding tinnitus is adequate. As explained in detail below, the Board finds that the May 2008 VA examiner's medical opinion regarding hearing loss is not adequate as it was based on factually inaccurate assumptions. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). That notwithstanding, the Board finds the May 2008 VA medical opinion to be irrelevant in deciding the claim for service connection for left ear hearing loss as the Board is granting presumptive service connection based on chronic symptoms in service. Further, the clinical findings in the May 2008 VA examination report are adequate and sufficient medical evidence to decide the claim for service connection for right ear hearing loss because there is no current right ear hearing loss disability that meets the criteria for VA compensation purposes (38 C.F.R. § 3.385), so the question of a nexus between right ear hearing loss and service is not reached. Moreover, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Accordingly, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The condition of sensorineural hearing loss is considered a "chronic disease" (i.e., organic disease of the nervous system) as listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) apply to the claim for hearing loss. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). On the other hand, tinnitus is not a chronic disease under 38 C.F.R. § 3.309(a), and that claim will be adjudicated using the general principles of service connection. Generally, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In the case of a veteran who engaged in combat with the enemy in a period of war, lay evidence of in-service incurrence or aggravation of a disease or injury shall be accepted if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the lack of official record of such incurrence or aggravation. See 38 U.S.C.A. § 1154(b); Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Collette v. Brown, 82 F.3d 389, 392-94 (Fed. Cir. 1996). The provisions of 38 U.S.C.A. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine, 9 Vet. App. at 522-23. The provisions of 38 U.S.C.A. § 1154(b) do not establish service connection for a combat veteran; it aids him by relaxing the adjudicative evidentiary requirements for determining what happened in service. Clyburn v. West, 12 Vet. App. 296, 303 (1999). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, 1 Vet. App. at 57. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal, 5 Vet. App. at 461 (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Right Ear Hearing Loss The Veteran contends that he was exposed to loud noises during service in basic training from rifle ranges. The Veteran further maintains that he was exposed to heavy machinery, aircraft noise, rockets, and mortars while stationed in Vietnam and assigned to a "bomb dump." After a review of all the evidence, the Board finds that the Veteran engaged in combat with the enemy and was exposed to loud noises (acoustic trauma) during service, to include during combat with the enemy in Vietnam. See 38 U.S.C.A. § 1154(b); see also July 2009 RO rating decision (verified Veteran's exposure to rocket and mortar attacks during service in Vietnam). That notwithstanding, the Board finds that service connection for right ear hearing loss is not warranted as the Veteran does not have right ear hearing loss to a disabling degree for VA compensation purposes that meets the criteria at 38 C.F.R. § 3.385. Impaired hearing is considered a disability for VA compensation purposes when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; the thresholds for at least three of these frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Court has held that a veteran may establish the required nexus between current hearing loss disability and his term of military service if he can show by competent evidence that his hearing loss disability resulted from the in-service acoustic trauma even where the hearing loss disability does not arise in service. Godfrey v. Derwinski, 2 Vet. App. 352 (1992). In the May 2008 VA audiological examination, puretone thresholds at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hertz in the right ear were 5, 5, 15, 20, and 35, respectively, with an average puretone threshold of 19 decibels. Speech discrimination in the right ear was 100 percent. As the bilateral auditory thresholds in any of the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz is not 40 decibels or greater, the thresholds for at least three of these frequencies are not 26 or greater, and the speech recognition score using the Maryland CNC Test was not less than 94 percent, the criteria for a current right ear hearing loss "disability" have not yet been met as required by 38 C.F.R. § 3.385. Because the evidence does not show that the Veteran's right ear hearing loss is to a disabling degree according to 38 C.F.R. § 3.385, the weight of the evidence demonstrates that the Veteran's right ear hearing loss has not met the threshold to establish current hearing loss "disability," and the claim must be denied. The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Because the preponderance of the evidence is against the claim for service connection for right ear hearing loss, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Left Ear Hearing Loss Unlike the Veteran's right ear, the Board finds that the Veteran has a sensorineural hearing loss "disability" in the left ear that meets the criteria of 38 C.F.R. § 3.385. In the May 2008 VA audiological examination, puretone thresholds at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hertz in the left ear were 10, 10, 10, 25, and 40, respectively, with an average puretone threshold of 21 decibels. Speech discrimination in the right ear was 96 percent. The diagnosis was mild sensorineural hearing loss in the left ear. The Board next finds that the evidence of record is in equipoise as to whether the Veteran experienced "chronic" symptoms of left ear hearing loss during service so as to warrant presumptive service connection for left ear (sensorineural) hearing loss disability under the provisions of 38 C.F.R. § 3.303(b). Where there is a showing of chronic symptoms during service, then a showing of continuity of symptomatology after service is not required to support a finding of chronicity, and subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). An audiometric evaluation was conducted on enlistment examination in October 1967. On audiological examination, puretone thresholds at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hertz in the left ear were 15, 15, 15, 25, and 25 decibels, respectively. Audiometric evaluation upon service separation examination in April 1971 revealed puretone thresholds at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hertz in the left ear as 25, 0, 20, 30, and 30 decibels, respectively. Although the Veteran was not specifically diagnosed with left ear hearing loss in service, some degree of left ear hearing loss beyond the normal ranges was shown by 25 decibels at the 500 Hertz range, 30 decibels at the 3000 Hertz range, and 30 decibels at the 4000 Hertz range in the left ear. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993) (holding that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss). The Board finds such evidence of a threshold shift during service, indicating some worsening that occurred during service, reflects worsening that is analogous to a showing of "chronic" symptoms of left ear hearing loss in service. The evidence of record also includes a May 2008 VA examination report where the examiner opined that symptoms of left ear hearing loss were less likely than not "chronic" in service and were not otherwise related to service. Instead, the VA examiner opined that the probable cause of the current left ear hearing loss complaints was presbycusis (age-related hearing loss). In support of this opinion, the May 2008 VA audiologist reasoned that review of service treatment records showed normal audiometric thresholds present throughout service, with the exception of significant threshold shifts recorded at separation from service. According to the VA examiner, the thresholds recorded at separation from service were mostly in the 25 to 30 decibel range and showed essentially a flat configuration rather than a high frequency sloping "acoustic notch" pattern that might be indicative of hearing loss or threshold shifts caused by acoustic trauma. The May 2008 VA examiner further noted that the senior audiologist also reviewed service treatment records, including audiometric data recorded throughout service and specifically recorded at separation from service. Both the senior audiologist and the May 2008 VA examiner noted that audiometric thresholds recorded at separation from service represented inflated audiometric thresholds and that the audiometric testing done at separation was most likely related to faulty equipment, improper testing technique (test administered in a loud environment), or a problem with the Veteran failing to respond at threshold levels at that time. The VA audiologist opined that the audiometric testing done at separation from service represented invalid, inflated threshold levels since the readings at that time were somewhat worse than current readings, specifically in the lower frequencies. The VA examiner assessed that, a the present time, the Veteran did have a sloping high frequency pattern of hearing loss and the VA audiologists opined that the most likely etiology of the Veteran's currently high frequency sensorineural hearing loss was presbycusis. In this particular situation, the May 2008 audiometric testing would invalidate the 1971 audiometric findings as not representing chronic, permanent hearing loss. The VA examiner also noted that service treatment records did not reveal complaints of hearing loss and the Veteran specifically check "no" to the question of hearing loss at separation from service. Upon review of the evidence of record, the Board finds that the May 2008 VA opinion was based on the factually inaccurate assumption that the April 1971 service separation audiological examination was invalid due to faulty equipment, improper testing technique (test administered in a loud environment), or a problem with the Veteran failing to respond at threshold levels at that time. Ultimately, the VA May 2008 VA examiner appears to have based his opinion on the fact that the service separation audiometric testing was an isolated, inaccurate, and "inflated" evaluation; however, the record reveals that the Veteran underwent an audiological evaluation in August 1971, four months after the April 1971 service separation examination, which showed that puretone thresholds at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hertz in the left ear were 25, 20, 25, 5, and 15 decibels, respectively. The Board finds that the August 1971 audiological evaluation demonstrates that the Veteran's puretone thresholds were not only indicative of some worsening since service entrance, but were relatively consistent with the audiometric testing results at the service separation examination in April 1971. In two separate audiological evaluations (April 1971 and August 1971), conducted within four months of service separation, the Veteran's left ear hearing loss showed some degree of hearing loss since service entrance. See Hensley, 5 Vet. App. at 157 (holding that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss). Despite the May 2008 VA examiner's notation that service treatment records and the Veteran's claims file were reviewed, the results of the August 1971 VA audiological examination were not discussed. This is especially problematic given that the August 1971 VA examination report was consistent with the findings at the April 1971 separation examination, which the VA examiner found to be "inflated." For these reasons, the Board finds that the May 2008 VA medical opinion, based upon the factually inaccurate assumptions of improper audiological testing at service separation, is of no probative value. See Reonal at 461. The Board further finds that the Veteran's current left ear hearing loss disability is not clearly shown as attributable to intercurrent causes. The weight of the competent evidence of record does not illustrate any intercurrent or injury to the Veteran's left ear, to include any post-service occupational or recreational noise exposure. Although there is some suggestion that left ear hearing loss may be age-related (presbycusis), the Board finds that this does not reflect clear intercurrent cause. Based on this evidence, the Board finds the Veteran was exposed to acoustic trauma while in service, symptoms of left ear hearing loss were shown to be chronic in service, the Veteran has a current diagnosis of left ear hearing loss for VA purposes that accounts for the same in-service chronic symptoms of hearing loss, and the current left ear hearing loss disability is not clearly shown as attributable to intercurrent causes. Such evidence shows chronic symptoms of hearing loss in service, and a currently diagnosed bilateral hearing loss disability that meets VA standards at 38 C.F.R. § 3.385. As there is no evidence the current left ear hearing loss disability is clearly attributable to intercurrent causes, such subsequent manifestations of the same chronic hearing loss now are to be service connected. See 38 C.F.R. § 3.303(b). For these reasons, and with resolution of reasonable doubt in favor of the Veteran, the Board finds that the criteria for presumptive service connection for left ear hearing loss under 38 C.F.R. § 3.303(b) are met. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 3.303(b). Service Connection for Tinnitus As with his claim for hearing loss, the Veteran contends that he was exposed to loud noises during service which lead to his current tinnitus. Further, as discussed in detail in the previous section, the Veteran was exposed to acoustic trauma during service, including during combat with the enemy in Vietnam. See July 2009 RO rating decision (verified Veteran's exposure to rocket and mortar attacks during service in Vietnam). In Charles v. Principi, 16 Vet. App. 370 (2002), the Court determined that tinnitus is the type of disorder associated with symptoms capable of lay observation. When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Based on the Veteran's assertions in the January 2008 claim for VA compensation and the May 2008 VA audiological examination, the Board finds that the Veteran has a current disability of tinnitus. The remaining question is whether there is a nexus or relationship between the Veteran's tinnitus and service, specifically the in-service noise exposure. A review of service treatment records reveals no complaints or diagnosis of tinnitus. The April 1971 service separation examination report reveals no complaints or diagnosis of tinnitus. Had the Veteran been suffering from tinnitus symptoms during service, in light of the record of other visits for treatment, such complaints would have been reflected by complaints or histories in the service treatment records, or history at the time of the separation examination report, which specifically asked him for a history any abnormalities of the ears and hearing loss. Such absence of complaints, findings, or treatment during service or at separation from service, in this context, is highly probative, contemporaneous evidence that the Veteran did not experience tinnitus at any time during in service. See Kahana v. Shinseki, No. 24 Vet. App. 428, 439 (2011) (citing Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (Lance, J., concurring) (VA may use silence in the service treatment records as evidence contradictory to a veteran's assertions if the service treatment records appear to be complete and the injury, disease, or symptoms involved would ordinarily have been recorded had they occurred). The Board finds that this evidence weighs against a finding that tinnitus was incurred in or is otherwise related to service. Further, although the Veteran now maintains, pursuant to his claim for VA compensation, that tinnitus has been present since service separation, the Board finds the Veteran's statements not credible. In this regard, the Board notes that the Veteran filed a claim for service connection for hearing loss in June 1971, one month after service separation. Although the Veteran was afforded a VA examination for hearing loss in August 1971, the Veteran did not report tinnitus and tinnitus was not noted by the VA examiner. Further, the June 1971 claim for service connection also does not reveal any reports of tinnitus. This is further evidence that suggests to the Board that there was no pertinent tinnitus symptomatology at that time. While inaction regarding filing a claim is not necessarily indicative of the absence of symptomatology, where, as here, a veteran takes action regarding other claims, it becomes reasonable to expect that the Veteran is presenting all issues for which he is experiencing symptoms that he believes are related to service. In other words, the Veteran demonstrated that he understood the procedure for filing a claim for VA disability compensation, and he followed that procedure in other instances where he believed he was entitled to those benefits. In such circumstances, it is more reasonable to expect a complete reporting than for certain symptomatology to be omitted. Thus, the Veteran's inaction regarding a claim for tinnitus, when viewed in the context of his action regarding other claims for compensation, to include a claim for hearing loss may reasonably be interpreted as indicative of the Veteran's belief that he did not sustain tinnitus in service and a lack of tinnitus symptomatology at the time he filed the claims. The Veteran first filed a claim for service connection for tinnitus in January 2008, 37 years after service separation. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (holding that the Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor to consider as evidence against a claim of service connection). The Board finds that the weight of the evidence of record shows that current tinnitus is not causally or etiologically related to service, to include exposure to loud noises in service. As noted in the previous section, the evidence of record also includes a May 2008 VA examination report where the examiner opined that the present tinnitus was less likely as not associated with service. The Board has found the May 2008 VA examination report to be of no probative value as to issue of hearing loss; however, the Board finds the May 2008 VA examination report is probative on the issue of tinnitus. In regards to tinnitus, the May 2008 VA audiologist opined that tinnitus was less likely as not related to service. Instead, the May 2008 VA examiner opined that current tinnitus was related to presbycusis. Presbycusis is a "lessening of hearing acuteness resulting from degenerative changes in the ear that occur especially in old age . . . and diabetes." Godfrey v. Brown, 8 Vet. App. 113, 120 - 21 (1995). In support of this opinion, the VA examiner reasoned that review of service treatment records did not reveal complaints of tinnitus and the Veteran specifically checked "no" to the hearing and ear-related questions at separation from service. The Board finds that the May 2008 VA medical opinion as it relates to tinnitus is further evidence weighing against a relationship between current tinnitus and service. The Board has also considered the Veteran's statements purporting to relate current tinnitus to in-service acoustic trauma. While the Board finds that the Veteran is competent to report symptoms as they come to him through his senses, tinnitus is not the type of disorder that a lay person can provide competent evidence on questions of etiology. See Layno, 6 Vet. App. at 465 (competent lay evidence is evidence not requiring that the proponent have specialized education, training, or experience, but is provided by a person who has knowledge of facts or circumstances and conveys matter that can be observed and described by a lay person); see also Rucker, at 74 (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). Tinnitus is a medically complex disease process because of its multiple possible etiologies. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis). The etiology of the Veteran's current tinnitus is a complex medical etiological question involving internal and unseen system processes, including disease or damage of the sensory nerves of the ears. Based on the evidence of record, the Board finds that the weight of the competent evidence is against a finding of relationship between the Veteran's current tinnitus and the loud noise exposure during service. For these reasons, the Board finds that a preponderance of the evidence is against the claim for service connection for tinnitus, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Increased Rating Criteria for PTSD Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Regarding the evaluations of PTSD, the Board has considered the entire period of initial rating to see if the evidence warrants the assignment of different ratings for different periods of time during the claim, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). As the Board will discuss in more detail below, symptoms and social and occupational impairment associated with the Veteran's PTSD are shown to have been relatively consistent throughout the appeal period. As such, the Board finds that staged ratings are not warranted in this case. The Veteran is in receipt of a 30 percent disability rating for PTSD under Diagnostic Code 9411 for the entire initial rating period. A rating of 30 percent is warranted for PTSD if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is assigned for 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 that is 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 worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, or for the veteran's own occupation or name. 38 C.F.R. § 4.130, Diagnostic Code 9411. In applying the above criteria, the Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence which does so). In determining the level of impairment under 38 C.F.R. § 4.130, a rating specialist is not restricted to the symptoms provided under the diagnostic code, and should consider all symptoms which affect occupational and social impairment, including those identified in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed. 1994) (hereinafter DSM- IV), and those that are "like or similar to" such symptoms. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that a claimant suffers symptoms from effects that cause an occupational or social impairment equivalent to those listed in that diagnostic code, the appropriate, equivalent rating is assigned. See Mauerhan, 16 Vet. App. 436. The Federal Circuit stated that evaluation under § 4.130 is "symptom-driven" and that "a veteran may only qualify for a given disability rating under [this criteria] by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that 38 C.F.R. § 4.130 "requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). Within the DSM-IV, Global Assessment Functioning (GAF) scale scores ranging from 1 to 100 reflect "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). GAF scores from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect 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). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which 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., a depressed patient who avoids friends, neglects family, and is unable to do work). DSM-IV at 46-47. In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Initial Rating Analysis for PTSD In the July 2009 rating decision on appeal, service connection was granted for PTSD, and an initial disability rating of 30 percent was assigned, effective January 14, 2009 (the date of the Veteran's initial claim for VA compensation for PTSD). The Veteran entered a notice of disagreement with the initial rating assigned, contending that an initial rating in excess of 30 percent was warranted for his service-connected PTSD. Specifically, the Veteran contends that he has lost interest in activities he once enjoyed, experiences short-term memory loss, has nightmares and difficulty sleeping, and has had two panic attacks in the last three months. See August 2009 notice of disagreement. For the entire initial rating period, the Board finds that the evidence is in equipoise as to whether the Veteran's PTSD has more nearly approximated occupational and social impairment with reduced reliability and productivity due to symptoms of depressed mood, anger outbursts, startled response, hypervigilance, disturbing dreams, sleep impairment, anxiety, passive suicidal ideation, and a decreased ability to form and maintain social and familiar relationships. The Veteran was afforded a VA psychiatric examination in June 2009. The VA examiner interviewed the Veteran and reviewed the evidence of record. During the examination, the Veteran reported symptoms of hypervigilance, avoidance of social activities, anger and aggression (the Veteran reported threatening a motorist with a pistol during a road rage incident), frequent discords with co-workers, depression, and difficulty establishing and maintaining relationships. In assessing the Veteran's PTSD, the VA examiner noted symptoms of re-experiencing, persistent avoidance, increased arousal, and depression. The VA examiner also noted that the Veteran experienced suicidal ideations; however, in a different section of the report, the VA examiner stated that the Veteran denied suicidal ideation. After conducting a mental status examination, the examiner diagnosed the Veteran with Axis I chronic PTSD and depressive disorder and assigned a GAF score of 62, indicative of mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. See DSM-IV at 32. A November 2009 VA PTSD examination reveals that the Veteran stated that he was unemployed and reported symptoms of hypervigilance, avoidance of social activities, anger and aggression, frequent discords with co-workers, depression, and difficulty establishing and maintaining relationships. The Veteran also reported experiencing passive suicidal ideation with no intent or plan. The VA examiner conducted a mental status examination and diagnosed PTSD and depressive disorder and assigned a GAF score of 45, which reflects serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). In a following September 2012 VA PTSD examination report, the Veteran again reported symptoms of anxiety, sleep impairment, difficulty establishing and maintaining relationships, difficulty in adapting to stressful circumstances, and suicidal ideation. The VA examiner noted that the Veteran continued to meet the criteria for PTSD and reported amotivation, hopelessness, and passive suicidal ideation without intent or plan. The VA examiner assigned a GAF score of 58, indicative of 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). Based upon review of all the lay and medical evidence of record, the Board finds that, for the entire initial rating period, the evidence is in equipoise as to whether the Veteran's PTSD symptoms are productive of occupational and social impairment with reduced reliability and productivity. As discussed in detail above, the VA psychiatric examinations reveal that the Veteran has experienced symptoms such as: depressed mood, anger outbursts with a period of violence, hypervigilance, disturbing dreams, sleep impairment, anxiety, passive suicidal ideation, and a decreased ability to form and maintain social and familiar relationships. Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's PTSD more nearly approximates a 50 percent disability rating for the entire initial rating period on appeal. 38 C.F.R. §§ 4.3, 4.7. The Board further finds that, for the entire initial rating period, the Veteran's PTSD has not been characterized by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In reaching this conclusion regarding the degree of occupational and social impairment, the Board has considered all the Veteran's psychiatric symptoms and impairment, whether or not the symptom is specifically listed in the rating criteria, considering such symptoms as "like or similar to" the symptoms in the rating criteria. See Mauerhan, 16 Vet. App. at 442 (stating that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and that, without those examples, differentiating between rating evaluations would be extremely ambiguous); Vazquez-Claudio, 713 F.3d at 116-17 (the rating criteria under § 4.130 is "symptom-driven" and "a veteran may only qualify for a given disability rating under [this criteria] by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration"). With this in mind, the evidence shows that the Veteran's overall PTSD picture for this period is adequately contemplated by the 50 percent rating granted herein. The Veteran does suffer from sleep problems, but this is specifically listed under the criteria for even a 30 percent rating, as are depression and anxiety, which are both symptoms contemplated under the 30 percent PTSD disability rating. Flattened affect, disturbance of motivation and mood, and difficulty in establishing and maintaining relationships are specifically contemplated in the 50 percent rating criteria. Further, the Veteran's depression has not been shown to be "near-continuous" as contemplated by the 70 percent PTSD rating criteria. In fact, the most recent September 2012 VA examination report demonstrates that the Veteran does not meet the criteria for depressive disorder. Further, although the Veteran reported passive suicidal ideation, he did not state that he the intent or plan to do so. Further, the record shows that the Veteran's self-care and conversation are normal. The VA examination reports show that the Veteran's thought process was generally logical, relevant, and goal directed. The Veteran has reported that he is married and has a good relationship with his children and grandchildren. The GAF scores of record are consistent with mild to moderate PTSD symptoms. See June 2009, November 2009, and September 2012 VA examination reports (revealing GAF scores of 62, 45, and 58, respectively). These GAF scores reflect mild, moderate, and severe PTSD symptoms and mild to severe occupational and social impairment. Although the Veteran experiences PTSD symptoms which impair his occupational functioning and mood, the Board finds that the Veteran's PTSD is not productive of occupational and social impairment with deficiencies in most other areas, such as family relations, judgment, and thinking. The Board recognizes that one of the Veteran's GAF scores (GAF score of 45 in the November 2009 VA examination report) may be indicative of serious PTSD symptoms; however, GAF scores are just one component of the Veteran's disability picture, and not have a "formula" to follow in assigning rating. Rather, the Board considers the Veteran's entire disability picture, including GAF scores, the degree of occupational and social impairment, and symptoms that cause such impairment. This includes the Veteran's specific symptoms which have consistently shown to be mild to moderate. The GAF scores both prior to and after the assignment of the November 2009 GAF score of 45 (i.e., in June 2009 GAF score was 62 and in September 2012 GAF score was 58) also reflect that the GAF of 45 is not reconcilable with the evidence as a whole, including actual symptoms at that time and the overall disability picture reflected by all other GAF scores. As such, in viewing the evidence of record in its entirety, the Board finds that the Veteran's overall disability picture continues to most closely approximate that contemplated by a 50 percent evaluation. Accordingly, the Board finds that a disability rating in excess of 50 percent is not warranted for the entire initial rating period. 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted for PTSD. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. 38 C.F.R. 3.321(b)(1). Turning to the first step of the extraschedular analysis, the Board finds that all the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, for the entire initial rating period, the Veteran's PTSD has been manifested by passive suicidal ideation, anxiety, anger outbursts, startled response, hypervigilance, disturbing dreams, sleep impairment, and a decreased ability to form and maintain social and familiar relationships. These symptoms and impairments are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with an acquired psychiatric disorder, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, consideration of a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) is not warranted. The Veteran's prior claim of TDIU was previously adjudicated and granted in a January 2010 RO rating decision. ORDER Service connection for right ear hearing loss is denied. Service connection for left ear hearing loss is granted. Service connection for tinnitus is denied. An initial rating for PTSD of 50 percent, but no higher, is granted. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs