Citation Nr: 1329954 Decision Date: 09/18/13 Archive Date: 09/25/13 DOCKET NO. 04-31 052 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for hepatitis C. 2. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with generalized anxiety reaction. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from August 1968 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2002 and July 2004 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. The Board has reviewed the Veteran's physical claims file, as well as the electronic file on the "Virtual VA" system, to ensure a complete review of the evidence in this case. On the August 2004 VA Form 9, the Veteran asked for a Travel Board hearing in connection with the appeal. After being notified that the Board hearing was scheduled for June 2007, the Veteran requested its postponement. See May 2007 letter from the Veteran. The RO subsequently attempted to reschedule the Travel Board hearing on several occasions; however, the Veteran repeatedly requested postponement. See, e.g., the August 2007, March 2009, November 2009, May 2010, April 2011, and August 2011 letters from the Veteran. The most recent motion to reschedule the Travel Board hearing scheduled for September 2011 was denied, and the Veteran did not appear for the scheduled hearing. For these reasons, the Board finds that the Veteran's hearing request has been withdrawn. 38 C.F.R. § 20.702 (2013). In March 2012, the Board adjudicated a number of issues and remanded the issues of service connection for hepatitis C and an increased evaluation in excess of 50 percent for PTSD with generalized anxiety reaction for further evidentiary development. The case now returns to the Board following satisfactory completion of the ordered development. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). As explained below, the Board finds that the issue of entitlement to a TDIU has been reasonably raised by the record in this case. Consequently, the issue is considered part of the Veteran's increased rating appeal and is included among the issues listed on the first page of this decision. The issues of service connection for hepatitis C and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT Throughout the rating period, the Veteran's PTSD with generalized anxiety reaction has been manifested by occupational and social impairment with deficiencies in the areas of work, judgment, thinking, and mood due to intermittent suicidal ideation, isolative behavior, frequent irritability with occasional assaultive behavior, frequent anxiety and/or depression affecting the ability to function independently and effectively, and difficulty adapting to stressful circumstances. CONCLUSION OF LAW The criteria for a 70 percent evaluation, but no more, for service-connected PTSD with generalized anxiety reaction have been approximated for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3-4.7, 4.27, 4.126, 4.130, Diagnostic Code (DC) 9400-9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). 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 from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). As noted in the March 2012 Board Remand, the Veteran was not provided with a notice letter for the increased rating claim for PTSD with generalized anxiety reaction prior to the initial denial of the claim. However, pursuant to the March 2012 Board remand directive, the AMC sent a notice letter to the Veteran in March 2012 that advised the Veteran that he may submit evidence showing that the service-connected PTSD had increased in severity, and described the types of information and evidence that he should submit in support of the increased rating claim. The RO also explained what evidence VA was responsible for obtaining or would assist in obtaining on the Veteran's behalf in support of the increased rating claim. The RO further explained how VA determines the disability rating and the effective date. The claim was readjudicated in a July 2013 supplemental statement of the case. In consideration of the foregoing, the Board concludes that the requirements of the notice provisions of the VCAA have been met, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. Prickett v. Nicholson, 20 Vet. App. 370, 376-78 (2006) (validating the remedial measures of issuing fully compliant VCAA notification and readjudicating the claim in the form of an SOC to cure timing of notification defect). Regarding VA's duty to assist in claims development, the Veteran underwent QTC general psychiatric examinations in connection with the increased claim in January 2002 and April 2005. Both examinations were performed by the same examiner. Collectively, the medical examination reports include all relevant findings and medical opinions needed to evaluate fairly the appeal. The QTC psychiatric examiner took a thorough history of the psychiatric disability from the Veteran, including history of onset, diagnosis, report of symptomatology, other limitations, and treatment. The QTC psychiatric examiner had adequate facts and data regarding the history and condition of the disability. See VAOPGCPREC 20-95 (interpreting that in some cases an accurate history by a veteran may be a valid basis for an examination report rather than claims file review); see also Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran). The QTC psychiatric examiner also considered the Veteran's subjective complaints as it related to current symptomatology and its effects on his daily life and performed a thorough mental status evaluation of the Veteran. In an effort to comply with the Board's March 2012 remand directive, the VA Medical Center (VAMC) in West Los Angeles, California attempted to schedule the Veteran for another VA medical examination on multiple occasions; however, the Veteran and/or his wife repeatedly cancelled the scheduled medical examinations reportedly for health-related reasons. In June 2013, an employee of the West Los Angeles VAMC spoke with the Veteran's wife by telephone and she stated that she was unable to state when the Veteran would be able to report for a medical examination. The following month, an employee at the AMC noted that the Veteran had missed three scheduled medical examinations and attempted to contact the Veteran to determine when it would be feasible to schedule a medical examination. The Veteran's wife returned the call and requested to have the Veteran's appeal again postponed for six months to allow the Veteran time to report for a medical examination. The AMC employee informed her that he was not at liberty to grant or extend the appeal for an additional six months because the appeal had been pending since March 2012. Despite the July 2013 request for another six month delay in scheduling the Veteran for a medical examination, neither the Veteran nor his wife has indicated that the Veteran's health status is likely to improve over the course of six months such that the Veteran would likely be able to undergo a medical examination in connection with the increased rating appeal. Indeed, the Veteran and/or his wife similarly requested postponements of the Board hearing due to reported health-related reasons on multiple occasions over a period of four years (i.e., from 2007 to 2011); however, the Veteran was not able to report for any Board hearing scheduled during that time. Also, the Veteran's private psychiatrist has submitted a statement regarding the severity of the Veteran's PTSD, as well as the Veteran's wife. For these reasons, the Board finds that the efforts extended by the RO in scheduling the Veteran for a VA medical examination in connection with the increased rating appeal were satisfactory, and no further efforts to schedule the Veteran for a medical examination are needed. The evidence already of record is sufficient for rating the Veteran's psychiatric disability. In this regard, the Board notes that post-service treatment records identified as relevant to the appeal have been obtained and are associated with the record. There are no additional treatment records found in the Veteran's Virtual VA folder. The RO/AMC attempted on several occasions to obtain the Veteran's treatment records from the private psychiatrist (Dr. B.L.) who has been treating him throughout the time relevant to the rating period, and the Veteran's private treating psychiatrist has not provided the Veteran's treatment records. Instead, he has submitted written statements in response to the requests. The Veteran's wife has submitted statements regarding the severity of the Veteran's psychiatric symptoms. The Veteran has not made the RO or the Board aware of any other evidence relevant to the appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed, and no further development is required to comply with the duty to assist in developing the facts pertinent to the increased rating appeal decided herein. In view of the foregoing, the Board will proceed with appellate review. Disability Evaluation Legal Criteria It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). The Board has thoroughly reviewed all the evidence in this case. The analysis below focuses on the most relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2, which require the evaluation of the complete medical history of a veteran's condition. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In a May 1970 rating decision, service connection was established for the psychiatric disability with a 10 percent disability rating effective April 11, 1970. In June 2001, the Veteran filed the current claim seeking an increased rating for service-connected PTSD with generalized anxiety reaction. Where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. Disability Rating Analysis The Veteran's PTSD with generalized anxiety reaction is currently evaluated as 50 percent disabling under the criteria found at 38 C.F.R § 4.130, DC 9400- 9411. Psychiatric disabilities are evaluated under the General Rating Formula for Mental Disorders. Upon review, the Board finds no other appropriate diagnostic code and/or rating schedule under which it would be appropriate to evaluate the psychiatric disability. Under the General Rating Formula for Mental Disorders, a 50 percent rating is prescribed when there is evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2013). A 70 percent rating is provided when there is evidence that the psychiatric disability more closely approximates 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); and inability to establish and maintain effective relationships. Id. A 100 percent rating requires evidence of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the Diagnostic and Statistical Manual of Mental Disorders at 32 (4th ed. 1994) (DSM-IV)). A score in the range of 51 to 60 indicates moderate symptoms (e.g., a flattened affect, circumstantial speech, occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., having few friends or having conflicts with peers or co-workers). A GAF score of 41 to 50 reflects a serious level of impairment (e.g., suicidal ideation, severe obsessive rituals, frequent shoplifting), or serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 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. 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. The Board notes that with regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. The use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only 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). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the rating schedule. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013), the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) determined that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." Thus, the demonstrated symptomatology is the primary focus when deciding entitlement to a given disability rating and a veteran may be entitled to a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Id. When a claimant has both service-connected and non-service-connected disabilities, the Board must attempt to discern the effects of each disability and, where such distinction is not possible, attribute such effects to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998). In this case, the Board has considered all of the Veteran's psychiatric symptoms and diagnoses in reaching its decision regarding entitlement to an increased rating when not easily distinguishable. After review of all the lay and medical evidence of record, the Board finds that the Veteran's PTSD with generalized anxiety reaction has been manifested by occupational and social impairment with deficiencies in the areas of work, judgment, thinking, and mood due to intermittent suicidal ideation, isolative behavior, frequent irritability with occasional assaultive behavior, frequent anxiety and/or depression affecting the ability to function independently and effectively, and difficulty adapting to stressful circumstances for the entire rating period. In consideration thereof, the Board finds that the evidence is in equipoise on the question of whether manifestations of the Veteran's psychiatric disability picture more closely approximates the schedular criteria for a 70 percent rating under the General Rating Formula for Mental Disorders. After review of the record, the Board finds that the Veteran has demonstrated significant occupational impairment due to psychiatric symptomatology during the rating period. Indeed, during the rating period, the Veteran's difficulty managing the stress of personal and family problems has caused significant impairment in his ability to work at various times. For example, approximately a year before filing the current increased rating claim, the Veteran told a private medical provider that he had been under a lot of stress recently due to legal problems involving his sons and had not been working for the past three months in an attempt to get his personal and family problems "straightened out." See May 2000 private treatment note. This evidence suggests significant impairment in the area of work because the Veteran's reported difficulty managing stress prevented him from working for at least a three-month period. Also, at the April 2005 QTC general psychiatric evaluation, the Veteran told the QTC examiner that he had stopped working in 2002 because he was unable to concentrate and other related emotional problems. The Veteran is competent to report having had difficulty with concentration and managing the stress of his personal and family problems to the point that he was unable to work for significant periods of time, and there is no indication in the record that the Veteran's account is not credible. Difficulty in adapting to stressful circumstances is a symptom contemplated by the criteria for a 70 percent disability rating under the rating formula for mental disorders. Also, the Veteran's impaired impulse control manifested by unprovoked irritability with periods of violence due to PTSD has caused significant occupational impairment during the rating period because it has, at times, resulted in conflict at the workplace. In a February 2004 statement, the Veteran wrote that he could not hold a job due to PTSD symptoms. He stated that he had worked for over thirty companies over the past twenty five years as heavy equipment operator and often became angry "over little things," became violent, and had occasionally assaulted his supervisor. He also told a treating medical provider, in February 2004, that he had not worked for two years and was emotionally stressed. The Veteran is competent to report that he could not hold a job due to irritability and assaultive behavior, and there is no indication that the Veteran's account is not credible. This evidence shows that the Veteran demonstrated impaired impulse control manifested by unprovoked irritability with periods of violence in the work setting, which is a symptom contemplated by the criteria for a 70 percent disability rating under the rating formula for mental disorder. The symptom also suggests impaired judgment and mood to some degree. The Board additionally notes that the Veteran's frequent anxiety manifested by panic attacks and difficulty leaving the apartment due to PTSD has caused significant occupational and social impairment because the Veteran has lost work and either has difficulty or is unable to interact with others outside of the home. At the January 2002 QTC general psychiatric examination, the Veteran reported that his panic attacks were the main symptom that caused him to "lose" work and feel "grossly uncomfortable." Also, on the August 2004 VA Form 9, the Veteran wrote that he was anxious and/or panicked daily and was not comfortable leaving the apartment. More recently, the Veteran's treating psychiatrist wrote, in a February 2013 statement, that the Veteran's anxiety had increased so badly when leaving the apartment that he had treated the Veteran at the apartment. This evidence shows that the Veteran demonstrated near-continuous panic affecting the ability to function independently, appropriately, and effectively, which is also a symptom contemplated by the criteria for a 70 percent disability rating under the rating formula for mental disorders. The Board further notes that the Veteran's PTSD is manifested by suicidal ideation during the rating period. Indeed, although the Veteran denied having suicidal ideation at the QTC general psychiatric examinations, he wrote, in a June 2001 statement, that he had wished to take his own life on more than one occasion. The Veteran is competent to report suicidal ideation at various times, and there is no indication that the account at that time is not credible despite his subsequent denial of suicidal ideation at the January 2002 and April 2005 QTC examinations. This evidence shows that the Veteran's PTSD is manifested by intermittent suicidal ideation, which is a symptom contemplated by the criteria for a 70 percent rating under the general rating formula for mental disorders, and indicates impaired thinking and mood to some degree. Moreover, the Board notes that the QTC examiner, despite having described the Veteran's PTSD as "moderate," assigned a GAF score of 45 for each of the Axis I diagnoses of PTSD and GAD at the April 2005 general psychiatric examination, which reflects serious symptoms (e.g., suicidal ideation, severe obsessive rituals, frequent shoplifting), or serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). As stated above, the Veteran has reported suicidal ideation, which considered a serious symptom consistent with a GAF score of 45. Also, although the Veteran described his relationships with friends as "fair" at the QTC general psychiatric examinations, he has not indicated that he has any meaningful interactions with friends and has denied having any outside activities or hobbies at QTC examinations. The Veteran's wife wrote, in a February 2004 statement, that the Veteran had become more and more withdrawn over the past five years. The Veteran told the QTC examiner, at the January 2002 QTC general psychiatric examination, that he avoided crowds. The Veteran has further competently and credibly reported that he is unable to keep a job, which is consistent with other evidence of record. See, e.g., January 2002 QTC general psychiatric report (noting that the Veteran reported that he last worked in December 2000); April 2005 QTC general psychiatric report (noting that the Veteran reported that he stopped working in 2002). Thus, the overall psychiatric disability picture as shown by the record more nearly approximates serious symptoms and a serious level of impairment due to psychiatric symptomatology throughout the rating period, which is consistent with a GAF score of 45. Thus, review of the lay and medical evidence of record reveals that the Veteran's PTSD with generalized anxiety reaction has been manifested by occupational and social impairment with deficiencies in the areas of work, judgment, thinking, and mood due to intermittent suicidal ideation, isolative behavior, frequent irritability with occasional assaultive behavior, frequent anxiety and/or depression affecting the ability to function independently and effectively, and difficulty adapting to stressful circumstances for the entire rating period. Although the QTC examiner, at the January 2002 general psychiatric examination, assigned a GAF score of 60 for both Axis I diagnoses of PTSD and GAD and found no impairment in the Veteran's ability to understand, remember or complete simple or complex commands, comply with job rules such as safety and attendance, respond to change in the normal workplace setting, or maintain persistence and pace in a normal workplace setting, other credible and probative evidence of record showed significant and serious impairment in the area of work due to PTSD symptoms throughout the rating period, which is more consistent with a 70 percent disability rating. The Board notes that several of the symptoms specifically delineated in the criteria for the 70 percent schedular rating are not shown during the rating period. Indeed, the evidence does not show that the Veteran's psychiatric disability is manifested by obsessional rituals which interfere with routine activities; speech that was intermittently illogical, obscure, or irrelevant; spatial disorientation; or neglect of personal appearance and hygiene. Also, the evidence does not show an outright inability to establish effective relationships. At both the January 2002 and April 2005 QTC general psychiatric examinations, the Veteran described his relationships with family and friends as "fair," and, during the rating period, the Veteran married his current wife. However, when evaluating the psychiatric disability picture associated with the Veteran's PTSD with generalized anxiety reaction on the whole, the Board resolves reasonable doubt in the Veteran's favor in finding that the psychiatric symptoms present are of the severity, frequency, and duration resulting in an overall level of impairment such that a 70 percent rating is approximated for the entire rating period. However, the Board finds that the Veteran does not have total occupational and social impairment due to PTSD with generalized anxiety reaction so that the next higher rating of 100 percent is warranted for any time during the rating period. Although the Veteran's psychiatric disability has caused significant occupational and social impairment, as explained above, the evidence does not show total impairment. During the rating period, the Veteran has performed work for various periods and maintained a relationship with his current wife, which does not indicate total occupational or social impairment. Also, the Veteran has not demonstrated any of the symptoms contemplated by the 100 percent schedular rating. Indeed, the Veteran has not shown gross impairment in thought processes or communication or persistent delusions or hallucinations. At the QTC general psychiatric examinations, no impairment in thought processes or communication were shown, and the Veteran denied having any delusions or hallucinations. The Veteran also did not demonstrate grossly inappropriate behavior at the QTC examinations. There is no evidence shown that contradicts the findings at the QTC psychiatric examinations during the rating period. Although the Veteran has demonstrated intermittent suicidal ideation and occasional assaultive behavior, there is no indication of persistent danger of hurting self or others. The QTC examiner noted that the Veteran was able to perform activities of daily living (including maintenance of minimal personal hygiene), and there is no evidence to the contrary of record. The Veteran has not demonstrated disorientation to time or place or memory loss for names of close relatives, own occupation, or own name. He was oriented and showed no difficulty with memory loss at either QTC examination. Therefore, in summary, the Board finds that the manifestations of the Veteran's PTSD with generalized anxiety reaction more nearly approximate the schedular criteria for a 70 percent rating, but no higher, for the entire rating period. 38 C.F.R. §§ 4.3, 4.7. The Veteran's PTSD symptoms and functional (occupational and social) impairment are contemplated by the 70 percent schedular rating for the rating period. Extraschedular Consideration Analysis The Board has further considered whether the increased rating appeal warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321. Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, it must be determined whether the disability picture is such that the schedular criteria are inadequate, i.e., whether there are manifestations or impairment that are not encompassed by the schedular criteria. If those criteria are not inadequate, the analysis does not need to proceed any further. In this case, the Board does not find any symptoms or functional impairment that is not already encompassed by the currently assigned 70 percent schedular rating. Here, the schedular rating criteria contemplate the impairments and symptoms associated with the Veteran's PTSD with generalized anxiety reaction. The symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, hyphenated DC 9400-9411, specifically provides for disability ratings based on a combination of symptoms and clinical findings. In this case, the Veteran's PTSD with generalized anxiety reaction is manifested by occupational and social impairment with deficiencies in the areas of work, judgment, thinking, and mood due to intermittent suicidal ideation, isolative behavior, frequent irritability with occasional assaultive behavior, frequent anxiety and/or depression affecting the ability to function independently and effectively, and difficulty adapting to stressful circumstances for the entire rating period. These symptoms are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Because the schedular rating criteria is adequate to rate the Veteran's PTSD with generalized anxiety reaction disability, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). ORDER An increased evaluation of 70 percent for service-connected PTSD with generalized anxiety reaction is granted for the entire rating period, subject to the laws and regulations governing the payment of monetary awards. REMAND After review of the record, the Board finds that additional evidentiary development is needed before evaluating the merits of the Veteran's service connection appeal for hepatitis C and a TDIU. Service connection for hepatitis C In March 2012, the Board remanded the issue of service connection for hepatitis C for a VA medical examination and medical opinion addressing the likely etiology of the Veteran's hepatitis C. Pursuant to the Board's Remand directive, there were multiple attempts to schedule the Veteran for a VA medical examination at the West Los Angeles (LA) VA Medical Center (VAMC); however, each scheduled VA examination was cancelled by the Veteran for various health-related reasons. See e.g., April 2012 letter from the Veteran's wife. In June 2013, the Veteran's wife, who has been authorized by the Veteran to communicate with VA about the appeal, stated that she was unable to give a time or date when the Veteran would be able to report for a VA medical examination, and the AMC readjudicated the claim in July 2013. Under the circumstances presented in this case, the Board finds that further development is warranted despite the meaningful efforts extended by the AMC to comply with the prior Board remand directive to provide the Veteran with a VA medical examination. Because the Veteran is unable to report for a VA medical examination for health reasons, he should be advised that he may submit a medical opinion from a treating medical provider regarding the likely etiology of hepatitis C. The AMC should also ask the Veteran to provide authorization and consent to release treatment records pertaining to treatment for hepatitis C from the Cedar Sinai hospital and any other medical facilities or medical providers from whom he has sought treatment for hepatitis C. See August 2013 letter from the Veteran's wife (noting that the Veteran was recently treated in the Cedar Sinai Emergency unit). Furthermore, a VA medical opinion based on review of the record should be obtained without examination of the Veteran. TDIU In a February 2004 statement, the Veteran wrote that he has been unable to hold a job due to PTSD. Also, at the April 2005 QTC examination, the Veteran reported that he stopped working in 2002 due to an inability to concentrate and other related emotional problems. After considering the Veteran's statements, the Board finds that a TDIU is reasonably raised by the record, and is part of the increased rating appeal before the Board. Rice v. Shinseki, 22 Vet. App. 447 (2009). That issue has neither been developed nor adjudicated by the RO. Therefore, a remand for issuance of proper notice and development for a TDIU is warranted. the Veteran is in receipt of a 100 percent combined schedular rating from April 15, 2005, as well as special monthly compensation (SMC) under 38 U.S.C.A. § 1114(k) from April 15, 2005. The Court has held that VA must consider a TDIU claim despite the existence of a schedular total rating and award of SMC if VA finds the separate disability supports a TDIU independent of the other 100 percent disability rating. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008); see also DVA Sum. Op. Gen. Counsel Prec., 75 Fed. Reg. 11229-04 (March 10, 2010) (withdrawing VAOPGCPREC 6-99, 64 Fed. Reg. 52375 (1999) (the logic of Bradley suggests that, if a Veteran has a schedular total rating for a particular service-connected disability and subsequently claims TDIU for a separate disability, VA must consider the TDIU claim despite the existence of the schedular total rating and award SMC under section 1114(s) if VA finds the separate disability (or disabilities) support a TDIU independent of the other 100 percent disability rating). Accordingly, the case is REMANDED for the following actions: 1. Ask the Veteran to identify any VA or non-VA medical treatment he has received for hepatitis C since May 2003. After securing any necessary consent and authorization, obtain the identified records, to include any records from the Cedar Sinai hospital. Advise the Veteran that he may also submit the relevant treatment records to VA himself. Any negative responses should be properly documented in the record, to include following the procedures outlined in 38 C.F.R. § 3.159(e). 2. Advise the Veteran that he may provide a medical opinion from a treating medical provider regarding the likely etiology of hepatitis C in support of the appeal. 3. After actions (1) and (2) above have been completed, obtain a VA medical opinion from an appropriate medical provider regarding the likely etiology of hepatitis C, without medical examination of the Veteran. All relevant documents should be reviewed when rendering the opinion. The VA reviewer must confirm that the record was reviewed in the examination report. Based on review of the appropriate records, the VA reviewer should state whether or not it is as likely as not (i.e., to a 50 percent degree of probability or greater) that the Veteran's hepatitis C disability had its onset during active military service or is otherwise causally or etiologically related to service. Provide a rationale for the medical opinion. In providing the medical opinion, the VA reviewer should provide a discussion of all of the risk factors identified by the Veteran and by the medical record. The VA reviewer should consider this combat Veteran's account of having been exposed to the blood and excrement of wounded Marines as fact. Additionally, the VA reviewer should consider the medical evidence showing that the Veteran has other possible risk factors for hepatitis C, to include drug use; the January 2002 VA medical examination showing a current diagnosis of hepatitis C; and private treatment records showing that the Veteran did not have diagnosed viral hepatitis pursuant to lab work dated in July 1999. The term "as likely as not" does not mean within the realm of medical possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as to find against it. A rationale should be provided for all opinions given, and the factors upon which each medical opinion is based must be set forth in the report. 4. Provide the Veteran with proper notice explaining how to substantiate a claim for a TDIU, to include which information and evidence that he is to provide, and which information and evidence that VA will attempt to obtain on his behalf. 5. After any additional development deemed necessary is completed, to include consideration as to whether a VA medical opinion is needed on the TDIU claim, the remanded issues should be adjudicated. If the benefits sought on appeal remain denied, the Veteran should be provided with a Supplemental Statement of the Case that contains notice of all relevant actions taken, including a summary of the evidence and applicable law and regulations considered pertinent to the issues. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. The Veteran 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). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs