Citation Nr: 1316524 Decision Date: 05/20/13 Archive Date: 05/29/13 DOCKET NO. 09-11 042A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected PTSD. 2. Entitlement to service connection for hepatitis C. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD. 4. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD David Gratz, Counsel INTRODUCTION The Veteran served on active duty from March 1965 to March 1968. He had active service in the Republic of Vietnam from October 13, 1965 to October 4, 1966. His decorations included the Combat Infantry Badge, the Purple Heart, the Vietnam Service Medal, and the Vietnam Campaign Medal. He died in November 2010. In May 2011, his surviving spouse substituted as the appellant for his pending claim. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which granted service connection for PTSD and assigned a 10 percent rating effective as of the February 21, 2007 date of claim for service connection, and denied service connection for erectile dysfunction, hepatitis C, and hypertension. In a December 2012 rating decision, the RO in Philadelphia, Pennsylvania increased the Veteran's rating for PTSD to 30 percent as of February 21, 2007. The claims have since been returned to the RO in Atlanta, Georgia. The issues of entitlement to service connection for hepatitis C and entitlement to service connection for hypertension are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The most probative evidence fails to link the Veteran's erectile dysfunction to active service, or to his service-connected PTSD. 2. The Veteran's PTSD symptoms resulted in depressed mood, anxiety, chronic sleep impairment, dreams of combat experiences, cold sweats, sporadic breathing, difficulty concentrating, daydreaming, forgetfulness, a quick temper, irritability, intrusive memories, nightmares, flashbacks, detachment, anger, concentration problems, hypervigilance, agitation, hyperarousal, avoidance of others (in part due to medical problems), avoidance of reminders of Vietnam, guardedness, distrust, dysphoria, constricted affect, and startle response. CONCLUSIONS OF LAW 1. The criteria for service connection for erectile dysfunction, including as secondary to service-connected PTSD, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 2. The criteria for a rating in excess of 30 percent for the Veteran's PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.125, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). Pelegrini v. Principi, 18 Vet. App. 112, 120-121 (2004). This notice should be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). With respect to the issue of entitlement to service connection for erectile dysfunction, VA's notice requirements were satisfied by a March 2007 letter which advised the appellant of the criteria for establishing service connection, and which was sent prior to the initial adjudication of the Veteran's claim in April 2007. With respect to the issue of entitlement to an initial rating in excess of 30 percent for PTSD, VA has met its duty to notify for this claim. Service connection for that issue was granted in an April 2007 rating decision. The Veteran is now appealing the downstream issue of the initial rating that was assigned. Moreover, the Veteran received an additional notice letter in June 2008, prior to the initial September 2008 adjudication of the higher initial rating claim. Therefore, additional notice under the Veterans Claims Assistance Act of 2000 (VCAA) is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1131 (Fed. Cir. 2007), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Next, VA has a duty to assist the Veteran in the development of his claim. This duty includes assisting him in the procurement of pertinent medical records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the RO has obtained and associated with the claims file the Veteran's service treatment and service personnel records, and records of his post-service VA and private treatment. The Veteran was afforded a VA compensation and pension examination germane to his claim for service connection for erectile dysfunction on appeal in April 2007. He was also afforded such examinations for his PTSD claim on appeal in March 2007 and July 2008. These examination reports are adequate because the examiners based their opinions upon consideration of the Veteran's prior medical history, described the disabilities in sufficient detail so that the Board's evaluations of the claimed disabilities would be fully informed, and supported all conclusions with analyses that the Board could consider and weigh against contrary opinions. Additionally, the VA examiners fully described the functional effects caused by the Veteran's erectile dysfunction and PTSD. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). For the foregoing reasons, the Board concludes that VA made all reasonable efforts to obtain evidence necessary to substantiate the Veteran's claims. Therefore, no further assistance to the Veteran with the development of evidence is required. Service Connection for Erectile Dysfunction In seeking VA disability compensation, an appellant generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with active service in the Armed Forces, or if preexisting such service, was aggravated therein. Establishing direct service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Service connection may also be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2012). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439 (1995). As an initial matter, the Board notes that the Veteran had claimed service connection for erectile dysfunction as secondary to diabetes in his February 2007 letter. However, because he is not in receipt of service connection for diabetes, service connection for erectile dysfunction as secondary to diabetes is not warranted. The appellant contends that the Veteran's erectile dysfunction resulted from his service. In his June 2007 notice of disagreement, the Veteran asserted that his erectile dysfunction is secondary to his service-connected PTSD. The Veteran's service treatment records include no complaints, diagnosis, or treatment of erectile dysfunction. At the Veteran's February 1968 Report of Medical Examination, a clinician found that his genitourinary (G-U) system was normal. In April 2007, VA provided the Veteran with a compensation and pension examination germane to his claim for service connection for erectile dysfunction. The VA examining physician noted that the Veteran has had anal cancer which was treated with chemotherapy and radiation therapy in 2000. The Veteran reported that one year after receiving the radiation therapy, he could not have an erection at all. Based on the foregoing, the VA examiner opined that the Veteran's erectile dysfunction is related to the radiation treatment for his anal cancer. The VA physician's opinion is competent because he is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). Also, the VA physician's etiological opinion is credible based on its internal consistency and his duty to provide truthful opinions. The Board further finds that the April 2007 VA physician's opinion is most probative because he considered the Veteran's medical records and discussed his medical history, provided an unequivocal and conclusive opinion, and offered clear reasoning demonstrating that the Veteran's erectile dysfunction was attributable to his radiation treatment for anal cancer, as it had its onset one year after receiving radiation treatment. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As the VA examiner's opinion is consistent with the evidence of record, including the contemporaneous in-service findings of a normal genitourinary system, the Board finds that his reasoning and conclusions warrant the greatest probative weight. The Board recognizes that the Veteran was competent to observe his erectile dysfunction. However, lay evidence is not always competent evidence of a nexus, particularly where complex medical questions or the interpretation of objective medical tests are involved. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (rheumatic fever is not a condition capable of lay diagnosis). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Here, the Veteran's June 2007 assertion that his erectile dysfunction was caused by his service-connected PTSD, and the appellant's adoption of said contention, is not competent because the relationship between those disorders is of a complex nature and requires medical expertise and the interpretation of medical literature to evaluate. Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony falls short in proving an issue that requires expert medical knowledge). Consequently, the lay statements from the Veteran and the appellant asserting a nexus do not constitute a competent medical nexus opinion. Moreover, even if the lay nexus opinions were held competent in this case, the Board finds that their probative value is outweighed by the April 2007 VA physician's opinion based on his greater medical expertise and the consistency of his findings with the chronology of onset on the Veteran's erectile dysfunction shortly after his radiation treatment for anal cancer. Similarly, the appellant's submission of articles discussing the effects of PTSD on cardiovascular systems warrants less probative weight than the April 2007 VA physician's opinion because the articles do not account for the radiation treatment present in the Veteran's case. In sum, the Board finds that the most probative evidence fails to link the Veteran's erectile dysfunction to service, or to his service-connected PTSD. Accordingly, reasonable doubt does not apply, and the appeal of the issue is denied. Initial Rating in Excess of 30 Percent for PTSD Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian life. Generally, the degree of disability specified 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 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate Diagnostic Codes identify the various disabilities and the criteria for specific ratings. If two disability 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. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the appellant. 38 C.F.R. § 4.3. The appellant is presumed to be seeking the maximum benefit allowed by law and regulation. AB v. Brown, 6 Vet. App. 35, (1993). The record shows that the Veteran first sought service connection for his PTSD on February 21, 2007. He underwent a VA examination in March 2007. The RO issued a rating decision in April 2007 that granted the Veteran's claim for service connection and assigned a 10 percent rating. The Veteran filed a timely Notice of Disagreement, then underwent a second VA examination in July 2008. The RO issued a Statement of the Case in January 2009. The Veteran filed a timely Substantive Appeal. In a December 2012 rating decision, the RO increased the Veteran's rating to 30 percent as of February 21, 2007, the date of claim. The Veteran's PTSD has been evaluated under the General Rating Formula for Mental Disorder. 38 C.F.R. § 4.130, DC 9411. Under the General Rating Formula, a 30 percent disability rating is warranted when 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, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted when there is 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 worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent disability rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. The symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In addition, in Mittleider v. West, 11 Vet. App. 181 (1998), the U.S. Court of Appeals for Veterans Claims (Court) held that VA regulations require that when the symptoms and/or degree of impairment due to a veteran's service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. In evaluating psychiatric disorders, the VA has adopted and employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). See 38 C.F.R. § 4.130. As such, the diagnosis of a mental disorder should conform to DSM-IV. See 38 C.F.R. § 4,125(a). Diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). A GAF of 61 to 70 is indicative of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 51 to 60 is defined as 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). A GAF score of 41 to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, the determination must be made as to whether the evidence supports the claim or is in relative equipoise, with an appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Following a review of the evidence of record, the Board finds that an initial rating in excess of 30 percent for PTSD is not warranted. In reaching this decision, the Board has reviewed the evidence of record, to include VA examination reports and the statements of the Veteran and the appellant. The appellant contends that a higher initial rating for PTSD is warranted. In June 2008, the Veteran's representative asserted that the Veteran was unable to work due to his PTSD, and should be assigned a 100 percent disability rating. Also in July 2008, the Veteran reported experiencing worsening dreams of combat experiences, cold sweats, sporadic breathing, awakening from sleep every nine minutes, refusal to go out or associate with people, difficulty concentrating, daydreaming, forgetfulness, and a quick temper. His spouse wrote in July 2008 that the Veteran avoids people, does not go out like he used to, and leaves a light on at night. In his February 2009 substantive appeal, the Veteran asserted that he lost his job due to PTSD, lives like a hermit, refuses to socialize with people, and locks himself in his bedroom or a dark closet. In March 2007, a VA clinical psychologist examiner interviewed the Veteran. The Veteran denied any hospitalizations for a mental disorder. The Veteran reported getting depressed for a few minutes every day. He reported being married and having several friends. He denied any suicide attempts and any violence/assaultiveness. The examiner found that the Veteran's affect was irritable, and that he was intact to person, time, and place. The Veteran had no inappropriate behavior, no obsessive or ritualistic behavior, no panic attacks, and no homicidal or suicidal thoughts. His memory was normal. He had intrusive memories, nightmares, and flashbacks. He also avoided talking about Vietnam, felt detachment, averaged 5 hours of sleep per night, experienced irritability and anger, had concentration problems most of the time, and had hypervigilance most of the time. The Veteran reported working on a part-time basis, and having missed less than 1 week of work in the past 12 months, due to flu. The VA examiner diagnosed the Veteran with PTSD and assigned a GAF score of 65. The examiner opined that the Veteran was not unemployable due to his PTSD. The examiner characterized the Veteran's PTSD as having signs and symptoms that are transient or mild and decrease work efficiency and ability to perform occupational tasks only during periods of significant stress; specifically, the Veteran had some irritability with his wife, and some concentration problems at work. In November 2007, the Veteran's treating VA psychiatrist found that the Veteran had severe symptoms of PTSD, including dreams, flashbacks, agitation, anger, hyperarousal, avoidance of others (in part due to medical problems), and avoidance of reminders of Vietnam. The Veteran tended to be very guarded, easily aggravated, and distrusting. Although he felt close to his wife, he otherwise avoided social interactions. His mood was depressed and dysphoric, and his sleep was inadequate. He denied any suicidal ideas. The VA psychiatrist diagnosed the Veteran with PTSD and assigned a GAF score of 42. In May 2008, the same November 2007 treating VA psychiatrist wrote that the Veteran is unable to work due to disabling PTSD, and is unable to cope with work-related stress. In July 2008, the same March 2007 VA clinical psychologist examiner interviewed the Veteran. The Veteran reported being depressed on a daily basis for an unspecified duration. The Veteran denied anhedonia. The Veteran reported having 3 or 4 friends, no history of suicide attempts, and one incident of fighting in which the other individual struck him first. The examiner found that the Veteran had a constricted affect. The Veteran was intact to person, time, and place. He had no delusions, hallucinations, inappropriate behavior, obsessive or ritualistic behavior, panic attacks, or homicidal or suicidal thoughts. The Veteran reported having upsetting memories, nightmares, detachment, marked avoidance of the trauma, interrupted sleep, irritability, anger, hypervigilance, and startle response. The VA examiner diagnosed the Veteran with PTSD and assigned a GAF score of 65. With respect to social functioning, the Veteran described his marriage in positive terms, reported positive relationships with his three adult children from his first marriage, and reported having 3 or 4 friends. With respect to employability, the examiner found that: The veteran worked as a printer until 5/07. A 5/28/08 letter from his VA psychiatrist indicated that the veteran could not work due to PTSD. However, a 5/25/07 letter from the veteran's last employer described the veteran as "an excellent employee." The letter reflected that the veteran was being let go due to "problems you were having with your legs and your foot." In addition, the most recent VA psychiatry note (5/28/08) described the veteran's PTSD as "improved." Considering all of this information, the veteran is not unemployable due to PTSD. The July 2008 VA examiner concluded that the Veteran's PTSD symptoms are not severe enough to interfere with occupational and social functioning. In December 2009, the November 2007 treating VA psychiatrist noted that the Veteran reported having more nightmares and anxiety, and was somewhat distressed with hunting season. The Veteran reported no significant depression. The psychiatrist found that the Veteran was pleasant and open, with a coherent and logical thought process. The Veteran had no delusions, hallucinations, or suicidal or homicidal ideations. His mood was euthymic, and his affect full and appropriate. The VA psychiatrist diagnosed the Veteran with PTSD and assigned a GAF score of 57. The Board finds that, for the entire appeal period, the Veteran's PTSD is manifested by such symptoms as depressed mood, anxiety, and chronic sleep impairment. Based on the evidence of record described above, the Board finds that the Veteran's PTSD does not result in 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; or difficulty in establishing and maintaining effective work and social relationships. The Board notes that the evidence of record reflects that the Veteran has additional symptomatology which includes dreams of combat experiences, cold sweats, sporadic breathing, sleep disturbances, difficulty concentrating, daydreaming, forgetfulness, a quick temper, depression, irritability, intrusive memories, nightmares, flashbacks, detachment, anger, concentration problems, hypervigilance, agitation, hyperarousal, avoidance of others (in part due to medical problems), avoidance of reminders of Vietnam, guardedness, distrust, dysphoria, constricted affect, startle response, and anxiety. See Mauerhan, 16 Vet. App. 436 (2002). However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 30 percent under the General Rating Formula as they are not of such a severity or frequency to result in occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. Additionally, the Board notes that the Veteran was assigned GAF scores of 65 in March 2007, 42 in November 2007, 65 in July 2008, and 57 in December 2009. As noted above, a GAF score of 57, which represents the average score, reflects 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). Therefore, the Board finds that the Veteran's PTSD does not more nearly approximate a rating in excess of 30 percent. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected PTSD; however, the Board finds that his symptomatology has been essentially stable throughout the appeal. Therefore, assigning staged ratings for such disability is not warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected PTSD with the established criteria found in the rating schedule. The Board finds that the Veteran's PTSD symptomatology is fully addressed by the rating criteria under which such disability is rated. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Moreover, even if the rating criteria were found inadequate to describe the severity and symptoms of the Veteran's PTSD, the Board further finds that this case does not present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. Specifically, the Veteran denied hospitalization due to his PTSD, and, as the July 2008 VA examiner explained in detail, the Veteran's employer only cited leg and foot disabilities as the causes of interference with his employment. The July 2008 VA examiner's findings are more probative than those of the treating VA psychiatrist in this regard because they are more consistent with the entirety of the record, including the Veteran's employer's own statements. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Finally, the Court of Appeals for Veterans Claims has held that a total disability rating based on individual unemployability (TDIU) is a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). 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, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied, and VA must consider whether the Veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The Board finds that the most probative evidence-including the Veteran's employer's statement and the July 2008 VA examiner's report-shows that the Veteran is not unemployable due to his PTSD. As noted above, the July 2008 VA examiner's findings are more probative than those of the treating VA psychiatrist in this regard because they are more consistent with the entirety of the record, including the Veteran's employer's own statements. Thus, TDIU is not raised by the record. In summary, the Board finds that the Veteran's PTSD symptoms result in no more than 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, and chronic sleep impairment. Accordingly, the Board concludes that reasonable doubt does not apply, and the criteria for a rating in excess of 30 percent for the Veteran's PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1-4.14, 4.130, Diagnostic Code 9411. ORDER Service connection for erectile dysfunction is denied. A disability rating in excess of 30 percent for PTSD is denied. REMAND As an initial matter, the appellant should be given an opportunity to identify any healthcare provider who had treated the Veteran for his claimed hepatitis C and hypertension. Thereafter, any identified records that are not already included in the claims file should be obtained for consideration in the appeal. The Board finds that medical opinions are necessary prior to adjudication of the issues of entitlement to service connection for hepatitis C and entitlement to service connection for hypertension. A medical examination or medical opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but: (A) Contains competent lay or medical evidence of a currently diagnosed disability or persistent or recurrent symptoms of disability; (B) Establishes that the Veteran suffered an event, injury or disease in service, or has a disease or symptoms of a disease listed in §§ 3.309, 3.313, 3.316, or 3.317 manifesting during an applicable presumptive period provided the claimant has the required service or triggering event to qualify for that presumption; and (C) Indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service or with another service-connected disability. See 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). Hepatitis C With respect to hepatitis C, the information and evidence of record includes multiple diagnoses thereof during the pendency of the claim. See, e.g., VA treatment records dated June 2006, January 2007, February 2007, February 2008, July 2010, and November 2010. Additionally, the Veteran has provided competent lay evidence of events during service with which his hepatitis C may be associated. Specifically, in documents dated February 2006, May 2006, June 2006, February 2007, June 2007, April 2008, and March 2009, the Veteran reported exposure during his combat service in Vietnam to: (1) foreign matter on a punji stake which pierced his right foot, for which he was awarded the Purple Heart; (2) the bodily fluids of his wounded comrades; (3) putrid water; (4) chemical herbicides; (5) a filthy needle which he injected into his leg as a prophylactic against a reported gas attack; and (6) leeches from a swamp. The record also reflects that the Veteran got tattoos on his hands in 1960 or 1961, prior to service. See May 2006 Hepatitis Questionnaire. When considering the evidence, the medical expert should presume the veracity of the Veteran's six reported in-service combat injuries. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). In addition to the foregoing, a medical opinion is required because the February 2007 VA examiner did not provide one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Hypertension With respect to hypertension, the information and evidence of record includes multiple diagnoses thereof during the pendency of the claim. See, e.g., VA treatment records dated February 2008 and July 2010. Additionally, the Veteran has provided medical treatise evidence relating hypertension to his service-connected PTSD. See, e.g., September 2007 and January 2007 articles. Significantly, no etiological opinion as to the Veteran's hypertension is of record. Accordingly, the case is REMANDED for the following action: 1. The appellant should be given an opportunity to identify any healthcare provider who treated the Veteran for his hepatitis C and hypertension. After securing any necessary authorization, obtain all identified treatment records which are not already of record. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, that should be documented and the appellant allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. After obtaining the records described above, obtain medical opinions as to the etiology of the Veteran's hepatitis C and hypertension. The claims file should be made available for review of the Veteran's pertinent medical history. The author should offer an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran's hepatitis C resulted from his military service, including from his exposure during his combat service in Vietnam to: (1) foreign matter on a punji stake which pierced his right foot, for which he was awarded the Purple Heart; (2) the bodily fluids of his wounded comrades; (3) putrid water; (4) chemical herbicides; (5) a filthy needle which he injected into his leg as a prophylactic against a reported gas attack; and (6) leeches from a swamp. The veracity of those six events should be presumed. The author should also consider that the Veteran got tattoos on his hands in 1960 or 1961, prior to service. The author should offer an opinion as to whether the Veteran's hypertension resulted from his military service, which included exposure to herbicides, or from service connected disability. Specifically, the should offer an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran's hypertension was incurred in service, to include from herbicide exposure; or was caused or aggravated by his service-connected PTSD. In reaching an opinion, the author should consider the September 2007 and January 2007 articles regarding the relationship between hypertension and PTSD submitted by the Veteran. The rationale for any opinion offered should be provided. If the author is unable to render an opinion without a resort to speculation, then the author must explain why this is so. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If any claim remains denied, the appellant and her representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs