Citation Nr: 1332056 Decision Date: 10/03/13 Archive Date: 10/07/13 DOCKET NO. 09-27 743A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a respiratory disability, to include as due to asbestos exposure. 3. Entitlement to service connection for a low back disability. 4. Entitlement to service connection for neuropathy of the lower extremities. 5. Entitlement to service connection for erectile dysfunction. 6. Entitlement to service connection for a bladder disability. 7. Entitlement to service connection for a prostate disorder. 8. Entitlement to service connection for a muscle disability. 9. Entitlement to service connection for a skin disability (a rash of the legs). 10. Entitlement to service connection for a cervical spine disability. 11. Entitlement to service connection for a bilateral arm disability. 12. Entitlement to increases in the ratings assigned for posttraumatic stress disorder (PTSD)( 50 percent prior to November 17, 2011 and 70 percent from that date). WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD James R. Siegel, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from January 1968 to January 1970. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Philadelphia, Pennsylvania Department of Veterans Affairs (VA) Regional Office (RO). A November 2008 rating decision denied service connection for a respiratory disorder, low back, right knee, bladder, muscle, and skin disabilities, neuropathy of the lower extremities and erectile dysfunction. A July 2009 rating decision denied service connection for an enlarged prostate and cervical spine and bilateral arm disabilities. A July 2011 rating decision granted service connection for PTSD, rated 50 percent effective April 18, 2008; the Veteran disagreed with the rating assigned. A February 2012 rating decision denied a total rating based on individual unemployability due to service-connected disability (TDIU). In May 2012 a videoconference hearing was held before the undersigned; a transcript is associated with the claims file. A September 2012 Board decision remanded these matters for additional development, and denied service connection for bilateral hip, bilateral ankle, bilateral foot and left knee disabilities. A July 2013 rating decision increased the rating for PTSD to 70 percent, and awarded TDIU, both effective November 17, 2011. As the Veteran has not expressed satisfaction with the increased rating for PTSD, that matter remains on appeal. See AB v Brown, 6 Vet. App. 35 (1993). The issue is characterized to reflect that "staged" ratings are assigned, and that both "stages" of the rating are on appeal. He has not disagreed with decision regarding the TDIU rating, and that matter is no longer on appeal. The issues of service connection for right knee and low back disabilities are being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if action on his part is required. FINDINGS OF FACT 1. The Veteran's lung disability (chronic obstructive pulmonary disease (COPD)) was not manifested in, and not shown to be related to, his military service, to include as due to exposure to asbestos or Agent Orange therein 2. The Veteran's paresthesias of the lower extremities were not manifested in service, and are not shown to be related to his military service; acute or subacute peripheral neuropathy is not diagnosed. 3. The Veteran's erectile dysfunction was not manifested in, and is not shown to be related to his military service, to include as due to exposure to Agent Orange. 4. The Veteran is not shown to have a bladder disability. 5. The Veteran is not shown to have a muscle disability. 6. A chronic skin disability has not been shown during the pendency of the Veteran's claim. 7. The Veteran's prostate disorder, benign prostatic hypertrophy (BPH), was not manifested in, and is not shown to be related to, his service, to include as due to exposure to Agent Orange. 8. The Veteran's cervical stenosis was not manifested in, and is not shown to be related to, his military service. 9. The Veteran is not shown to have a bilateral arm disability. 10. Prior to November 17, 2011, the Veteran's PTSD was manifested by disturbed sleep and hypervigilance and resulted in reduced reliability; deficiencies in most areas due to PTSD were not shown. 11. From November 17, 2011, the PTSD has been manifested by suspiciousness and some memory loss, resulting in deficiencies in most areas; gross impairment of thought process, persistent delusions or hallucinations or other symptoms of such gravity, productive of total occupational and social impairment, are not shown. CONCLUSIONS OF LAW 1. Service connection for a respiratory disability is not warranted. 38 U.S.C.A. §§ 1110, 1116, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 2. Service connection for neuropathy of the lower extremities is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 3. Service connection for erectile dysfunction is not warranted. 38 U.S.C.A. §§ 1110, 1116, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 4. Service connection for a bladder disability is not warranted. 38 U.S.C.A. §§ 1110, 1116, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 5. Service connection for a muscle disability is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 6. Service connection for a skin disability is not warranted. 38 U.S.C.A. §§ 1110, 1116, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 7. Service connection for a prostate disability is not warranted. 38 U.S.C.A. §§ 1110, 1116 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 8. Service connection for a cervical spine disability is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 9. Service connection for a bilateral arm disability is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 10. Ratings for PTSD in excess of 50 percent prior to November 17, 2011 and in excess of 70 percent from that date are not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code (Code) 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 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, 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of his claims prior to their initial adjudication. Letters dated in April and September 2008, April and June 2009, and August 2011 explained the evidence necessary to substantiate his claims, the evidence VA was responsible for providing, and the evidence he was responsible for providing. These letters also informed the appellant of disability rating and effective date criteria. He has had ample opportunity to respond and supplement the record, and has not alleged that notice in this case was less than adequate. The appeal regarding the ratings for PTSD is from the initial rating assigned with the award of service connection. The statutory scheme contemplates that once a decision awarding service connection, disability ratings, and effective dates has been made, statutory notice has served its purpose, and its application is no longer required because the claim has been substantiated. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). A March 2013 supplemental statement of the case (SSOC) properly provided notice on the downstream issues of an increased initial rating. A July 2013 SSOC readjudicated the claim after further development was completed. It is not alleged that notice has been less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (when a claim has been substantiated, the Veteran bears the burden of demonstrating prejudice from defective notice with respect to downstream issues). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims held that 38 C.F.R. 3.103(c)(2) requires that a RO official or VLJ who conducts a hearing fulfill two duties: (1) to fully explain the issues and (2) to suggest the submission of evidence that may have been overlooked. The transcript of the May 2012 hearing reflects the undersigned specifically noted that to establish service connection it must be shown you have a chronic problem and that it is related to service. The Veteran's testimony in response to the questions posed by the undersigned focused on the elements necessary to substantiate the current appellate claim; i.e., by his testimony he demonstrated that he is aware of the elements necessary to substantiate his claims, and what still needed to be shown. The Veteran's service treatment records and pertinent post-service treatment records have been secured. The RO arranged for VA examinations. The Board has found those examinations adequate to consider the issues addressed on the merits. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the record, as it stands, includes adequate competent evidence to allow the Board to decide these matters, and that no further development of the evidentiary record is necessary. See generally 38 C.F.R. § 3.159(c)(4). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Factual background, Legal criteria and Analysis The Board has reviewed all of the evidence in the appellant's claims file and in Virtual VA. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that each item of evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board will summarize the evidence as deemed appropriate, and the Board's analysis will focus specifically on what the evidence of record shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires evidence of: (1) a current disability (for which service connection is sought); (2) evidence of incurrence or aggravation of a disease or injury in service; and (3) evidence of a nexus between the claimed disability and the disease or injury in service. See Shedden v, Principi, 381 F.3d 1153, 1166-1167 (Fed. Cir. 2004). If a Veteran was exposed to an herbicide agent during active service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Type 2 diabetes; Hodgkin's disease; chronic lymphocytic leukemia; B cell leukemia, Parkinson's disease, multiple myeloma; non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma); and ischemic heart disease, (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina). 75 Fed. Reg. 53202 (August 31, 2010), 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which a veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). (VA recently its regulation regarding acute and subacute peripheral neuropathy, but the revisions have no applicability in this case, as pertinent diagnosis is not shown.) The Secretary of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See 72 Fed. Reg. 32,395 (2007). The United States Court of Appeals for the Federal Circuit has held, however, that a claimant is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, the fact that a veteran may not meet the requirements for service connection on a presumptive basis does not in and of itself preclude the establishment of service connection, as entitlement may alternatively be established on a nonpresumptive direct-incurrence basis. The Veteran's service treatment records show that in November 1968 he was seen for urethral discharge. The impression was urethritis of unknown etiology. He was seen further on two occasions the next month, and no discharge was noted. He reported burning during urination and a urethral exudate in December 1969. The impression was probable gonococcal urethritis. In a report of medical history in January 1970, the Veteran denied having, or ever having had skin disease, chest pain, shortness of breath, back trouble or a bone or joint deformity. His lungs and chest, spine, genitourinary system, upper and lower extremities, and skin were normal on clinical evaluation on service separation examination in January 1970; neurological evaluation was also normal; a chest X-ray was negative. In a report of medical history on examination for Reserve service in September 1977, the Veteran denied having, or ever having had, skin disease, chest pain, shortness of breath, back trouble or a bone or joint deformity. It was noted that in 1973 he was stabbed in the right anterior chest, and suffered a pneumothorax. On clinical evaluation his lungs and chest, spine, genitourinary system, lower and upper extremities, and skin were normal; neurological evaluation was also normal; a chest X-ray was negative. VA outpatient treatment records disclose the Veteran was seen in November 1999, and reported recurrent joint weakness. He also reported a history of asbestos exposure. The assessments were history of Agent Orange exposure and history of asbestos exposure. A November 2001 VA letter to the Veteran advised him of examination results, noting that his complaints included breathing problems. A chest X-ray revealed chronic obstructive pulmonary disease (COPD) and asbestos exposure. A January 2002 billing statement from a private physician notes diagnoses of COPD, asbestosis and erectile dysfunction. VA treatment records show that in February 2002 the Veteran was instructed in the use of an inhaler. When seen by a private physician in March 2007, the Veteran reported bilateral arm pain. It was described as an aching, burning sensation. He also reported numbness. It was reported his symptoms had started two weeks earlier. The diagnoses were general osteoarthrosis and hypertrophy of the prostate. On VA respiratory examination in August 2008 it was noted that the Veteran was a flame service unit operator in service, and that this military occupational specialty (MOS) is recognized as highly probable for exposure to asbestos. The examiner indicated she reviewed the claims folder and the electronic records. The Veteran reported a 25-pack-year history of smoking. A chest X-ray demonstrated scattered pleural based calcifications in the left hemithorax, considered likely to be related to prior infection or trauma. The diagnosis was asbestos exposure. The examiner noted she discussed the chest X-ray findings with another physician, and it was stated they could be consistent with asbestos exposure, but given the unilateral findings, the history of trauma or infection was thought to be more likely. The examiner noted that the Veteran's trauma was right-sided, and the findings of calcification were noted to be left-sided. If his condition were due to asbestos, bilateral findings would be expected normally. The physician cited an article noting that asbestosis usually reveals small bilateral parenchymal opacities, but such findings were not present in the Veteran's case. It was further noted that the Veteran had a significant smoking history and had been informed he has emphysema secondary to smoking. He was noted to be asymptomatic; the assessment was COPD. A diagnosis of asbestosis was not established. The examiner commented that pulmonary function testing the previous month could be consistent with either COPD or asbestos exposure related disease. She concluded that given the unilateral findings, the lack of symptoms and lack of an established diagnosis, particularly in the setting of emphysema, she could not resolve the issue [i.e., conclusively whether the Veteran has asbestos -related disease] without resort to mere speculation. In September 2008 The Veteran was seen by a private physician with complaints of bilateral pelvic pain of gradual onset. The diagnoses were cervical spine stenosis and paresthesias. B.B. Moore, M.D. wrote in October 2008 that he had examined the Veteran that month for ongoing problems in his arms, trunk and legs. It was reported the Veteran had developed a lot of cramping in his chest, arms and legs over the past several years. The Veteran related that after leaving Vietnam many years ago, he developed some of these symptoms, which had been present for the previous 15 years or more. It was noted that he worked as a heavy equipment operator. The Veteran endorsed having spastic jumping of the legs in bed at night on occasion. He also indicated that, at times, he felt weak in the arms with certain activities. His most bothersome symptom was that he would be using his arms and would suddenly develop muscle spasms and cramps in, among other places, the arms. He did not have any overt weakness in his arms, except when he developed the cramping episodes. He had noticed some increased discomfort in his neck. The examiner reviewed a magnetic resonance imaging (MRI) scan of the cervical spine which showed severe stenosis from C4-5 through C7-T1. He explained to the Veteran that compression of the spinal cord and nerves in the neck was accounting for his symptoms. In a letter dated in January 2009, D.A. Wait, M.D. stated the Veteran had been a patient since March 2007. At that time, he complained of multiple arthralgias, including in the neck. Dr. Wait reviewed a statement the Veteran prepared listing other complaints, including a rash on his legs, muscle soreness, bladder weakness, erectile dysfunction, a respiratory condition and peripheral neuropathy. He noted that the Veteran described his duties in service. After careful examination, review of records, and repeated visits for similar complaints, Dr. Wait determined that most of the Veteran's ailments were chronic. He added that he had no reason to believe there was an explanation for his chronic injuries other than that stated. He commented it was highly likely they stemmed from his duties in service. He noted the Veteran had loss of sensation in both feet, with hyperpigmentation of the legs. He certified the Veteran had multiple physical disabilities which he had no reason to doubt stemmed from service. On evaluation for cervical spondylosis by a private physician in May 2009 the Veteran reported increasing difficulty with weakness in his upper extremities. He reported complaints arising from riding over rough terrain and hitting bumps and potholes. He also said he had some cramping in his upper and lower extremities for several years. Surgery was recommended, and performed the following month. The Veteran was seen for a postoperative checkup in June 2009. His neck pain radiated down both arms. It was noted that the mechanism of injury included direct trauma at work about eight months prior. Additional private records show that in September 2009 the Veteran reported that he had been having some recent difficulties with tingling involving the hands and fingers. He indicated that he had carpal tunnel syndrome diagnosed. On examination, there were mild bilateral Tinel's signs at the volar wrist regions, considered indicative of carpal tunnel syndrome. On VA genitourinary examination in March 2010, the examiner noted he reviewed the claims folder and the medical records. It was noted that the Veteran had non-specific urethritis in service which resolved without sequelae, and that there was no history of urinary symptoms. It was noted that the Veteran reported a 5-10 year history of partial erectile dysfunction; the examiner stated the most likely etiology was decreased libido and that the problem was age appropriate. The diagnoses included that no bladder condition was identified; that BPH was noted on examination (and the Veteran was being followed by a private provider); and that there was no evidence of urinary tract disease. The examiner observed that the Veteran's condition in service (urethritis) was acute and transitory, and apparently did not involve the bladder. He opined there was no indication of chronicity or continuity of treatment and no indication that any presently noted genitourinary condition was associated with, caused by, or the result of any genitourinary condition in service. A chest X-ray at a private facility in March 2011 revealed calcific pleural plaques that suggested prior asbestos exposure versus prior trauma. The Veteran was seen in a VA outpatient treatment clinic in November 2011, when examination of the prostate found mild hypertrophy. It was noted that the Veteran used medication for erectile dysfunction as needed. On VA examination of the prostate in April 2013, the examiner noted he reviewed the claims folder and all available records. It was noted that the Veteran had iatrogenic erectile dysfunction for many years. He did not have a voiding dysfunction, a urinary tract infection or prostate cancer. On VA respiratory examination in April 2013 the examiner stated that he reviewed the claims folder and the electronic medical records. The Veteran complained of dyspnea on exertion and a chronic cough for the last 10 to 15 years. He reported that during service he was involved in loading and unloading 55 gallon drums containing napalm and other chemicals. He denied any significant asbestos exposure. He indicated he had casual asbestos exposure following service. The diagnoses were COPD and asbestos pleural disease. The examiner commented there was no definite asbestos exposure (other than casual) that was service-connected. The Veteran had COPD that was due to cigarette smoking and not to any other exposures. There was no history of any significant chemical inhalation injury during service. The examiner indicated there were insufficient findings to support a diagnosis of a service-connected respiratory impairment. On VA examination for an arm disability in July 2013 the examiner noted she reviewed the Veteran's claims folder and the electronic records. He did not report any history of an arm problem, and the records reviewed were silent for such. There was normal range of motion of the upper extremities. On July 2013 VA cervical spine examination it was noted that the claims folder and the electronic records were reviewed. The diagnosis was degenerative disc disease/spinal stenosis of the cervical spine, status post surgery. The Veteran reported he had no history of trauma. The examiner noted the Veteran had worked as a heavy equipment operator for 39 years, and this would be the more likely cause of his neck problem and symptoms reported in 2009. On July 2013 VA examination for a muscle injury, it was noted that the Veteran did not currently have, nor had ever had a diagnosis of, a muscle injury. He did not have an injury to the muscle groups of the feet, legs, forearms or hands. On VA skin examination in July 2013, the examiner stated she reviewed the claims folder and the electronic records. She observed that no skin condition was noted historically, and indicated that the Veteran did not then have a skin disorder. The examiner concluded that based upon her evaluation (and the April 2013 VA examination) the Veteran did not have any clinical manifestations of illness that would be related to asbestos or Agent Orange exposure. It was noted that he had COPD due to smoking. The examiner stated that no muscle or joint illnesses related to asbestos or herbicide exposure were found, and the Veteran did not report or identify such during her evaluation. She added that the April 2013 examination found that no prostate, bladder or erectile dysfunction issues that would be clinically considered to be related to asbestos or herbicide exposure, and that the Veteran was not claiming this currently. She reiterated the conclusion that the Veteran's work in heavy labor would be deemed the likely cause of his neck disorder found prior to the 2009 surgery. Respiratory disorder There are no laws or regulations that specifically address the adjudication of claims seeking service connection for disability due to asbestos exposure. However, the VA Adjudication Procedure Manual, M21-1 MR, and opinions of the United States Court of Appeals for Veterans Claims (Court) and General Counsel provide guidance in adjudicating these claims. The Court has held that VA must analyze an appellant's claim for service connection for asbestosis or asbestos-related disabilities under the appropriate administrative guidelines. Ennis v. Brown, 4 Vet. App. 523 (1993); McGinty v. Brown, 4 Vet. App. 428 (1993). The adjudication of a claim for service connection for a disability resulting from asbestos exposure should include a determination as to whether or not: (1) service records demonstrate the Veteran was exposed to asbestos during service; (2) development has been accomplished sufficient to determine whether or not the Veteran was exposed to asbestos either before or after service; and (3) a relationship exists between exposure to asbestos and the claimed disease in light of the latency and exposure factors. VA Manual at Subsection (h). The relevant factors discussed in the manual must be considered and addressed by the Board in assessing the evidence regarding an asbestos related claim. See VAOPGCPREC 4-2000. In 1988, VA issued a circular on asbestos-related diseases providing guidelines for considering asbestos compensation claims. See Department of Veterans Benefits, Veterans' Administration, DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988). The information and instructions contained in the DVB Circular since have been included in VA Adjudication Procedure Manual, M21-1 MR, part IV, Subpart ii, Chapter 2, Section C (December 13, 2005). In this regard, the M21-1 MR provides the following non-exclusive list of asbestos-related diseases/abnormalities: asbestosis, interstitial pulmonary fibrosis, tumors, effusions and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum, lung cancer, bronchial cancer, cancer of the larynx, cancer of the pharynx, cancer of the urogenital system (except the prostate), and cancers of the gastrointestinal tract. See M21-1 MR, part IV, Subpart ii, Chapter 2, Section C, 9 (b). The M21-1 MR also provides the following non-exclusive list of occupations that have higher incidence of asbestos exposure: mining, milling, work in shipyards, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, and manufacture and installation of roofing and flooring materials, asbestos cement sheet and pipe products, and military equipment. See M21-1 MR, part IV, Subpart ii, Chapter 2, Section C, 9 (f). The Board notes that the M21-1 MR provides that a clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. Symptoms and signs include dyspnea on exertion, end-respiratory rales over the lower lobes, compensatory emphysema, clubbing of the fingers at late stages, and pulmonary function impairment and cor pulmonale that can be demonstrated by instrumental methods. See M21-1 MR, part IV, Subpart ii, Chapter 2, Section C, 9 (e). Notably, a governing statue (38 U.S.C.A. § 1103) prohibits a finding that a disability is due to disease or injury incurred or aggravated in service on the basis that such disability resulted from the use of tobacco products in service. The Veteran alleges he has a respiratory disorder that is due to exposure to either asbestos or to Agent Orange in service. The Veteran served in Vietnam, and is presumed to have been exposed to Agent Orange in service. 38 U.S.C.A. § 1116(f). Service personnel records show he served in a flame service unit; therefore, it may reasonably be assumed that he was exposed to asbestos in service. During the hearing before the undersigned in May 2012, the Veteran testified he had trouble breathing when he returned from Vietnam; he stated he did not see a doctor for such problem until around 2006. His allegations regarding breathing problems in service are inconsistent with his denial of such problems on service separation, and with no findings of lung or chest abnormality on service discharge examination in January 1970, when a chest X-ray was also normal. Furthermore, examination for Reserve service in September 1977 also did not find any breathing problems, and a chest X-ray at the time was negative. Such allegations are also self-serving, and the Board finds them not credible. The first indication of record that the Veteran had problems breathing is contained in a November 2001 letter from VA listing his complaints. It was then noted that a chest X-ray showed COPD and asbestos exposure. As noted above, in July 2013, a VA physician concluded the Veteran did not have any clinical illness that could be related to exposure to asbestos or Agent Orange. She also concurred with the opinion of the April 2013 VA examiner that the Veteran's COPD is due to smoking and not any other exposure. The Board has reviewed the opinion of Dr. Wait, the Veteran's private physician, who noted the Veteran had complaints of a respiratory condition and that such was highly likely it stemmed from his duties in service. An evaluation of the probative value of a medical opinion is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusions reached. The credibility and weight to be attached to such opinions are within the providence of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed by the physicians and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). Dr. Wait listed the Veteran's complaints, but did not provide a diagnosis of a respiratory disability based on his own examination findings. He simply stated the complaints were due to service. While he apparently had access to some of the Veteran's records (though it is not clear whether he reviewed any service treatment records), his opinion reflects that he relied on the Veteran's accounts, and does not reflect a review of the entire record, or familiarity with the Veteran's complete disability picture. Significantly Dr. Wait did not acknowledge the veteran's history of tobacco use, and does not appear to have considered that his respiratory problem might be related to such use. Furthermore, the opinion is unaccompanied by rationale for the stated conclusion. Therefore, it is lacking in probative value. The Board finds the April and July 2013 opinions of the VA examiners warrant the greater probative weight. They indicated that there were insufficient findings to support a diagnosis of asbestos-related lung disease, and attributed the Veteran's COPD to smoking. As is noted above, service connection for a disability based on use of tobacco products is prohibited by Statute (38 U.S.C.A. § 1103). The July 2013 VA examiner specifically concluded the Veteran did not have any respiratory disability that was associated with asbestos exposure. This conclusion is buttressed by the opinion of the August 2008 VA examiner (whose rationale regarding the diagnosis or nondiagnosis of an asbestos-related lung illness the Board finds to be the most complete of those in the record, and persuasive). The August 2008 VA examiner provided a thorough explanation of why the lung pathology found was inconsistent with a diagnosis of asbestosis. Accordingly, the Board finds the VA opinions to be the more probative evidence, and persuasive. As mentioned above, the Veteran appears to be claiming his respiratory disability might be related to his exposure to Agent Orange in service. VA has determined that certain diseases are associated with exposure to Agent Orange. Although the Veteran did serve in Vietnam, there is no clinical evidence in the record that he has respiratory cancer. See 38 C.F.R. § 3.309(e). COPD is not among the disease listed in § 3.309(e) as related to herbicide exposure. Notably, a VA examiner specifically concluded in July 2013 that the Veteran did not have a disability related to Agent Orange. The Veteran's assertions that he has a respiratory disorder that is related to service, to include exposure to asbestos or Agent Orange, are not competent evidence in the matter. While he is competent to report his symptoms, the diagnosis and etiology of a respiratory disorder such as COPD are matters that fall outside the realm of resolution by lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). They require medical expertise. The Veteran has not submitted any probative (as the medical opinion he has submitted is unaccompanied by rationale and is based on an incomplete factual background) medical opinion or medical literature evidence supporting that his respiratory problems are related to asbestos or Agent Orange exposure. Accordingly, the Board finds that the preponderance of the evidence is against this claim for service connection for a respiratory disorder. Prostate, bladder and skin disabilities, and erectile dysfunction The Veteran asserts he has prostate, bladder and skin disabilities, as well as erectile dysfunction that are related to his service, including as due to exposure to Agent Orange therein. At the May 2012 hearing, he testified his legs itched when he was in Vietnam and that he had a rash which he claimed has been present since. He also testified that his erectile dysfunction began approximately one month after he returned from Vietnam. He stated that he began having bladder problems after his return from Vietnam. Service treatment records show that on several occasions during service the Veteran was seen/treated for urethritis/ burning on urination. However, no pertinent abnormalities were reported or noted on service separation examination in January 1970, and for many years following service there was no indication of problems related to the prostate, bladder, erectile dysfunction or a skin disability. The Veteran's allegations that his disabilities have been present since service are undermined by the fact that on both service separation examination in January 1970 and on examination for Reserve service in September 1977 the genitourinary system and skin were normal. The initial reference in the record to erectile dysfunction is in January 2002; and on 2010 VA examination the Veteran reported only a 5-10 year (hence beginning at best some 30 years postservice) history of partial erectile dysfunction. Therefore the reported self-observations of continuing erectile dysfunction beginning in service and continuing since are found to not be credible. Significantly, on March 2010 VA genitourinary examination, the examiner concluded the Veteran's urethritis in service was acute and transitory and resolved. He observed that it did not involve the bladder. He added the Veteran's erectile dysfunction is due to decreased libido and is age-appropriate. A bladder disability was not found on examination. The examiner noted the Veteran had BPH, and opined that any genitourinary condition was not related to service. Further, an April 2013 VA genitourinary examination found that the Veteran did not have a voiding dysfunction, urinary tract infection or prostate cancer. The examiner stated the Veteran's erectile dysfunction was iatrogenic. Thus, a bladder disorder is not been shown at any time during the pendency of the instant claim (or for that matter at any time since the Veteran's discharge from active duty service). In Brammer v. Derwinski, 3 Vet. App. 223 (1992), the Court noted that Congress specifically limited entitlement to service-connection to cases where disease or injury in service resulted in a chronic disability. In the absence of proof of a present disability, there is no valid claim of service connection. The only evidence supporting the Veteran's assertions is in the January 2009 statement from Dr. Wait. He noted the Veteran provided a list of complaints, which included bladder weakness and erectile dysfunction. Dr. Wait stated that based on examination, a review of records and numerous visits for similar complaints, the Veteran's ailments were chronic. He opined it was highly likely the conditions stemmed from service. While Dr. Wait recounted the Veteran's complaints, he did not provide physical examination findings or offer diagnoses of specific disability underlying the findings. The Veteran has been shown to have BPH, but this was initially demonstrated many years after service, and there is no clinical evidence relating it to service. Erectile dysfunction was first reported many years following the Veteran's discharge from service. The Board concludes the findings and opinions reported on the VA examinations in March 2010 and April 2013 have much greater probative value than the statement from Dr. Wait (which is conclusory and unaccompanied by rationale) or the Veteran's own allegations regarding either the existence or the etiology of any claimed disability. The fact remains the evidence does not show that the Veteran has a chronic bladder disability, and both BPH and erectile dysfunction were first manifested or diagnosed many years following service, and are not shown to be etiologically related to service. Regarding the claim of service connection for a skin disability, claimed as a rash on the legs, the Veteran's service treatment records are silent for such complaints or findings. In fact, he specifically denied having a skin disease on service separation examination in January 1970 and on Reserve service examination in September 1977, contradicting his recent allegations that he had onset of skin problems in service and continuity since. His more recent accounts alleging onset in, and continuity of complaints from, service are, therefore, found not credible. Dr. Wait's statement that the Veteran had a complaint of a rash on his legs is the only post-service reference to a skin problem; however, he did not provide a diagnosis of a skin disorder at the time. In this regard, the Board notes that the July 2013 VA examination of the found the Veteran did not have a skin disability. The examiner observed that a review of the record also found that no skin disease had been demonstrated. The Veteran's assertions that he has bladder, prostate and skin disabilities, as well as erectile dysfunction, that are related to service, to include as due to exposure to Agent Orange therein, are not competent evidence in these matters. Laypersons are competent to provide opinions on some medical issues. However, diagnosis and etiology of specific bladder, skin and prostate disorders, and erectile dysfunction, fall outside the realm of common knowledge of a layperson. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Veteran appears to be claiming his disabilities might be related to his exposure to Agent Orange in service. The Board notes that the VA has determined that certain diseases are associated with exposure to Agent Orange. Although the Veteran did serve in Vietnam, there is no clinical evidence in the record that he has prostate cancer or chloracne. See 38 C.F.R. § 3.309(e) . In fact, the recent VA examinations specifically found that the Veteran did not have prostate cancer or a skin disability (and a VA examiner who reviewed the record specifically stated the Veteran did not have any illness that is associated with exposure to Agent Orange. In summary the evidence of record establishes that the Veteran does not have bladder or skin disabilities and that BPH and erectile dysfunction became manifest many years after, and are not shown to be related to, his service. Accordingly, the Board finds that the preponderance of the evidence is against the claims for service connection for bladder, prostate and skin disabilities, and for erectile dysfunction. Cervical spine disability, neuropathy of the lower extremities, and bilateral arm and muscle disorders The Veteran asserts that he frequently rode in tanks in service going over rough terrain resulting in his being bounced around and shaken. He states that whenever the tanks were in motion, he braced himself and tried to lock his neck in a rigid position. He maintains this led to his neck condition with pain radiating to his upper extremities. Initially, it is noteworthy that the earliest postservice reference to what might be a pertinent complaint was when the Veteran was seen in a VA outpatient treatment clinic in in November 1999 and reported joint weakness. No specific findings were noted at that time. In March 2007 a private physician noted that the Veteran had bilateral arm pain of two weeks duration. In September 2008 he was noted to have cervical spine stenosis and paresthesias. Dr. Moore reported in October 2008 that the Veteran described cramping in his arms and legs for several years. The Veteran also indicated he had developed these symptoms after leaving Vietnam, and said they had been present for at least 15 years. As noted above, the Veteran underwent surgery for spinal stenosis in June 2009. Significantly, on follow-up evaluation he identified the precipitating factor as a work-related injury. Given that this information was provided in a clinical setting (and with no ulterior motive identified or suggested) it is highly probative evidence regarding a postservice etiological factor for the Veteran's current cervical pathology. His subsequent allegations denying postservice injury and attributing all of his current cervical disability to service/injury therein are therefore considered to be self-serving and not credible. It is also noteworthy also that based on a review of the claims folder, a VA physician opined in July 2013 that the Veteran's cervical degenerative disc disease/spinal stenosis was, more likely than not, related to his work for 39 years as a heavy equipment operator. VA examinations in July 2013found the Veteran does not have either a chronic arm disability or a muscle disability; there is no evidence in the record to the contrary (i.e., showing findings or diagnosis of an arm or muscle disability). In Brammer, 3 Vet. App. 223, the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. In the absence of proof of a present disability, there is no valid claim of service connection for an arm or muscle disability. The Board finds the preponderance of the evidence is against the claims of service connection for cervical spine, bilateral arm and muscle disabilities, and neuropathy of the lower extremities. Accordingly, the appeal seeking service connection for such disabilities must be denied. Rating for PTSD Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). A 100 percent evaluation is warranted for PTSD with 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. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech 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. A 50 percent evaluation is warranted if 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; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. One factor which may be considered is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)); see also Richard v. Brown, 9 Vet. App. 266 (1996); Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. A score of 51 to 60 indicates 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 peer or coworkers). A GAF score of 41 to 50 indicates serious symptoms and serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep job), while a GAF score of 31 to 40 indicates major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). See DSM-IV. In Mauerhan v. Principi, 16 Vet. App. 436 (2002), the Court noted that the list of symptoms in the VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather is to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. It was indicated the regulation requires an evaluation of the effects of the symptoms, and not a search for a set of particular symptoms. On VA psychiatric evaluation in October 2008, it was noted that the Veteran had no history of counseling or inpatient treatment. He related that while he was married, he and his wife each went their own way, and had "not clicked" for years. He said his friendships are quite good and that he had lots of friends at work. He went to many activities of his grandchildren. He asserted there were a couple of people at work he did not get along with. He maintained he did not feel he had any mental health problems. He denied problems with depression, acute anxiety or psychosis. When asked about specific memories about Vietnam, he admitted that at times the memories bothered him, but that he keeps it to himself. He had dreams on occasion, but they did not really bother him. He also reported having some psychological distress, but the symptoms did not appear to the examiner to fall outside the range of normal. He noted he only slept a few hours a night. He had some symptoms of hypervigilance occasionally. He denied significant problems with rage outburst. While he had an occasional startle, it did not seem outside the range of normal limits. He did not like very large crowds, but frequently went into smaller crowd situations. There was no evidence of panic disorder. He worried at times. On mental status evaluation, the Veteran was casually dressed and groomed. He was alert and oriented. His affect was broad-ranged, euthymic. He had good eye contact. His speech was within normal limits. There was no suicidal or homicidal ideation. His thought process was clear, coherent and goal-directed. Thought content was free of any obsessions, compulsions, delusions or hallucinations. There was no evidence of any major concentration or memory disturbances. Insight and judgment were pretty good. The diagnostic impression was there was no acute psychiatric diagnosis. The Global Assessment of Functioning score was 85-95. The examiner commented that while the Veteran had some trauma symptoms regarding Vietnam, the symptoms described fall within normal limits and do not appear to represent psychopathology. There was no acute psychiatric diagnosis. On VA psychiatric evaluation in April 2010 the Veteran again described a problematic relationship with his spouse, noting there were frequent arguments and anger. He did not have much of a social life as the friends with whom he was close had been killed or died. He reported he was close to one friend who he might see one month, but then not for a few months after that. He went to the American Legion three times a week and would talk with some guys, but was not close to them. He spent most of his time watching television. He described problems sleeping, irritability, anger outbursts, being on guard and being easily startled. Mental status evaluation revealed no impairments in thought processes or communication. The Veteran had no formal signs of delusions, hallucinations or other psychotic symptoms. He reported some symptoms that seemed more related to anxiety and hypervigilance, such as seeing things out of the corner of his eyes or hearing things that make him get up and look around the house. His eye contact was within normal limits and he interacted appropriately. He was oriented to person, place and time. He did not describe any obsessive or ritualistic behaviors that interfered with routine activities. The rate and flow of speech were within normal limits, and indicated logical, goal-directed thoughts. He had not had recent problems with impulse control. He denied suicidal or homicidal ideation. He showed symptoms of general anxiety much of the time in terms of hypervigilance and checking behaviors. There were no signs of a panic disorder. He asserted he had significant problems with his memory. His sleep was very disturbed. He described himself as basically socially isolated. He described a life in which he was very anxious and hypervigilant. The examiner stated it appeared his PTSD signs and symptoms had caused deficiencies in work in the form of fighting at work and being verbally reprimand. He had not missed an excessive number of days at work or suffered in terms of work performance. He had also experienced significant family relations problems, and issues of thinking and mood. The diagnosis was PTSD, chronic. The GAF score was 60. The examiner stated that the GAF score rating reflected the fairly moderate level of symptom severity and the fact the Veteran described having few friends and conflicts with co-workers. On VA psychiatric evaluation on November 17, 2011 the Veteran related he maintained relationships with his adult children. He stated his relationship with his wife had declined in the previous four years due to conflict and her possible infidelity. He said he tried to avoid her as much as possible. He alleged she was trying to get back at him for things he did years ago. He claimed he had a close friend from childhood whom he saw twice monthly, but their contact was very limited. He saw friends from work at a social club three times a week. He denied any history of counseling or individual therapy, and remarked he just started complaining about it a year ago, when he was started on medication. He related he recalled several experiences from combat in Vietnam. His symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances. The examiner also noted the Veteran had problems initiating and maintaining sleep associated with hypervigilance. The diagnosis was PTSD, and the Global Assessment of Functioning score was 60. It was reported 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. The examiner commented the Veteran reported regularly reexperiencing memories of combat situations. The Veteran acknowledged his occupational difficulties were primarily related to his physical complaints. While he reported generally functioning normally at work, his difficulty concentrating and sleep disturbance as a function of his hypervigilance and regular irritability in interpersonal situations would likely cause intermittent periods of inability to perform work. A VA medical center letter to the Veteran in November 2011 noted he had completed a clinical interview by telephone. It listed the symptoms the Veteran indicated he was having at least occasionally included sadness or depression, difficulty sleeping, feeling tired or low in energy, and difficulty concentrating. VA outpatient treatment records disclose the Veteran was seen in November 2011 and reported symptoms consistent with PTSD, including extremely disturbing memories and dreams, being upset and re-experiencing events quite a bit, avoiding thoughts and avoiding activities. It was also noted he was irritable, had difficulty concentrating, felt nervous and was easily startled. It was reported in February 2012 that the Veteran continued to decline behavioral health services. On VA psychiatric evaluation in April 2013 the Veteran reported he was forgetful and could not take care of things around the house. He stated there were a number of fires due to his forgetfulness. He related he puts something on the stove, goes downstairs and forgets to turn the stove off. The examiner reviewed the claims folder and commented there was sufficient clinical information to indicate the Veteran has a severe cognitive deficit. He stated he would rate the Veteran's "General Adaptation Functioning" score as 39, and that the Veteran's PTSD symptoms were at least as likely as not to have aggravated an already demented brain, rendering him unemployable. He added the Veteran qualified for an increase in his evaluation for PTSD. The examiner acknowledged his opinion differed from that rendered on the November 2011 VA psychiatric examination. The Veteran denied his comments at that examination that the conflicts with his wife were related to her infidelity, and stated they fought over money. The initial question is whether a rating in excess of 50 percent is warranted for PTSD, prior to November 17, 2011. The Board notes that the Veteran was fully employed at the time of the October 2008 VA psychiatric examination. He related he had many friends at work. Although he described having dreams and memories that bothered him, the examiner commented his symptoms were in the normal range. The examination report discloses no suicidal ideation, obsessional rituals or thought disorder. There was no indication of any panic attacks. The examiner emphasized that the Veteran's symptoms did not rise to the level to warrant a psychiatric diagnosis, and assigned a GAF score of 85-95. This examination report certainly does not support a rating in excess of 50 percent. It reflects there was minimal , if any, impairment of social and occupational functioning due to PTSD, and the GAF score provided, if anything, weighs heavily against the Veteran's claim. It reflects essentially normal functioning. (and does not provide an independent basis for awarding an increased rating). The April 2010 VA psychiatric examination revealed that the Veteran indicated he had a limited social life, and reported he was subject to irritability, anger outbursts and he had difficulty sleeping. It is significant to point out, however, that the examination findings show he had no delusions or hallucinations, and was fully oriented. He did not have any obsessional rituals, problems with impulse control or panic attacks. In addition, there was no suicidal or homicidal ideation. Notably, the Veteran remained employed (and while he reported conflict with co-workers, for which he reported being reprimanded, impaired work performance was not reported. Although his friendships were limited, nonetheless, he apparently maintained some. Such findings do not reflect deficiencies in most areas. Likewise, the GAF score assigned of 60 reflects no more than moderate symptoms/impairment (as the examiner observed), and does not provide an independent basis for an increased rating. The RO assigned a 70 percent evaluation based on the findings recorded on the November 17, 2011 VA psychiatric examination. At that time, it was noted that the Veteran's symptoms included depressed mood, suspiciousness and hypervigilance. Regarding whether a rating in excess of 70 percent for PTSD is warranted from November 17, 2011, the Board notes that the examiner assigned a GAF score of 60 on the November 2011 VA examination. While such score is not dispositive, it is relevant evidence indicating there was no more than moderate disability/impairment of function. The Board acknowledges that VA examiner in April 2013 provided a different assessment of the findings on the November 2011 VA psychiatric examination. The Board notes a 100 percent evaluation is assigned for total occupational and social impairment. In this regard, the Board notes the November 2011 VA psychiatric examination shows the Veteran was able to maintain a relationship with his children (though not his spouse), and he saw friends several times a week. The examiner commented the Veteran had occasional decrease in work efficiency and his symptoms resulted in only intermittent periods of inability to perform work. Significantly, he was still working (weighing quite heavily against a finding of total occupational impairment), and maintained some social relations (albeit not close ones), weighing against a finding of total social impairment. Significantly, the April 2013 did not provide a complete mental status evaluation (the examination primarily addressed whether the Veteran was unemployable). The examiner did not note any of the symptoms commensurate with a 100 percent schedular rating (while the primarily disabling symptom noted was a cognitive impairment, it was not noted to be such as inability to remember own or relative's names, address, occupation). The examiner opined, in essence, that the Veteran is unemployable, and the RO therefore awarded a TDIU rating. (increasing the schedular rating to 70 percent). The GAF score likewise does not provide an independent basis for an increased rating, as (consistent with the symptoms noted), it reflects major, but not total occupational and social impairment. In reviewing the present appeal, the Board has given consideration to all demonstrated symptoms, not merely the examples set forth in the rating criteria. However, the effects of the symptoms shown prior to November 17, 2011 do not result in deficiencies in most areas so as to warrant a rating in excess of 50 percent, and the effects of the symptoms shown since do not reflect total social and occupational impairment so as to warrant a total schedular rating. Finally, the Board has considered whether referral for extraschedular consideration is warranted. The Board notes that all findings and impairment (disturbed sleep, dreams and memories of his Vietnam experiences, and PTSD related cognitive impairment resulting in occupational and social impairment) associated with the PTSD shown are encompassed by the schedular criteria for the ratings assigned. Therefore, those criteria are not inadequate, and referral for consideration of an extraschedular rating is not necessary. See Thun v. Peake, 22 Vet. App. 111 (2008). The Board has considered the applicability of the benefit of the doubt doctrine. As the preponderance of the evidence is against these claims, that doctrine does not apply. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). ORDER The appeal seeking service connection for a respiratory disability, to include as due to exposure to asbestos, neuropathy of the lower extremities, erectile dysfunction, a bladder disability, a prostate disability, a muscle disability, a skin disability (rash on the legs), a cervical spine disability and a bilateral arm disability is denied. Ratings for PTSD in excess of 50 percent prior to November 17, 2011 and in excess of 70 percent from that date are denied. REMAND The Veteran claim she has right knee and low back disabilities as a result of being jostled while riding in tanks in service. Service treatment records show that in January 1969 he was seen for a compliant of right knee pain, and that he had fallen the previous night. Examination revealed point tenderness. The impression was contusion. No further right knee complaints were noted in service, and the separation examination in January 1970 revealed no right knee abnormality. On March 2010 VA examination chronic right knee strain was diagnosed, it was indicated the examination was essentially normal. Private medical records show the Veteran was seen in January 2010 and complained of right knee pain that was gradual in onset. He reported intermittent right knee pain for several years in August 2010. A right knee MRI later that month revealed a torn lateral meniscus and chondromalacia patella. The July 2013 VA examination noted that the Veteran reported no history of a knee condition. The examiner indicated the records were silent in this regard, and stated that the Veteran did not have and never had a knee injury. Since this is inconsistent with the record, the examination and opinion are inadequate for rating purposes, and another examination to secure an opinion that reflects accurate review of the record is necessary. Regarding the claim of service connection for a low back disability, the Board notes that a lumbar spine MRI at a private facility in July 2004 revealed mild degenerative disc disease with no evidence of herniated nucleus pulposus. On July 2013 VA examination the examiner observed that the Veteran had not been diagnosed with a low back condition and the records on review were silent [for such disability]. As the examiner's observation is contradicted by the July 2004 MRI finding, the opinion offered is premised on an inaccurate factual basis, and is inadequate . Accordingly corrective action in the form of a remand for another examination to secure an opinion based on the actual record is necessary. The case is REMANDED for the following: 1. The RO should arrange for the Veteran to be scheduled for an orthopedic examination (by a provider other than the one who conducted the July 2013 examination) to determine the nature and etiology of any current right knee or low back disability. The Veteran's record must be reviewed by the examiner in conjunction with the examination. Based on examination of the Veteran and review of the record the examiner should provide opinions that respond to the following: (a) Please identify (by diagnosis) each low back and right knee disability found. [If a low back disability is not diagnosed, reconcile that finding with the 2004 MRI.] (b) Please identify the likely etiology for each low back and right knee disability entity diagnosed. Specifically, is it at least as likely as not (a 50 % or better probability) that such entity is related to the Veteran's service events therein (riding in a tank) and as to the right knee the injury noted in January 1969. The examiner must explain the rationale for all opinions. 2. The RO should then review the record and readjudicate the remaining claims. If either remains denied, the RO should issue an SSOC and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further appellate consideration. The appellant has the right to submit additional evidence and argument on the r matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs