Citation Nr: 1343398 Decision Date: 12/31/13 Archive Date: 01/07/14 DOCKET NO. 10-33 417 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for right ear hearing loss disability. 2. Entitlement to an initial rating for posttraumatic stress disorder (PTSD) higher than 50 percent disabling. 3. Whether new and material evidence has been received to reopen a claim for service connection for peripheral neuropathy of the bilateral upper extremities. 4. Whether new and material evidence has been received to reopen a claim for service connection for peripheral neuropathy of the bilateral lower extremities. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from November 1967 to November 1970. These matters come before the Board of Veterans' Appeals (Board) from November 2009 (PTSD), April 2011 (right ear hearing loss disability), and January 2012 (peripheral neuropathies) rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO) in Milwaukee, Wisconsin. During the pendency of the appeal, the RO, in a July 2012 rating decision granted the Veteran a 50 percent evaluation for his PTSD effective from the date of service connection. In a June 2013 rating decision, the RO granted service connection for left ear hearing loss disability. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The earliest clinical evidence of right ear hearing loss disability is in 2011, more than 40 years after separation from service. 2. The most probative competent credible evidence of record is against a finding that the Veteran's right ear hearing loss disability is causally related to, or aggravated by, active service. 3. During the rating period on appeal, the Veteran's PTSD has been manifested by complaints of nightmares, panic attacks, and isolationism with continued evidence that he has friends, can live and function independently, and has an assignment of a GAF score of 55, demonstrating no more than occupational and social impairment with reduced reliability and productivity. Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood is not shown. 4. In an unappealed February 2007 rating decision, the RO denied the Veteran's claim of entitlement to service connection for peripheral neuropathy of the bilateral upper extremities. 5. Evidence received since the February 2007 rating decision does raise a reasonable possibility of substantiating the claim for entitlement to service connection for peripheral neuropathy of the bilateral upper extremities. 6. In an unappealed February 2007 rating decision, the RO denied the Veteran's claim of entitlement to service connection for peripheral neuropathy of the bilateral lower extremities. 7. Evidence received since the February 2007 rating decision does raise a reasonable possibility of substantiating the claim for entitlement to service connection for peripheral neuropathy of the bilateral lower extremities. 8. The most probative evidence of record is against a finding that the Veteran has peripheral neuropathy related to diabetes. 9. There has been no demonstration by competent medical evidence, or competent and credible lay evidence, that the Veteran has peripheral neuropathy causally related to, or aggravated by, active service, or a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for right ear hearing loss disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1154, (West 2002); 38 C.F.R. § 3.303, 3.304, 3.307, 3.309 (2013). 2. The criteria for an evaluation in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.126, 4.130, Diagnostic Code 9411 (2013). 3. Evidence received since the February 2007 RO decision that denied service connection for peripheral neuropathy of the bilateral upper extremities, which was the last final denial with respect to this issue, is new and material; the claim is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156, 20.302, 20.1103 (2012) 4. Evidence received since the February 2007 RO decision that denied service connection for peripheral neuropathy of the bilateral lower extremities, which was the last final denial with respect to this issue, is new and material; the claim is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156, 20.302, 20.1103 (2012) 5. The criteria for service connection for peripheral neuropathy of the bilateral upper extremities have not been met. 38 U.S.C.A. §§ 1101, 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 6. The criteria for service connection for peripheral neuropathy of the bilateral lower extremities have not been met. 38 U.S.C.A. §§ 1101, 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also 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); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Kent v. Nicholson, 20 Vet. App. 1 (2006). Notice was provided to the Veteran in May 2009 (PTSD), August 2010 (hearing loss disability), and June 2011 (new and material evidence). VA also has a duty to assist the Veteran in the development of evidence. The claims file includes service treatment records (STRs), post service clinical records, Social Security Administration (SSA) records, Vet Center records, and the statements of the Veteran in support of his claims. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. VA is not required to provide a medical examination to a claimant seeking to reopen a previously and finally disallowed claim prior to a determination that new and material evidence has been received. See Paralyzed Veteran's of Am. v. Sec'y of Veterans Affairs, 345 F.3d 1334 (Fed. Circ. 2003). Nevertheless, Veteran was provided with a VA examination. He has also been provided with VA examinations and/or opinions with regard to his hearing loss in 2011 and 2013, and with regard to his PTSD in 2009 and 2012. 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 adequate VA examinations with opinions have been obtained in this case. The examination reports are predicated on examinations of the Veteran, and review of his claims file. The examiners considered the pertinent evidence, to include the Veteran's medical history, and the statements of the Veteran with regard to his reported symptoms. The reports provide rationale for the opinions offered. The mental health report provides findings relevant to the criteria for rating the disability at issue. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008), Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012). Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations or opinions has been met. 38 C.F.R. § 3.159(c) (4). Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, 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). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease," whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Organic diseases of the nervous system are included in 38 C.F.R. § 3.309(a). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). New and Material Evidence In general, RO decisions that are not timely appealed are final. See 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.200 (2013). An exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. The Board must consider the question of whether new and material evidence has been received because it goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim de novo. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). If the Board finds that no such evidence has been offered, that is where the analysis must end, and what the RO may have determined in that regard is irrelevant. Barnett, supra. Further analysis, beyond consideration of whether the evidence received is new and material is neither required nor permitted. Id. at 1384. See also Butler v. Brown, 9 Vet. App. 167, 171 (1996). "New" evidence is existing evidence not previously submitted to agency decision makers. "Material" evidence is existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). However, lay assertions of medical causation cannot serve as the predicate to reopen a claim under § 5108. See Moray v. Brown, 5 Vet. App. 211, 214 (1993). In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. The VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the appellant in developing the facts necessary for the claim has been satisfied. See Elkins v. West, 12 Vet. App. 209 (1999), but see 38 U.S.C.A. § 5103A (West 2002) (eliminating the concept of a well-grounded claim). Rating Disabilities - in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Moreover, an appeal from the initial assignment of a disability rating, such as the appeal in this case, requires consideration of the entire time period involved, and contemplates staged ratings where warranted. Specific schedular criteria for rating mental disorders PTSD is rated by applying the criteria in 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411 (2013). The VA Schedule rating formula for mental disorders reads in pertinent part as follows: 100 percent rating (the maximum schedular rating) - 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. 70 percent - 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. 50 percent -- Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 30 percent-- 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, and mild memory loss (such as forgetting names, directions, recent events). 10 percent -- Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency 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 the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Global Assessment of Functioning (GAF) GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994)). According to the pertinent sections of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV), a GAF score of 71 to 80 indicates that if symptoms are present, they are transient and expectable reactions so psychosocial stressors and there is no more than slight impairment in social, occupational, or school functioning. A GAF score of 61 to 70 indicates some mild symptoms or some difficulty social occupational or school functioning but that an examinee is generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning. A GAF score of 31 to 40 indicates that the examinee has some impairment in reality testing or communication such as speech is illogical, obscure, or irrelevant, or that the examinee has major impairment in several areas. See Quick Reference to the Diagnostic Criteria from DSM-IV, 46-47 (1994). Analysis The Board has reviewed all of the evidence in the Veteran's claim file, with an emphasis on the medical evidence pertinent to the claims on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Entitlement to service connection for right ear hearing loss disability The Veteran avers that he has right ear hearing loss disability as a result of active service, to include exposure to weapon firing. An essential element of a claim for service connection is evidence of a current disability. A February 2011 VA examination report reveals that the Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 40 45 45 45 60 Based on the foregoing, the Veteran does have a current right ear hearing loss disability for VA purposes. 38 C.F.R. § 3.385 disability. A second element of a claim for service connection is medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease. The Veteran's DD 214 reflects that his primary specialty in service was as a light weapons infantryman. In addition, the Veteran's DD 214 reflects that he had service in Vietnam and was awarded the Combat Infantryman Badge. Exposure to acoustic trauma is consistent with the Veteran's service as an infantryman in service. The Veteran's November 30, 1967 report of medical examination for enlistment purposes reflects that his hearing acuity, upon pure tone audiometry test, was as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 5 - 5 The Veteran's October 1970 report of medical examination for separation (ETS) purposes reflects that his hearing acuity, upon pure tone audiometry test, was as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 10 - 15 The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Thus, the Veteran had normal hearing upon separation from service. Moreover, there was no a significant threshold shift (15 dB or more) in hearing acuity from enlistment to separation. In the 1960's, the military changed its standard of reporting hearing acuity. The American Standards Association (ASA) units were replaced with the current International Standards Organization (ISO) units. The Veteran's report of medical examination for entrance purposes was dated November 30, 1967. Under VA policy, audiology test results in STRs, which are dated October 31, 1967 or prior, are presumed, unless otherwise noted, to be recorded under the older ASA units. Those after October 31, 1967 are presumed to use the current ISO units. To convert the units from ASA to ISO, the Board adds 15 decibels to 250 Hz., 15 decibels to 500Hz, 10 decibels to 1,000 Hz, 10 decibels to 2000 Hz, 10 decibels to 3,000 Hz., and 5 decibels to 4,000 Hz. The 2013 VA examiner, as discussed in further detail below, stated that it was his opinion that the Veteran's November 1967 audiology results were recorded in ASA standards; however, he did not provide any evidence to support this. As the enlistment results were dated after October 31, 1967, it is presumed that they were reported in the current ISO units. Nonetheless, because the issue was raised by the examiner, the Board has considered whether the November 1967 audiology results may have been in ASA units. As noted above, the 1967 entrance results were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 5 - 5 If the results were originally reported in ASA units and then converted to ISO units, the 1967 results would reflect abnormal hearing upon entrance, as evidenced by the following converted results and considering the Court's finding in Hensley: HERTZ 500 1000 2000 3000 4000 RIGHT 30 25 15 - 10 Moreover, they do not reflect a significant threshold shift when compared with the separation examination results. If the Veteran's entrance results were in ISO units, the Veteran's 1970 separation results reflect that the Veteran's hearing had actually improved during service. Thus, regardless if the Veteran's 1967 results were in ASA units or ISO units, the Veteran did not have a significant threshold shift in service or abnormal hearing upon separation. A third requirement for service connection is competent credible evidence of a nexus between the current disability and the in-service disease or injury. The Board finds, for the reasons noted below, that this third requirement for service connection has not been met. A February 2011 VA examination report reflects that the examiner considered the Veteran's reported noise exposure in service and post service. The examiner opined, in pertinent part, as follows: The Institute of Medicine (IOM) Report (National Academy of Sciences, 2006), indicated that there is no scientific basis, at this time, for delayed or late onset noise-induced hearing loss. Therefore, with the IOM report and with the veteran's enlistment and separation audiograms [within normal limits], [bilaterally], with no evidence of threshold shift for VA purposes from time of entrance to time of separation, it is my professional opinion that the veteran's hearing loss and tinnitus is less likely as not related to his in-service noise exposure and rather to an unknown etiology instead. A February 2013 VA examination report reflects the opinion of the clinician that the Veteran's current hearing loss is not at least as likely as not caused by or a result of military service. The examiner also opined, as follows: The veteran's separation hearing test indicated that the veteran's hearing was within normal limits (20dB HL or better) for all test frequencies 500-6000 Hz. There was no evidence of significant threshold shift when the veteran's discharge hearing test was compared with his enlistment hearing test. Thus, the clinical evidence is against a finding that the Veteran has right ear hearing loss causally related to, or aggravated by, active service. The Veteran is competent to attest to factual matters of which he has first-hand knowledge. To this extent, the Board finds that the Veteran is competent to report that he has current difficulty with hearing. The Veteran has not been shown to have the experience, training, or education necessary to make an etiology opinion to the claimed disability. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issues in this case in light of the education and training necessary to make a finding with regard to the complexities of hearing loss as it relates to acoustic trauma and age. The Board finds that such etiology findings fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The earliest clinical evidence of right ear hearing loss is in 2011, more than 40 years after separation from service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board acknowledges that the absence of any corroborating medical evidence supporting assertions, in and of itself, does not render lay statements incredible, such absence is for consideration in determining credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that the absence of contemporaneous medical documentation may go to the credibility and weight of appellant's lay testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible). See also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (noting that lay evidence can be competent to establish a diagnosis when . . . a layperson is competent to identify the medical condition.) However, in the present case, not only is there a lack of clinical records in the 40 years after separation from service, but the Veteran's separation examination reflected normal hearing. In addition, the Veteran filed a claim for service connection for a kidney disability in November 1970. The Board finds that if the Veteran experienced hearing loss at that time, it would have been reasonable for him to have filed a claim for it, when he filed his other claim; however, he did not. Moreover, a January 1971 VA examination report reflects that the Veteran's ear canals and drums were normal, there was no discharge from his ears, and that no hearing loss was noted upon examination. In Hensley, the Court held that "when audiometric test results at a veteran's separation from service do not meet the regulatory requirements for establishing a 'disability' at that time, he or she may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service." Id. at 160. Notably, the Court did not hold that normal results cannot be considered by a medical examiner, along with the other evidence of record, when providing an opinion on causation. See Salisbury v. Shinseki, 2013 WL 240930 Vet.App. (January 23, 2013). While the regulation does not necessarily preclude service connection when hearing loss first meets the regulation's requirements after service, it also does not hold that service connection is warranted, or mandatory, for hearing loss disability in the absence of a competent credible clinical nexus opinion or credible continuity of symptomatology from service. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Increased Rating for PTSD The Veteran is service connected for PTSD, evaluated as 50 percent disabling effective from April 2009. In order to be assigned a particular rating, a Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The key element for a rating under the General Formula for Mental Disorders is the degree of social and occupational impairment caused by those symptoms. A March 2009 VA mental health outpatient record reflects that the Veteran reported transient suicidal ideation but denied any attempts, plans, or intents. He did not pose a risk to others. He was lucid, aware of the situation, and felt that his mental health symptoms were severe enough to warrant getting help. It was noted that the Veteran reported that he had income/benefits, a supportive best friend, and leisure or recreational interests. Additional March 2009 VA records reflect the Veteran reported claustrophobia, but denied manic, psychotic, and obsessive compulsive disorder. He reported that he copes with his mental problems with staying busy with housework, exercise, and socializing with his best friend. He began taking citalopram in March 2009 and was pleased with the medication and felt that his worry had improved. He had abstained from alcohol since age 50 (i.e. 12 years earlier). The Veteran indicated that he had severe depression; however, the examiner felt that his demeanor was more suggestive of a more moderate level. The examiner assigned the Veteran a GAF score of 55. April 2009 VA mental health notes reflect that the Veteran again had a GAF score of 55. The Veteran noted benefits to his medication, but had stopped one because it made him "loony". The Veteran attributed his recent depression to being more isolated in the winter months and to a diagnosis of MDS in August 2008. He reported that he gets depressed when alone and manages it by walking, cleaning, or going out to visit friends. He also noted that he would be able to ride his bike more regularly as the weather was now better. He reported that he managed his frequent flashbacks, nightmares and claustrophobia with humor and trying to make others happy. His social worker records also reflect that the Veteran had memories/dreams/nightmares related to his Vietnam experiences. The Veteran underwent a June 2009 VA examination. The Veteran reported 2-4 nightmares per week about "clearing tunnels" [in Vietnam]. The Veteran reported thinking about Vietnam on a daily basis, with the symptoms being moderate in severity with a duration that can last for several hours and with remissions that can last up to 2-3 days, which included improved capacity for adjustment during those periods of time. The Veteran reported that he had four or five good friends and goes to a VSO (Veteran's Service Organization) once a month for support groups. He reported that he spends his free time cleaning his home and fishing. He denied any history of assaultiveness or suicide attempts. The examiner stated that the Veteran reported a moderate current psychosocial functional status. It was noted that he had worked successfully until an accident, he keeps up with his routine responsibilities of self-care, he has never married or had children, and is not close with his family of origin. His social/interpersonal relationship and recreation/leisure pursuits appeared limited. The mental health report reflects the following: The veteran demonstrated no impairment of thought process or communication as well as delusions or hallucinations during this interview. His eye contact and interaction in the session were within normal limits. He denied suicidal or homicidal thoughts, etc., and he endorsees a good history of maintaining minimal personal hygiene and other basic activities of daily living. He was oriented to person, place, and time. He denied memory loss or impairment, obsessive or ritualistic behavior and panic attacks. The rate and flow of the veteran's speech were within normal limits. The examiner also stated that based on a review of the "veteran's medical records as well as the veteran's verbal report, this examiner is comfortable diagnosing the veteran with Axis 1 posttraumatic stress disorder, chronic, moderate severity with a GAF equaling 55 to indicate moderate symptoms." The examiner also stated that the Veteran had depression, also with a GAF score of 55, which was less likely than not related to service or his PTSD, and is more likely related to his recent medical and physical problems, specifically his diagnosis of bone marrow cancer in August 2008. The examiner further stated, in pertinent part, as follows: There are PTSD signs and symptoms that are transient or mild and decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The veteran reported that at work he cold sometimes get jumpy with loud noises. The veteran stated that he generally got along with co-workers, and he worked 7 days a week. He was a very hard worker with a very good work ethic. Thus, it is this examiner's opinion that the veteran's moderate PTSD would pose only mild vocational limitations. June 2009 VA clinical records reflect that the Veteran reported that he had started drinking alcohol after years of abstinence and that it was an attempt to cope with emotion and thoughts of Vietnam brought up by therapy. (July 2009 record reflects that the Veteran had successfully terminated drinking). However, subsequent records reflect that the Veteran had not started drinking but had only told mental health that he had been drinking to "get them off [his] back" and avoid further "exposure" treatment. (See October 2009 records) A September 2009 social worker record reflects that the Veteran decided to end his mental health support at VAMC because the Veteran perceived that his therapist "blew out of proportion" events, memories and issues which the Veteran described. The Veteran further reported that his nightmare frequency dropped when he stopped going to VAMC. The Veteran reported "issues" with crowds, elevators, enclosed spaces, heavy traffic, and any place where he feels trapped, and a startle issue. An October 2009 VA mental health record reflects that the Veteran was "currently doing very well from a psychiatric standpoint." In a VA Form 9, dated in July 2010, the Veteran asserted that he has had an inability to establish and maintain effective relationships since his return from Vietnam. He cited a lack of close friends, with the exception of a few fellow Vietnam veterans, estrangement from his family, his lack of marriage or children, frequent panic attacks, avoidance behavior, and anxiety. SSA records reflect that the Veteran was disabled due to primary diagnoses of COPD (chronic obstructive pulmonary disease) and chronic pulmonary insufficiency, with a secondary diagnosis of obesity. The record reflects that the Veteran reportedly chooses to sleep on the floor rather than in a bed. He reported that when he tried sleeping in a bed, as recommended by his social worker, it did not work for him. He reported that he always "slept rough", even as a child, and "thought nothing of sleeping all night on the ground when he was off fishing." Vet Center records reflect PTSD symptoms of persistent nightmares, interrupted sleeping, and intrusive memories. Records reflect that the Veteran was sleeping 6-7 hours a night. Correspondence from the Vet Center, dated in May 2012, reflects that the Veteran experiences "strong symptoms of PTSD". The social worker, a readjustment counselor, noted that the Veteran continues to describe recurrent and frequent intrusive memories, significant withdrawal in social situations, avoidance of remainders of events, and difficulties in relationships, especially within his family of origin. It was noted that he had never married, and has lived alone his entire adult life. In an April 2012 statement (VA Form 21-4138), the Veteran stated that he has been virtually isolated in his life because of his Vietnam service. A June 2012 VA examination report reflects the opinion of the examiner that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. It was noted that since the last examination, the Veteran had not been hospitalized psychiatrically, and had joined a group of veterans who meet at a VSO office monthly. It was also noted that the Veteran reported no criminal justice contacts, and denied any suicidal or homicidal ideation, had no drug use, and had no alcohol use. It was noted that he had depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, disturbance of motivation and mood, and an inability to establish and maintain effective relationships. He was assigned a GAF score of 55 for his PTSD. An October 2012 VA record reflects that the Veteran reported trouble with nightmares, waking in sweat, shaking, and keeping everyone "at arm's length." The Veteran reported that he likes to live alone, but does maintain some social contact by going to Wal-Mart in town and speaking with staff whom he has grown to know over the years. He reported that he has stopped most pleasurable activities over the years, and watches television but does not particularly like anything he watches. The probative value of a medical opinion is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guarneri v. Brown, 4 Vet. App. 467, 470-71 (1993). There is no requirement that additional evidentiary weight be given to the opinion of a medical provider who treats a veteran; courts have repeatedly declined to adopt the "treating physician rule." See White v. Principe, 243 F.3d 1378, 1381 (Fed. Cir. 2001); Van Slack v. Brown, 5 Vet. App. 499, 502 (1993) The Board finds based on the evidence noted above, that the Veteran's PTSD symptoms do not warrant a 100 percent rating for any period on appeal. Again, the Board is mindful that in order to be assigned a particular rating, a Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. The Board has considered the examples in the rating criteria for a 100 percent evaluation and notes that the Veteran does not have gross impairment in thought processes or communication; persistent delusions or hallucinations, 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, or persistent danger of hurting self or others. Moreover, the clinical opinions do not reflect total occupational and social impairment. In addition to not having the symptoms noted above, the Veteran is able to live by himself and maintain his own home, to include chores. He also maintains his own hygiene, has friends, and goes out in public. His GAF score of 55 is also evidence against a finding of total occupational and social impairment. A GAF score of 55 is indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning. Next, the Board has considered whether the Veteran's symptoms warrant a 70 percent evaluation for any period on appeal, but finds that they do not. The Board has considered the examples in the rating criteria for a 70 percent. A 70 percent or higher rating is warranted where the Veteran has occupational and social impairment, with deficiencies in most areas. As noted above, examples of such deficiencies would include 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. The evidence is against a finding of 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. Although the Veteran contends that he has panic attacks, the evidence reflects that he denied panic attacks in June 2009, and that, even though he reported panic attacks of more than once a week, he has been able to live independently. The 2012 examiner considered the Veteran's reported panic attacks and still found that the Veteran only had moderate symptoms. The evidence does not support a finding of near continuous panic affecting his ability to function independently. In addition, while the Veteran has depression, it has not been shown to affect his ability to function independently and has been found unrelated to his PTSD. Even if related to his PTSD, the Veteran has been able to function independently as evidenced by the fact that he lives alone, maintains his home and maintains his personal hygiene. The Board also notes that the evidence is against a finding that the Veteran has an inability to establish and maintain effective relationships. Although, the Veteran has reported that he is estranged from his family and has never married, he has reported that he has friends. (See evidence dated in March 2009 - Veteran has a supportive best friend; April 2009 - he manages depression by visiting friends; June 2009 - Veteran has four or five good friends; and July 2010 - Veteran has a few friends.) Thus, despite the findings of any examiner, the record does not support a finding that the Veteran has an inability to maintain relationships. The Board has considered the private and VA clinical reports and the opinions of the examiners, and the GAF scores. As a whole, the report, opinions, and GAF scores do not reflect that the Veteran has a total occupational and social impairment or occupational and social impairment, with deficiencies in most areas such as to warrant a 70 percent evaluation. The Veteran's symptoms are reflective of a disability which warrants no higher than a 50 percent evaluation. The Board has also considered that the Veteran has been prescribed medication for his mental health. An April 2009 record reflects that the Veteran had noticed a benefit in symptoms after taking his medication, citalopram, in March 2009, but had stopped taking it because it made him "loony." At the April 2009 appointment, he had a GAF score of 60. In addition, the records reflect that the Veteran had a GAF score of 55 prior to medication. Thus, the evidence does not support a finding that even without the medication, the Veteran's symptoms would rise to the level of a 70 percent or 100 percent rating. In sum, the Board acknowledges the Veteran's symptoms such as difficulty with sleep, isolationism, and anxiety in small places. However the Board finds that such symptoms are adequately contemplated in the 50 percent evaluation. In addition, the Board notes that the 2012 VA examiner's opinion was that the Veteran's symptoms more closely resembled a lower, 30 percent, evaluation as they caused only occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks and social impairment with reduced reliability and productivity. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013). Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990) in assigning a rating of 70 percent and assigning an effective date of that rating as January 25, 2011. Extraschedular Ordinarily, the VA Schedule 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). An extra-schedular disability rating would be 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). The Board has reviewed the evidence of record and finds that it does not show such an exceptional disability picture. The effects of the Veteran's disability have been fully considered and are contemplated in the rating schedule; hence, an extraschedular rating is not warranted. The rating formula for mental disorders allows for them to be rated based on the level of occupational and social impairment. While the code lists examples to be considered, the Veteran's PTSD-related symptoms have been considered, whether or not they are listed as an example. The evaluations are based on the severity of the Veteran's symptoms and the code allows for various evaluations based on levels of symptoms from mild or transient to those causing total impairment. Thus, regardless if the actual related symptom is listed in any criteria, it is still considered based on its severity. The Board finds that the Veteran does not experience any chronic symptomatology not contemplated by the rating schedule. Referral for extraschedular consideration is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). New and Material Evidence to reopen a claim for service connection for Peripheral Neuropathy of the bilateral upper and lower extremities Historically, in a February 2007 rating decision, the RO denied the Veteran's claim for entitlement to service connection for peripheral neuropathy of the bilateral upper and lower extremities. The appellant did not timely appeal the decision and it became final. Evidence of record at time of last final denial At the time of the last final denial in February 2007, the evidence included the Veteran's STRs, and post service medical records. A January 2006 VA general medical note reflects complaints of leg cramps, which go away with walking. A December 2006 VA examination report reflects that the Veteran reported intermittent tingling in the hands, legs, and feet, which may occur twice a week. The Veteran reported that it is related to "top position" and resolves with changes in position. It was further noted that the Veteran reported that he has had this for 15 years or more and that he has not been treated for it. The Veteran had a right radial nerve transportation in 1989 for radial nerve injury on the right. Upon examination, his vibration was intact. He had normal pinprick of both feet and the right hand. He had slight decreased pinprick of the left hand in distribution of radial nerve, which the Veteran had not been aware of prior to the pinprick testing. The clinical assessment was no peripheral neuropathy. Evidence of record since the last final denial A May 2008 VA examination report reflects that the Veteran reported intermittent tingling in the hands, legs, and feet. He reported that it is infrequent in the feet. In the hands, it had become more noticeable in the last 3 - 4 months. It was resolved by shaking his hands. Upon examination, vibration and pin-prick were intact in both hands and feet. There was a negative Tinel's test. After Phalen's maneuver, the Veteran had a sensation of tingling around the wrist on the dorsal surface but not in any nerve distribution. The report is negative for a diagnosis of peripheral neuropathy. A December 2011 VA examination report reflects the opinion of the physician as follows: This veteran does not have neuropathic symptoms compatible with diabetic neuropathy. His symptoms are more suggestive of nerve entrapment in that the symptoms are positional and relieved with change in position. His symptoms are not constant, as diabetic neuropathy is. Also, he has other reasons such as DJD and herniated disc which could be giving him his nerve symptoms. Even though there is a note in the CPTRs record that someone wrote in 2008 he had diabetic peripheral neuropathy. I opine he does not have peripheral neuropathy caused by diabetes mellitus 2. Similarly, I do not get the history nor the documentating in the files that there has been a worsening of his symptoms (ie, no aggravation from the DM2). A March 2012 VA clinical record reflects that the Veteran reported numbness, burning, and tingling in the hands and feet bilaterally. The diabetic foot sensory examination notation reflects that the Veteran had "monofilament sensory foot exam at this visit or admission. Result of Exam: Abnormal." A July 2012 VA clinical record reflects that with regard to "Diabetes complications", the Veteran "claims numbness in feet, tingling in fingers." A February 2013 VA clinical record reflects that with regard to "Diabetes complications, Peripheral neuropathy", the Veteran was positive for numbness in the feet and tingling in fingers." An April 2013 VA clinical record with regard to "Diabetes complications" reflects that the category "peripheral neuropathy" was checked as positive. Old and new evidence of record considered as a whole The Board finds that clinical records dated after February 2007 are new because they were not previously in evidence. In addition, they are material because they reflect that the Veteran was positive for peripheral neuropathy as a complication of diabetes. In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Board is mindful of the Court's opinion in Shade v. Shinseki, 24 Vet. App. 110 (2010), in which the Court held that the phrase "raises a reasonable possibility of substantiating the claim" must be viewed as "enabling" reopening of a previously denied claim rather than "precluding" it. The Veteran's claims for service connection for peripheral neuropathy of the bilateral upper and lower extremities were denied in February 20007 because the evidence reflected that he did not have peripheral neuropathy. Thus, the newly received clinical records raise the reasonable possibility of his substantiating the claims. De Novo analysis of reopened claims Having reopened the Veteran's claims, the Board must now determine whether the reopened claims of entitlement to service connection for peripheral neuropathy of the bilateral upper and lower extremities may be granted on the merits, de novo. The Veteran will not be prejudiced by the Board action in reconsidering the matter as the RO previously reopened and reconsidered the claims on the merits. The first element of a claim for service connection is that there must be evidence of a current disability. The Veteran is competent to report symptoms such as tingling and numbness of the extremities. However, he has not been shown to have the experience, training, or education to make a competent etiology opinion. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issues in this case in light of the education and training necessary to make a finding with regard to the complexities of diabetes and peripheral neuropathy, and the other disabilities which may be responsible for tingling and numbness of the extremities. The Board finds that such etiology findings fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As noted above, a December 2011 VA examination report reflects the opinion of the physician as follows: This veteran does not have neuropathic symptoms compatible with diabetic neuropathy. His symptoms are more suggestive of nerve entrapment in that the symptoms are positional and relieved with change in position. His symptoms are not constant, as diabetic neuropathy is. Also, he has other reasons such as DJD and herniated disc which could be giving him his nerve symptoms. As noted above, the probative value of a medical opinion is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guarneri v. Brown, 4 Vet. App. 467, 470-71 (1993). There is no requirement that additional evidentiary weight be given to the opinion of a medical provider who treats a veteran; courts have repeatedly declined to adopt the "treating physician rule." See White v. Principe, 243 F.3d 1378, 1381 (Fed. Cir. 2001); Van Slack v. Brown, 5 Vet. App. 499, 502 (1993). The notations in the VA records that the Veteran has diabetic neuropathy are not supported by a complete adequate rationale. However, the December 2011 opinion is supported by the record. The evidence reflects that the Veteran had a right radial nerve transportation in 1989 for radial nerve injury on the right, and a diagnosis of disk herniation, and degenerative joint disease of the low back. (See October 2011 and April 2012 VA records.) The clinician also provided an adequate rationale with regard to why it is less likely as not that the Veteran's symptoms are diabetic neuropathy (i.e. symptoms are positional and intermittent.) The Board finds that the December 2011 is the most probative of record with regard to the issue at hand. As a service connection claim requires, at a minimum, medical evidence of a current disability, service connection for diabetic peripheral neuropathy of the bilateral upper and lower extremities is not warranted in this case. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In addition, there has been no demonstration by competent medical evidence, or competent and credible lay evidence, that the Veteran has peripheral neuropathy causally related to, or aggravated by, service or a service-connected disability. The Veteran contends that he has had tingling since approximately 1991, an onset of more than 20 years after separation from service. The evidence does not support a finding that he has had peripheral neuropathy within one year after separation from service, due to exposure to herbicides in service, or that it is acute or subacute peripheral neuropathy. Thus, service connection on a presumptive basis is not warranted. 38 C.F.R. § 3.309(a) and (e). The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to service connection for right ear hearing loss disability is denied. Entitlement to a rating in excess of 50 percent for PTSD is denied. Since new and material evidence has been received to reopen the claim of entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, the claim is reopened, and the appeal is allowed to this extent. Service connection for peripheral neuropathy of the bilateral upper extremities is denied. Since new and material evidence has been received to reopen the claim of entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, the claim is reopened, and the appeal is allowed to this extent. Service connection for peripheral neuropathy of the bilateral lower extremities is denied. REMAND In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. Entitlement to TDIU is raised where a Veteran : (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The evidence reflects that the Veteran has been unemployed since 1997 due to COPD and chronic pulmonary insufficiency. Since that time, he has now been service-connected for several disabilities. Accordingly, the case is REMANDED for the following action: 1. Issue a VCAA notice letter for the issue of entitlement to a total rating for compensation purposes based on individual unemployability (TDIU) in accordance with 38 U.S.C.A. §§ 5102, 5103, and 5103A (West 2002), 38 C.F.R. § 3.159 (2013), and applicable legal precedent. 2. Thereafter, schedule the Veteran for a general medical examination or obtain a clinical opinion, on the issue of whether the Veteran's service-connected disabilities, considered in combination, (and only his service-connected disabilities) render the Veteran unemployable. The clinician is requested to furnish an opinion as to whether it is at least as likely as not (50 percent or greater) that the Veteran's service-connected disabilities are so severe that it is impossible for the him to sustain substantially gainful employment. The clinician is requested to provide a complete rationale for his or her opinion, as a matter of medical probability, based on his or her clinical experience, medical expertise, and established medical principles. The clinician should review the claims folder, and this fact should be noted in the accompanying medical report. 3. Following completion of the above, adjudicate the issue of entitlement to TDIU. If the benefit sought is not granted, issue a Supplemental Statement of the Case and afford the appellant and his representative an appropriate opportunity to respond. Thereafter, the case should be returned to the Board, as appropriate for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matter 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. 2011). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs