Citation Nr: 1517936 Decision Date: 04/27/15 Archive Date: 05/05/15 DOCKET NO. 13-13 701 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a left leg and foot disorder, claimed as muscle tingling and pain. 3. Entitlement to service connection for a right leg and foot disorder, claimed as muscle tingling and pain. REPRESENTATION Veteran represented by: Daniel Smith, Attorney at Law ATTORNEY FOR THE BOARD A. Zenzano, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1966 and February 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Board notes that, in addition to the issues listed on the title page, the Veteran's appeal initially included entitlement to service connection for tinnitus. However, in an April 2013 rating decision, the RO granted service connection for tinnitus. Since this constitutes a full grant of the benefits sought on appeal, such claim is no longer in appellate status. Grantham v. Brown, 114 F.3d. 1156 (Fed. Cir. 1997). Additionally, the Board observes that the Veteran was scheduled for a Board video-conference hearing before a Veterans Law Judge in December 2013. However, in correspondence dated in November 2013, he withdrew his request for a Board hearing. 38 C.F.R. §§ 20.702(e), 20.704(e) (2014). The Board further notes that the Veteran via his attorney submitted additional evidence in January 2014 with a waiver of agency of original jurisdiction (AOJ) consideration. 38 C.F.R. § 20.1304(c). Therefore, the Board may properly consider such newly received evidence. In addition to the paper claims file, there are paperless, electronic (Virtual VA and Veterans Benefits Management System (VBMS)) claims files associated with the Veteran's claims. A review of the electronic files reveals that, with the exception of VA treatment records dated through November 2012, which were considered by the RO in the April 2013 statement of the case, and the aforementioned withdrawal of the Veteran's hearing request, they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The issues of entitlement to a left and right leg and foot disorder, claimed as muscle tingling and pain, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDING OF FACT For the entire appeal period, the Veteran's PTSD results in social and occupational impairment with reduced reliability and productivity due to a myriad of symptoms, including sleep impairment, disturbances in motivation and mood, anger and irritability, social withdrawal, and difficulty establishing and maintaining effective social and work relationships, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. CONCLUSION OF LAW The criteria for an initial 50 percent rating, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.125, 4.130, Diagnostic Code 9411 (2014). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. As relevant to the Veteran's underlying service connection claim, VA has satisfied its duty to notify under the VCAA. Specifically, September 2009 and December 2009 letters, sent prior to the initial decision issued in June 2010, advised the Veteran of the evidence and information necessary to substantiate his service connection claim as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Thereafter, the June 2010 rating decision granted service connection for PTSD and assigned an initial 30 percent rating. The Veteran subsequently appealed with respect to the propriety of the initially assigned rating. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claim for service connection for his PTSD was granted and an initial rating was assigned in the June 2010 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Next, VA has a duty to assist a Veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). As relevant, the Veteran's post-service VA treatment records have been obtained and considered. The Board notes that the Veteran reported receiving treatment for conditions other than PTSD at the White County Medical Center. The RO attempted to obtain records from that facility on two occasions, however they were informed that the medical center had no records for the Veteran. The Veteran was advised of such in June 2010 and April 2013 rating decisions, along with the April 2013 statement of the case. As there is no suggestion that such records are relevant to the Veteran's PTSD claim, and the Veteran has been informed of the RO's inability to obtain such records, the Board finds no prejudice to him in proceeding to a decision on his claim. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran was afforded VA examinations in March 2010 and October 2012 in order to assess the severity of his PTSD. The Board finds that such examinations are adequate in order to evaluate the Veteran's service-connected PTSD as they include an interview with the Veteran, a review of the record, and a full physical examination, addressing the relevant rating criteria. The Board notes that the Veteran has not alleged worsening since the October 2012 VA examination. In this regard, while he has claimed that his PTSD is worse than the current 30 percent rating, he has not contended that the condition has increased in severity since the October 2012 VA examination. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (mere passage of time not a basis for requiring of new examination). Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's initial rating claim and no further examination is necessary. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected PTSD is evaluated as 30 percent disabling, effective July 21, 2009, under the criteria of Diagnostic Code 9411. See 38 C.F.R. § 4.130. Under this regulatory provision, a 30 percent rating contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occasional tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating contemplates 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; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent is warranted when the Veteran experiences occupational and social impairment, with deficiencies in most area, 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 work like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. The Board recognizes that, in Mauerhan v. Principi, 16 Vet. App. 436 (2002), the Court stated that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. However, the Court further indicated that without those examples, differentiating a 30 percent evaluation from a 50 percent evaluation would be extremely ambiguous. Id. at 442. In Vasquez-Claudio v. Shinseki, F.3d 112, 117 (Fed. Cir. 2013), the Court also held that a Veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. The Court further held that, in assessing whether a particular disability rating is warranted requires a two-part analysis, including (1) an initial assessment of the symptoms displayed by the Veteran and, if they are of the kind enumerated in the regulation and (2) an assessment of whether those symptoms result in the occupational and social impairment contemplated by that particular rating. See Id. at 118. Indeed, considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). A GAF score between 31to 40 is indicated when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 indicates moderate symptoms, or moderate difficulty in social, occupational, or school functioning. A GAF score of 61 to 70 reflects 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 with some meaningful interpersonal relationships. The pertinent evidence of record consists of VA examinations conducted in March 2010 and October 2012, VA outpatient treatment records, and lay statements from the Veteran and his family. During the March 2010 VA examination, the Veteran reported anger, anxiety, irritability, sadness, sleep disturbances and difficulty concentrating. He stated he had difficulty at work and at home due to such symptoms, and he reported feeling emotionally detached and losing interest in activities that he previously enjoyed. The Veteran reported that he was married and that he had a few friends that he enjoys playing cards with, but described an increasing level of social isolation, as such interactions caused him discomfort. He also stated that he is in a fairly isolated work position and tried to avoid interactions with others at work. He reported occasional suicidal ideation, but denied a plan or intent. He conveyed an ability to carry out activities of daily living. Upon examination, he was alert, oriented and cooperative. His mood appeared depressed and his affect blunted. Hist thoughts were clear and goal oriented. The was no evidence of delusions or hallucinations. Memory and judgment were intact and his speech and communication was appropriate. Grooming and hygiene was appropriate. There was no panic, paranoia or obsessional rituals; however, ongoing hypervigilance was noted. The Veteran was diagnosed with PTSD and assigned a GAF score of 55. In October 2012, the Veteran underwent another VA examination. It was noted that the Veteran still lived with his wife of 47 years, and occupied himself by working on the computer, writing poetry and doing household maintenance. He also reported meeting with friends once every 2-3 weeks to play cards and attending church services. The Veteran reported full-time work at his current job for the past 7 years and that he worked alone and intended to stay as long as possible at his current job. In assessing the Veteran's PTSD, the examiner noted that the Veteran suffered from distressing dreams, feeling detached from others, a markedly diminished interest in significant activities, restricted range of affect, sleep difficulties, irritability or outburst of anger, difficulty concentrating and hypervigilance. The examiner assessed the Veteran's PTSD as causing 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 following symptoms were noted: depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships and suicidal ideation. The Veteran was again diagnosed with PTSD and assigned a GAF score of 55. In statements submitted by the Veteran, he described his anger, hypervigilance, lack of motivation, difficulties at work and being withdrawn from his family. He further described his hopelessness and despair over the state of his life. Statements submitted by his family similarly describe his depression, social isolation, strained relationships, anger, feelings of hopelessness, problems sleeping and hypervigilance. VA outpatient treatment notes reflect that the Veteran has been oriented to person, place and time and groomed appropriately during each visit. During a November 2008 mental health consultation, the Veteran described problems sleeping and stated that he was drifting apart from his wife and was not close with his children. He screened positive for depression and PTSD. Upon examination, his speech was clear, coherent and relevant, and his affect pleasant and constricted. His mood was depressed, anxious and irritable. His thoughts were coherent, relevant and circumstantial, but vague at times. Hallucinations, delusions, homicidal/suicidal intent and obsessions were denied. His memory and insight were fair, his judgement and impulse control were poor. The Veteran was assigned a GAF score of 45. A December 2008 mental health consult reflects some improvement, with the Veteran reporting that a change in medication was helpful. He was sleeping better, had no recent nightmares, and his irritability had decreased. However, there was no change in his relationship with his wife or coworkers. The clinician noted that the Veteran was smiling more and kidding around. A GAF score of 55 was assigned. Continued improvement was seen in February 2009, when the Veteran reported he was having card games again, talking with his wife, and had been helping a neighbor. His speech was clear, attitude was cooperative and mood euthymic. His affect was pleasant and appropriate with good stability and his thoughts were coherent, goal-directed and had good continuity. Insight, judgment, impulse control and memory were good. Hallucinations, delusions, homicidal/suicidal intent, and obsessions were denied. A GAF score of 75 was assigned. In November 2011, the Veteran underwent a depression screen which was negative. A September 2012 suicide screen was negative. In November 2012, during a routine checkup, the Veteran reported, "I always have a little depression, worse in winter." After resolving all doubt in favor of the Veteran, and after considering the lay and medical evidence of record, the Board finds that the schedular criteria for a 50 percent rating are met for the entire appeal period. In this respect, the credible lay and medical evidence establishes that the Veteran's service-connected PTSD has more nearly approximated occupational and social impairment with reduced reliability and productivity due to impairment of affect, memory, judgment, disturbance of motivation and mood with difficulty in establishing and maintaining effective social relationships. However, such is not manifested by more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. In making the determination that a 50 percent rating is warranted from the date of service connection of July 21, 2009, the Board notes that the symptoms listed in the criteria are meant not as an exhaustive list of symptoms, but rather, as examples of the type and degree of the symptoms or effects that would justify a particular rating. See, e.g., Mauerhan. It is the impact of a Veteran's psychiatric symptoms on occupational and social functioning that is of primary importance, and from the clinical evidence, including VA outpatient treatment notes, which include some GAF scores of 45, statements from the Veteran and his family, and VA examinations which reveal a flattened affect, impaired judgment, disturbance of motivation and mood and difficulty in establishing and maintaining effective work and social relationships, it cannot be said that the preponderance of the evidence is against a conclusion that the criteria for a 50 percent rating were met from July 21, 2009. Unless the preponderance of the evidence is against the Veteran's claim, it cannot be denied, and when a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. See 38 C.F.R. § 4.3. As such, and without finding error in the assignment of the ratings for such disability by the AOJ and consistent with Mauerhan, the Board will exercise its discretion to find that the evidence is in relative equipoise and conclude that the criteria for an initial 50 percent rating for PTSD have been met from July 21, 2009, the effective date of the grant of service connection. Id. As for whether an even higher rating (i.e., 70 percent) may be assigned, considering the pertinent evidence of record set forth above, the Board finds that the criteria for a rating in excess of 50 percent for PTSD are not met at any point during the appeal period. First, while not dispositive of the matter, the examiner who conducted the October 2012 VA examination, in reporting what best summarized the level of occupational and social impairment resulting solely from psychiatric disability as set forth in the rating criteria, selected the level of disability characterized by a 30 percent rating as codified under 38 C.F.R. § 4.130. Indeed, the Board notes that the Veteran exhibits symptoms characteristic of both a 30 percent and 50 percent disability rating. However, the Board, in assessing the Veteran's disability picture as a whole, and affording him the benefit of the doubt, has determined that he meets the criteria for a 50 percent rating. Thus, an even higher 70 percent rating is not warranted. A 70 percent rating would also not be consistent with the fact, as set forth in the reports from the October 2012 VA examination report and elsewhere, that the Veteran works full-time in quality control. Moreover, although the Veteran is socially withdrawn and has reported strained familial relationships, he does regularly attend church and get together with friends to play cards. Furthermore, he has remained married for over 47 years. Additionally, while the Veteran demonstrates depression, such has not been reported to significantly affect his ability to function independently, appropriately and effectively. The Board notes that the Veteran has previously exhibited suicidal ideation, however, such has been transient, and he has denied a plan or intent. Additionally, the Veteran does not demonstrate many of the types of symptoms listed for a 70 percent rating; namely, near-continuous panic or depression affecting the ability to function independently, abnormal speech, spatial disorientation, neglect of personal appearance and hygiene, or the complete inability to establish and maintain effective relationships. Finally, the Veteran's GAF scores, while ranging from 45-75, denoting serious to mild difficulty in social or occupational functioning, trend toward the moderate range, and would not be consistent with a 70 percent rating. Therefore, the Board finds that the criteria for 70 percent rating for PTSD are not met at any time since the grant of service connection. 38 C.F.R. § 4.130, DC 9411. Moreover, the Board finds that the criteria for a 100 percent rating under the General Rating Formula are not met. In this regard, the evidence does not show that the Veteran has 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. Moreover, the Veteran is employed full-time and, thus, is not totally occupationally impaired. As such rating criteria requires that there be total occupational and social impairment, the Veteran does not meet the requirements for a 100 percent rating for his PTSD. In determining that the criteria for a rating in excess of 50 percent for the Veteran's PTSD are not met, it is again emphasized that the Board has considered the applicable rating criteria not as an exhaustive list of symptoms, but rather, as examples of the type and degree of the symptoms or effects that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule in determining that a rating in excess of 50 percent is not for assignment. See supra, Mauerhan. In so finding, the Board has found that the descriptions of symptomatology and limitations provided by the Veteran are credible and consistent with the evidentiary record. His lay reports have been relied upon to support the assigned 50 percent rating. To this extent that he argues for a higher rating still, the Board places greater probative weight to the findings and opinions of the VA medical examiners and clinicians who have greater expertise and training than the Veteran in evaluating the nature and severity of his PTSD. There is no further doubt of material fact to be resolved in the Veteran's favor. Therefore, for the foregoing reasons, the Board finds that the Veteran is not entitled to a rating in excess of 50 percent for PTSD for the entire appeal period. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that 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. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected PTSD with the established criteria found in the rating schedule. In evaluating the Veteran's PTSD, all relevant symptomatology, to include those not enumerated in the rating criteria, are considered. See Mauerhan, supra. Specifically, the Federal Circuit provided guidance in rating psychiatric disabilities, emphasizing that the list of symptoms under a given rating is nonexhaustive. Vazquez-Claudio, supra. The psychiatric symptoms present in this case are either listed in the schedular criteria or are similar in kind to those listed, as discussed above. Review of the record does not reveal that the Veteran suffers from any symptoms of PTSD that are not contemplated in the nonexhaustive list of symptoms found in the schedular criteria. The Board notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. However, in this case, as the appeal does not involve evaluation of multiple service-connected disabilities, further discussion of Johnson is not necessary. Thus, the Board finds that the rating criteria reasonably describes the Veteran's disability level and symptomatology of his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Accordingly, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the evidence reflects that the Veteran has been employed throughout the course of the appeal. Therefore, the Board finds that the issue of entitlement to a TDIU is not expressly raised by the Veteran or reasonably raised by the record and, consequently, further consideration of such is not necessary. ORDER An initial 50 percent rating, but no higher, for PTSD, is granted, subject to the laws and regulations governing the payment of monetary awards. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran is seeking service connection for bilateral pain and tingling in his legs and feet. The record indicates the Veteran has advanced his theory of entitlement on the basis of exposure to herbicides while in Vietnam; and, in the alternative, that his bilateral leg and foot disorder pre-existed service and was aggravated therein. See July 2009 claim and February 2014 representative's statement. During an October 1964 pre-induction examination, the Veteran reported a history of cramps in his legs and paralysis, and the examiner noted a history of legs cramps and "polio as a child-no residuals." See October 1964 Report of Medical History. At service entrance, it was noted that the Veteran had polio at age four and now had weakness in his legs if he stood for several hours. The Veteran again reported a history of cramps in his legs and paralysis. See October 1965 Report of Medical History. A February 1966 treatment note indicates cramping pain in the lower legs when walking and marching, and notes the Veteran's childhood history of polio. The impression was muscle strain. In March 1966, the Veteran was again seen for complaints of a stiff right leg which often gave out on him. Findings were negative for fracture, shin splints and thrombophlebitis; a knee exam was unremarkable. He was prescribed leg exercises and an ice massage. At the February 1968 separation examination, the Veteran again reported a history of cramps in his legs and paralysis; his history of childhood polio was also noted. He was evaluated as clinically normal in all respects. In August 2012, the Veteran underwent a VA examination to determine the nature and etiology of his claimed bilateral leg and foot disorder. The Veteran reported constant pain in his legs, thighs and calves. He stated his legs felt heavy when he walked, hurt badly and interfered with his ability to sleep. He reported muscle cramps, worsening with the cold. He denied numbness or tingling in his toes. The examiner noted the Veteran's presumed Agent Orange exposure and that he has not been diagnosed with diabetes mellitus or cancer, which, she stated, can cause generalized peripheral neuropathy. Examination findings suggested lumbar stenosis, postpolio syndrome and sequelae of hypothyroidism, but were essentially negative for peripheral neuropathy. The examiner opined that the Veteran's complains of "subacute polyneuropathy/bilateral feet/legs tingling numbness" was not related to service or aggravated beyond its natural progression therein, as findings were most consistent with a combination of post-polio syndrome, hypothyroidism and lumbar stenosis. The Board finds the August 2012 opinion inadequate, as the examiner did not provide a fully explained rationale for her findings, nor did she state why the Veteran's pertinent diagnoses were not related to service. Additionally, the Board notes that, as the Veteran has alleged aggravation of a pre-existing disability, a medical opinion is required regarding whether the Veteran had a current diagnosis which was noted on his service entrance examination, and if so, whether the disorder(s) increased in severity in service. Therefore, the Board finds that an addendum opinion is necessary. Additionally, the record is unclear as to whether there remain outstanding private treatment records relating to the Veteran's claimed bilateral leg and foot disorder. Specifically, in a statement received in October 2009, the Veteran indicated he was treated by "two internal medicine doctors" for disorders he believes are related to his Agent Orange exposure, and he asked that the AOJ notify him if he needed to supply additional information. To date, it does not appear the AOJ has attempted to obtain these records. Thus, these records should be obtained prior to adjudication of the issues. 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and ask him to provide authorization to obtain any outstanding private treatment records relevant to his claimed bilateral leg and foot disorder, to include from the two internal medicine doctors identified by him in correspondence dated October 2009. Make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. 2. After any outstanding records have been obtained, return the claims file to the VA examiner who conducted the Veteran's August 2012 examination. The claims file and a copy of this Remand must be made available to the examiner. The examiner shall note in the examination report that the claims folder and the Remand have been reviewed. If the August 2012 VA examiner is not available, the claims file should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the record, and any necessary testing (if the Veteran is being examined), the examiner should address the following inquiries: (A) Identify all current diagnoses of the bilateral legs and feet. (B) If any of the current diagnoses were noted on the Veteran's service entrance examination, the examiner is asked to opine as to whether the disorder(s) increased in severity in service. If so, the examiner is asked to opine as to whether there is clear and unmistakable evidence that such increase in severity is due to the natural progress of the condition. (C) If any current disorder was not noted on entrance, the examiner is asked to opine as to whether there is clear and unmistakable evidence that the disorder(s) pre-existed service. (i) If there is clear and unmistakable evidence that the disorder(s) pre-existed service, the examiner is asked to opine as to whether there is clear and unmistakable evidence that the pre-existing disorder(s) did not undergo an increase in the underlying pathology during service, i.e., was not aggravated during service. If there was an increase in the severity of the Veteran's disorder(s), the examiner should offer an opinion as to whether such increase was clearly and unmistakably due to the natural progress of the disease. (ii) If there is no clear and unmistakable evidence that any current disorder pre-existed service, then the examiner is asked whether it is at least as likely as not that the disorder is directly related to service, including as due to herbicide exposure. In providing the requested opinion(s), the examiner must consider and discuss the Veteran's history of childhood polio, and his reports of leg cramps/pain prior to and during service. The examiner must provide a comprehensive report including a complete rationale for all opinions and conclusions reached, citing the objective medical findings leading to the conclusion(s). 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of 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). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs