Citation Nr: 1504272 Decision Date: 01/29/15 Archive Date: 02/09/15 DOCKET NO. 12-07 396 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent disabling for the service-connected bilateral hearing loss. 2. Entitlement to an evaluation in excess of 10 percent disabling for the service-connected left knee degenerative joint disease (DJD) and to include whether a separate rating is warranted for instability. 3. Entitlement to an evaluation in excess of 10 percent disabling for the service-connected right knee DJD and to include whether a separate rating is warranted for instability. 4. Entitlement to an evaluation in excess of 30 percent disabling for the service-connected posttraumatic stress disorder (PTSD). 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 6. Entitlement to special monthly compensation (SMC) based on the need for Aid and Attendance. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD K. L. Wallin, Counsel INTRODUCTION The Veteran had active service from February 1960 to October 1963 and from May 1964 to August 1984. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. The Veteran died in July 2010. The Appellant in this case is the Veteran's surviving spouse who has been properly substituted for the Veteran in accordance with the Veterans' Benefits Improvement Act of 2008, Pub. L. No. 110-389, § 212, 122 Stat. 4145, 4151 (2008) (creating a new 38 U.S.C. § 5121A allowing substitution in the case of the death of a claimant who dies on or after October 10, 2008); 79 Fed. Reg. 52977 (September 5, 2014) (codified at 38 C.F.R. § 3.1010) (2014)). Under this statute, an eligible person may process any pending claims to completion following the death of a veteran. Such request must be filed not later than one year after the date of the Veteran's death and, as provided for in the provision, a person eligible for this substitution will include "a living person who would be eligible to receive accrued benefits due to the claimant under section 5121(a) of this title . . . ." Id; 38 U.S.C.A. § 5121A (West 2002). In August 2010, within a year from the Veteran's death in July 2010, the Appellant filed a request to substitute for the Veteran in the claims under appeal at the time of his death. Thus, the claims listed on the cover page of this decision are properly before the Board with the Appellant substituting for the deceased Veteran. The Board notes that there is a distinction between a claim based on substitution and a claim for accrued benefits. Claims for accrued benefits are limited to consideration of the existing ratings, decisions, and evidence in the claims file at the time of the Veteran's death; additional evidentiary development is generally not appropriate. See 38 C.F.R. § 3.1000(a). In contrast, in a claim for substitution, the appeal continues and additional evidence may be added to the record after the Veteran's death. Therefore, the claims pertaining to PTSD, SMC, and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Based on audiometric test results, the service-connected bilateral hearing loss is shown to be productive of disability resulting in at worse a Level II designation in the right ear under 38 C.F.R. § 4.85, Table VI, and a Level VI designation in the left ear under Table VIa, which results in no more than a 10 percent rating under Table VII. 2. The service-connected right knee disability was not productive of limitation of flexion to 30 degrees or limited of extension to 5 degrees; instability of the right knee was no more than slight. 3. The service-connected left knee disability was not productive of limitation of flexion to 30 degrees or limited of extension to 5 degrees; instability of the right knee was no more than slight. CONCLUSIONS OF LAW 1. The criteria for the assignment of a rating in excess of 10 percent for the service-connected bilateral hearing have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.85, 4.86 including Tables VI -VII (2014). 2. The criteria for an evaluation in excess of 10 percent for the service-connected right knee DJD have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5256-5263 (2014). 3. The criteria for a separate 10 percent rating, and no higher, for instability of the right knee have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Code 5257 (2014). 4. The criteria for an evaluation in excess of 10 percent for the service-connected left knee DJD have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5256-5263 (2014). 5. The criteria for a separate 10 percent rating, and no higher, for instability of the left knee have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Code 5257 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the Veteran's claims. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided pre-adjudication notice by letter dated in June 2009. VA has obtained service treatment and personnel records, assisted in obtaining post-service treatment records, and afforded the Veteran VA examinations. The Board notes that outpatient treatment records from VA Southern Oregon Rehabilitation Center and Clinics dated between 1999 and 2002 are unavailable. See Formal Finding on the Unavailability of Federal Records dated in November 2012. Any further attempts to obtain these records would be futile. 38 C.F.R. § 3.159(c)(2). All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Appellant has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Appellant is not prejudiced by a decision on the claims at this time. II. Analysis The Board has reviewed all the evidence in the virtual record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran/Appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. VA should interpret 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. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. When considering functional impairment caused by a service-connected disorder, evaluations should be based on an assessment of the lack of usefulness, and adjudicators should consider the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath, 1 Vet. App. at 594. Separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). The Court has held that functional loss, supported by adequate pathology and evidenced by visible behavior of the veteran undertaking the motion, is recognized as resulting in disability. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.10, 4.40, 4.45. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). Bilateral Hearing Loss Assignments of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. 38 C.F.R. §§ 4.85, 4.86, Tables VI, VIA, VII. Audiometric evaluations are conducted using the controlled speech discrimination tests together with the results of the puretone audiometry test. 38 C.F.R. § 4.85(a). Numeric designations (I through XI) are assigned by application of Table VI, in which the percentage of discrimination is intersected with the puretone decibel loss. 38 C.F.R. § 4.85, Table VI. The results are then applied to Table VII, for a percentage rating. Id. "Puretone threshold average," as used in Tables VI and VIA, is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four. This average is used in all cases (including those in § 4.86) to determine the Roman numeral designation for hearing impairment from Table VI or Table VIA. 38 C.F.R. § 4.85(d). Under 38 C.F.R. § 4.86, evaluation of veterans with certain patterns of exceptional hearing impairment is contemplated. In the case where puretone thresholds are 55 decibels or more at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz), either Table VI or Table VIA is applied, and whichever results in the higher numeral shall be applied. 38 C.F.R. § 4.86(a). In addition, when the puretone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, the higher numeral of Table VI or Table VIA is also applied. 38 C.F.R. § 4.86(b). The Board has thoroughly reviewed all the evidence of record and after careful consideration, finds that the preponderance of the evidence is against a finding that the Veteran's bilateral hearing loss warrants a rating in excess of the 10 percent evaluation assigned. See 38 C.F.R. §§ 4.3, 4.7; see Hart, supra. In this regard, a June 2009 audiogram contained puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 45 45 55 75 90 LEFT 40 60 70 80 95 The Veteran's right ear manifested an average puretone threshold of 66.25 (rounded to 66) decibels and the left ear manifested an average puretone threshold of 76.25 (rounded to 76). Speech discrimination was 92 percent in the right ear and 94 percent in the left ear. The right ear test results translate to a Level II designation and the left ear tests results translate to a Level II designation under Table VI for hearing impairment based on puretone threshold average and speech discrimination. See 38 C.F.R. § 4.85(d). Together a Level II and a Level II results in a noncompensable rating under 38 C.F.R. § 4.85, Table VII. However, the Board has considered whether the Veteran's hearing loss fell into one of the exceptional patterns that would allow for employment of a different Table. The Veteran's sensorineural hearing loss in the left ear did fall under the exceptional patterns of hearing loss as contemplated under 38 C.F.R. § 4.86(a), as each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) were 55 decibels at each threshold or more. When applying the Veteran's numeric designation of hearing impairment under Table VIa, the left ear test result translates to a Level VI designation. Together a Level II and a Level VI results in a 10 percent rating. The left ear did not fall under the exceptional patterns of hearing loss contemplated under 38 C.F.R. § 4.86(b); the puretone thresholds were not 30 decibels or less at 1000 Hertz, though 70 decibels at 2000 Hertz. 38 C.F.R. § 4.86(b). The right ear did not fall under either exceptional pattern of hearing loss. The claim hinges on a mechanical application of specifically defined regulatory standards. Although the Board is mindful of the Veteran's description of his hearing loss prior to his death; regrettably, the Board is bound by the very precise nature of the laws governing evaluations of hearing loss disability. Accordingly, the claim of entitlement to a rating in excess of 10 percent must be denied. Bilateral Knee DJD Included within 38 C.F.R. § 4.71a are multiple diagnostic codes that evaluate impairment resulting from service connected knee disorders, including Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of semilunar cartilage), Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum). Additionally, if the knee condition involves arthritis, the knee disability may be rated under provisions for evaluating arthritis. Arthritis due to trauma is rated as degenerative arthritis according to Diagnostic Code 5003. Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, the disability is to be rated as follows: with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, 20 percent; with X- ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Relevant criteria, under applicable Diagnostic Codes are as follows: A 60 percent evaluation may be assigned for extremely unfavorable ankylosis of a knee in flexion at an angle of 45 degrees or more. A 50 percent evaluation may be assigned for ankylosis of a knee between 20 degrees and 45 degrees. A 40 percent evaluation may be assigned for ankylosis of a knee in flexion between 10 degrees and 20 degrees. A 30 percent evaluation may be assigned for ankylosis of a knee at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. 38 C.F.R. § 4.71a; Diagnostic Code 5256. For other knee impairment, recurrent subluxation or lateral instability of the knee, a severe case is to be rated 30 percent disabling; a moderate case is to be rated 20 percent disabling. For a slight case a 10 percent rating is appropriate. 38 C.F.R. § 4.71a, Diagnostic Code 5257. A 20 percent rating is assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Limitation of flexion of the leg to 60 degrees warrants a 0 percent rating. When flexion is limited to 45 degrees, a 10 percent rating is assigned. A 20 percent rating is appropriate where flexion is limited to 30 degrees. A 30 percent rating is appropriate where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of the leg to 5 degrees warrants a 0 percent rating. When extension is limited to 10 degrees, a 10 percent rating is assigned. A 20 percent rating is appropriate where extension is limited to 15 degrees. A 30 percent rating is appropriate where extension is limited to 20 degrees. A 40 percent rating is appropriate where extension is limited to 30 degrees. A 50 percent rating is appropriate where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Impairment of a tibia and fibula with slight knee or ankle disability may be assigned a 10 percent evaluation. Impairment of a tibia and fibula with moderate knee or ankle disability may be assigned a 20 percent evaluation; impairment of a tibia and fibula with marked knee or ankle disability may be assigned a 30 percent evaluation and nonunion with loose motion requiring a brace or malunion may be assigned a 40 percent evaluation. 38 C.F.R. § 4.71a; Diagnostic Code 5262. According to VA standards, normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. See 38 C.F.R. § 4.71, Plate II (2014). Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The VA Office of General Counsel has stated that compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 (degenerative arthritis) does not constitute pyramiding. VAOPGCPREC 23-97 (July 1, 1997). See also VAOPGCPREC 9-04 (which finds that separate ratings under Diagnostic Code 5260 for limitation of flexion of the leg and Diagnostic Code 5261 for limitation of extension of the leg may be assigned for disability of the same joint). The Veteran's knees have been assigned 10 percent ratings under Diagnostic Codes 5260 and 5010. In order to afford the broadest scope of review, and to ensure that each separate disability involving the knee is evaluated properly, the Board shall consider the service-connected symptomatology involving the knees under each and every applicable Diagnostic Code that provides rating criteria for evaluating knee disabilities. The pertinent facts found in the medical evidence of record are discussed below. Having carefully considered the claims in light of the evidence of record and the applicable laws and regulations, and as outlined in the reasons and bases below, the Board finds that the bilateral knee disabilities do not warrant ratings in excess of 10 percent for DJD based on limitation of motion. As will be explained in greater detail below, separate 10 percent ratings are warranted for slight instability of the bilateral knees. 38 C.F.R. § 4.7. In rating the Veteran's knee disability, the Board notes that under Diagnostic Code 5010, traumatic/degenerative arthritis established by x-ray findings is rated according to limitation of motion for the joint or joints involved. The criteria for rating extension and flexion of the knee are found at Diagnostic Codes 5260 and 5261, and detailed above. Here, review of the evidence shows that flexion was at worse limited to 125 degrees upon VA examination in June 2009 (flexion was full in outpatient treatment records dated in May 2009). This does not meet the criteria for a noncompensable rating let alone the criteria established for a 20 percent rating under Diagnostic Code 5260 (flexion limited to 30 degrees). Extension was full upon VA examination in 2009, which does not even meet the criteria established for a noncompensable rating under Diagnostic Code 5261. 38 C.F.R. § 4.71a. Thus, the criteria do not provide for ratings in excess of 10 percent for limited flexion or an additional separate ratings based on actual limitation of extension for either knee. 38 C.F.R. §§ 4.7, 4.25, 4.71a; See also VAOPGCPREC 23-97 (July 1, 1997, revised July 24, 1997); VAOPGCPREC 9-98 (Aug. 14, 1998); VAOPGCPREC 9-04 (September 17, 2004). The Board considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, the Veteran did not have pain on active range of motion or repetitive testing. There was some fatigue with repetition, but no additional functional loss. There was no evidence of incoordination or weakness of the knees. The complaints of pain reported at the outset of the examination in 2009 are clearly accounted for in the current 10 percent ratings as the Veteran's limitation of flexion did not even meet the criteria for even a noncompensable rating under this code section. 38 C.F.R. § 4.71a. The same can be said of limitation of extension. Turning next to disability due to instability, the June 2009 VA examination report noted bilateral laxity both medially and laterally by approximately five millimeters. It was classified as mild. There was no evidence of recurrent patellar subluxation or dislocation. Accordingly, there is a basis for providing separate 10 percent ratings, and no higher, for instability of the left and right knees under Diagnostic Code 5257. 38 C.F.R. § 4.71a. The Board has considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, 38 C.F.R. §§ 4.40 and 4.45, with respect to pain, are inapplicable to ratings under Diagnostic Code 5257 because it is not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7, 12 (1996). The Board has also considered other potentially applicable diagnostic codes that provide for the assignment of higher evaluations for the Veteran's bilateral knee disability. After review, however, the Board observes that no other code provisions can be applied for higher ratings based on the evidence of record. There was no evidence of ankylosis of the knees (Diagnostic Code 5256), dislocated or removal of symptomatic semilunar cartilage (Diagnostic Codes 5258, 5259) or impairment of the tibia and fibula (Diagnostic Code 5262). 38 C.F.R. § 4.71a. As such, based on its review of the medical evidence, the Board finds that ratings in excess of 10 percent are not warranted for either the left or right knee DJD productive of limitation of flexion under Diagnostic Codes 5010 and 5260. Separate ratings for limitation of extension are also not warranted under Diagnostic Code 5261. There was evidence of no more than slight instability of the bilateral knees to warrant separate 10 percent ratings under Diagnostic Code 5257. 38 C.F.R. §§ 4.7, 4.25, 4.71a; See also VAOPGCPREC 23-97 (July 1, 1997, revised July 24, 1997); VAOPGCPREC 9-98 (Aug. 14, 1998); VAOPGCPREC 9-04 (September 17, 2004). "Staged" ratings, other than what is already in effect, are not warranted for any period of the appeal. 38 C.F.R. § 4.71a; see Hart, supra. TDIU and Extraschedular Considerations The Court has held that, when evidence of unemployability is presented, the issue of whether a total compensation rating based on individual unemployability (TDIU) will be assigned, should be handled during the determination of the initial disability rating assigned at the time disabilities are determined to be service connected. See Rice v. Shinseki, 22 Vet. App. 447, 452-53 (2009). In Rice, the Court determined that there is no freestanding claim for a TDIU rating. Id. at 451. The issue of TDIU is addressed in the Remand portion below. The above determinations are based upon application of the pertinent provisions of VA's rating schedule. The Board finds that the record does not reflect that the Veteran's service-connected bilateral hearing loss and knee disabilities are so exceptional or unusual as to warrant the assignment of a higher rating on an extra- schedular basis. See 38 C.F.R. § 3.321(b)(1) (2014). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). In this case, the Board finds that the rating criteria used to evaluate the Veteran's service-connected bilateral hearing loss and knees reasonably described his disability level and symptomatology. As noted above, the hearing loss claim hinges on a mechanical application of specifically defined regulatory standards. The criteria with respect to the knees allow for ratings based on functional loss (due to such symptoms as pain), limitation of flexion, limitation of extension, and instability of the knee. Diagnostic Codes 5257, 5260, 5261. Even considering complaints of pain, the Veteran did not even meet the criteria for a compensable rating for limitation of flexion. There was no evidence of limitation of extension. There was no change in range of motion even after repetitive testing. Instability of the knees was only shown to be slight. Therefore, the Veteran's disability picture was contemplated by the rating schedule and no extraschedular referral is required. 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). ORDER Entitlement to an evaluation in excess of 10 percent disabling for the service-connected bilateral hearing loss is denied. Entitlement to an evaluation in excess of 10 percent disabling for the service-connected right knee DJD is denied. Entitlement to an evaluation in excess of 10 percent disabling for the service-connected left knee DJD is denied. Entitlement to a separate 10 percent rating for instability of the right knee is granted subject to the controlling regulations governing monetary awards. Entitlement to a separate 10 percent rating for instability of the left knee is granted subject to the controlling regulations governing monetary awards. REMAND A preliminary review of the record finds that the claims for PTSD, SMC, and TDIU are not ready for appellate review. The Veteran was afforded a VA PTSD examination in June 2009. The examiner was asked to identify all signs and symptoms attributable to the service-connected PTSD, as well as other co-existing mental disorders and if so, discuss their relationship with the Veteran's PTSD. The examiner noted considerable memory loss and dementia; however, the examiner failed to discuss their relationship with the Veteran's PTSD. Hence, an addendum opinion is necessary. See McClendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4). Consideration of the SMC and TDIU issues are deferred since the outcome of the PTSD issue may impact them. The RO should ensure that all due process requirements are met. The RO should also give the Appellant another opportunity to present information and/or evidence pertinent to the claims on appeal. 38 U.S.C.A. § 5103A (b) (West 2002). Accordingly, the case is REMANDED for the following action: 1. Obtain an addendum opinion from the June 22, 2009, VA PTSD examiner (TLV), if available. Otherwise, the opinion must be rendered by a similarly qualified provider. The examiner should offer an opinion in response to the following: is it at least as likely as not (a 50% or higher degree of probability) that all or part of the Veteran's memory loss/dementia was proximately due to, the result of, or aggravated by (chronically worsened beyond the natural progression of the disease) the Veteran's PTSD? The examiner should indicate whether it is possible to discern which signs and symptoms were attributable to PTSD and which were attributable to the memory loss/dementia at the time of examination in 2009. Note: if the examiner concludes that there is insufficient information to provide an etiology opinion without resorting to mere speculation, the examiner should state whether the inability to provide a definitive opinion was due to a need for further information (please identify) or because the limits of medical knowledge had been exhausted regarding the etiology of the claimed conditions. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 2. After completing the requested actions, and any additional notification and/or development deemed warranted, the RO should readjudicate the issues in light of all evidence of record. If any benefit sought on appeal remains denied, the RO must furnish to the Appellant and her representative with an appropriate supplemental statement of the case and afford a reasonable opportunity for response. The Appellant has the right to submit additional evidence and argument on the matter or 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 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 2014). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs