Citation Nr: 1610202 Decision Date: 03/14/16 Archive Date: 03/22/16 DOCKET NO. 13-03 999 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an initial compensable rating for diverticulitis. 2. Entitlement to service connection for a back disorder. 3. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 4. Entitlement to service connection for alcoholism, claimed as secondary to an acquired psychiatric disorder. REPRESENTATION Veteran represented by: National Association of County Veterans Service Officers WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Purcell, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1966 to December 1968, including service in Vietnam, and from July 1983 to March 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, which granted service connection for diverticulitis with a noncompensable evaluation, effective November 22, 2008, and denied service connection for a back disorder, PTSD, and alcoholism. The Veteran subsequently perfected an appeal of the propriety of the initially assigned rating for his diverticulitis and the denial of service connection for a back disorder, PTSD, and alcoholism. In September 2014, the matter was remanded in order to afford the Veteran his requested Board hearing. As such, in November 2015, the Veteran testified at a video-conference Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the record. The Board notes that, at such time, the Veteran's representative was not present; however, he indicated that he wished to proceed with the hearing on his own. He was assisted in the presentation of his case by a RO employee. Regarding the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, the Board notes that the RO originally characterized such as PTSD. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that, in determining the scope of a claim, the Board must consider the claimant's description of the claim, symptoms described, and the information submitted or developed in support of the claim. In light of the Court's decision in Clemons, the Board has recharacterized the issue on appeal as entitlement to service connection for an acquired psychiatric disorder. This appeal was processed using the Veteran Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. The issues of entitlement to service connection for a back disorder, an acquired psychiatric disorder, and alcoholism are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT For the entire appeal period, the Veteran's diverticulitis has been asymptomatic. CONCLUSION OF LAW The criteria for an initial compensable rating for diverticulitis are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.14, 4.114, Diagnostic Code 7327 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2015). Proper notice from VA must inform the claimant of any information and 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In the instant case, May 2009 and June 2009 letters, sent prior to the August 2010 rating decision on appeal, advised the Veteran of the evidence and information necessary to substantiate his underlying service connection claim as well as his and VA's respective responsibilities in obtaining such evidence and information. The June 2009 letter also advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. After the grant of service connection in the August 2010 rating decision, the Veteran appealed with respect to the propriety of the initially assigned rating for his diverticulitis. 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 diverticulitis was granted by the AOJ in August 2010, and a noncompensable rating was assigned effective November 22, 2008 (the date the Veteran's claim was received). 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 the Veteran in the development of a claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this regard, the record contains relevant service treatment records (STRs), post-service VA and private treatment records, and VA examination reports from January 2010 and August 2013. The Board acknowledges that the evidence of record suggests that the Veteran is receiving disability benefits from the Social Security Administration (SSA) based on a spinal tumor. While VA's duty to assist generally requires that such records be obtained, VA is only required to obtain Social Security records when those records are potentially relevant to the claim on appeal. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Relevant records are those that relate to the injury for which benefits are sought and have a reasonable possibility of helping to substantiate the claim. Id. However, in the instant case, as the Veteran has indicated that such records are relevant only to his back disorder, any extant Social Security records do not have a reasonable probability of helping to substantiate the Veteran's claims, and are therefore not relevant to the instant matter. Golz, 590 F.3d 131. Consequently, there is no need to remand for such records. Moreover, the Veteran's statements, including his testimony before the undersigned during his November 2015 Board hearing, in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified relating to this claim. Additionally, as mentioned in the preceding paragraph, the Veteran was afforded VA examinations in January 2010 and August 2013 relating to his diverticulitis. The Board finds that the January 2010 and August 2013 examinations are adequate to adjudicate the Veteran's initial rating claim. Specifically, as shown below, the examination reports were based upon consideration of the Veteran's pertinent medical history, his lay assertions, and current complaints, as well as a complete physical examination, addressing the relevant rating criteria, and a description of the nature and severity of the Veteran's diverticulitis in detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Furthermore, the evidence does not show or suggest that the Veteran's diverticulitis has materially worsened since the most recent evaluation in August 2013. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Accordingly, the Board finds that the January 2010 and August 2013 examination reports are adequate to adjudicate the Veteran's initial rating claim and no further examination is necessary. The Veteran also offered testimony before the undersigned Veterans Law Judge at a Board hearing in November 2015. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Decision Review Officer or Veterans Law Judge who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. At the November 2015 hearing, the undersigned Veterans Law Judge noted the issues on appeal at that time. With regard to the claim herein decided, the hearing focused on the nature and severity of the Veteran's diverticulitis, to include the frequency, severity, and duration of symptoms, to include the impact such has on his daily life and employability, as well as the treatment for such disorder. Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Furthermore, the hearing discussion did not reveal any outstanding evidence relevant to the claim decided herein. Under these circumstances, nothing gives rise to the possibility that evidence had been overlooked with regard to the Veteran's claim decided herein. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. As noted in the Introduction, in September 2014, the matter was remanded in order to afford the Veteran his requested Board hearing, which was conducted in November 2015. Therefore, the Board finds that the AOJ has substantially complied with the September 2014 remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). 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. 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 v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). As in the instant case, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126. The Veteran is seeking a higher initial rating for his service-connected diverticulitis. Currently, the Veteran's diverticulitis is assigned a noncompensable rating, effective November 22, 2008 (the date the Veteran's claim was received), pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7327. Pursuant to Diagnostic Code 7327, diverticulitis is rated as irritable colon syndrome (Diagnostic Code 7319), peritoneal adhesions (Diagnostic Code 7301), or ulcerative colitis (Diagnostic Code 7323), depending on the predominant disability picture. See 38 C.F.R. § 4.114, Diagnostic Code 7327. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Under Diagnostic Code 7319, mild irritable colon syndrome, with disturbances of bowel function with occasional episodes of abdominal distress, is evaluated as noncompensably disabling. Moderate irritable colon syndrome, with frequent episodes of bowel disturbance with abdominal distress, is rated 10 percent disabling. Severe irritable colon syndrome, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, is rated 30 percent disabling. Under Diagnostic Code 7301, mild adhesions of peritoneum are evaluated as noncompensably disabling. Moderate adhesions of peritoneum, pulling pain on attempting work or aggravated by movements of the body, or occasional episodes of colic pain, nausea, constipation (perhaps alternating with diarrhea) or abdominal distension, are rated 10 percent disabling. Moderately severe adhesions of peritoneum, partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain are rated 30 percent disabling. Severe adhesions of peritoneum, definite partial obstruction shown by X-ray, with frequent and prolonged episodes of severe colic distension, nausea or vomiting, following severe peritonitis, ruptured appendix, perforated ulcer, or operation with drainage, are rated 50 percent disabling. The Note associated with Diagnostic Code 7301 states that ratings for adhesions will be considered when there is a history of operative or other traumatic or infectious (intraabdominal) process, and at least two of the following: disturbance of motility, actual partial obstruction, reflex disturbances, presence of pain. Under Diagnostic Code 7323, moderate ulcerative colitis, with infrequent exacerbations, is rated 10 percent disabling. Moderately severe ulcerative colitis, with frequent exacerbations, is rated 30 percent disabling. Severe ulcerative colitis, with numerous attacks a year and malnutrition, the health only fair during remissions, is rated 60 percent disabling. Pronounced ulcerative colitis, resulting in marked malnutrition, anemia, and general debility, or with serious complication as liver abscess, is rated 100 percent disabling. Under Diagnostic Code 7329, resection of the large intestine with slight symptoms is rated 10 percent disabling. Resection of the large intestine with moderate symptoms is rated 20 percent disabling. Resection of the large intestine with severe symptoms, objectively supported by examination findings, is rated 40 percent disabling. A Note to Diagnostic Code 7329 provides that, where residual adhesions constitute the predominant disability, the disability is to be rated under Diagnostic Code 7301. Diagnostic Code 7330 provides that a fistula of the intestine, if healed, will be rated for peritoneal adhesions. The Board notes that words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be just. See 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Rather, all evidence must be evaluated in arriving at a decision for an initial disability rating. See 38 U.S.C.A. § 7104; 38 C.F.R. §§ 4.2, 4.6. Historically, while in service, the Veteran's diverticulitis resulted in perforation of his colon and surgery was required to repair it. See November 2008 Claim; May 2009 Veteran's Statement. A March 1991 STR shows a January 1991 operation of repair of enterocolic fistula, resection of sigmoid colon with end-to-end colocolostomy, incidental appendectomy, and incidental splenectomy, along with a diagnosis of diverticulitis. A January 2009 private treatment record shows the Veteran reported diarrhea the morning of a checkup, after eating pizza and salad the prior night, but otherwise reported feeling well. An April 2009 private treatment record from a checkup appears to show no pain and no masses in the abdomen, but notes a scar. The Veteran underwent VA examination in relation to his diverticulitis claim in January 2010. The VA examiner found that the Veteran had diverticulitis in service, which was complicated by perforation and required surgery and a partial colectomy. The VA examiner found that the Veteran had no further attacks. The VA examiner noted that the Veteran occasionally has diarrhea and constipation but not on any regular basis. The VA examiner found that the Veteran was on a regular diet without problems and his weight has remained stable. Upon examination, the VA examiner found an abdomen without tenderness or masses. The VA examiner diagnosed the Veteran with status post diverticulitis with perforation requiring surgery which was asymptomatic at the time. In a July 2013 Decision Review Officer (DRO) decision, the RO granted service connection for splenectomy with an evaluation of 20 percent, effective November 22, 2008, as secondary to the Veteran's service-connected diverticulitis. The Veteran underwent another VA examination in August 2013 in relation to his diverticulitis. The VA examiner noted that, in 1991, the Veteran underwent repair of enterocolic fistula, resection of sigmoid colon with end-to-end colocolostomy, incidental appendectomy, and incidental splenectomy. The Veteran reported that he had had no further surgery and no further attacks of diverticulitis since service. The VA examiner found that the Veteran did not require continuous medicine for control of his condition. The VA examiner found that the Veteran did not have abdominal pain, colic pain, diarrhea, alternating diarrhea and constipation, abdominal distension, anemia, nausea, vomiting, or pulling pain on attempting work or aggravated by movements of the body, attributable to any intestinal surgery. The Veteran did not have weight loss or inability to gain weight attributable to intestinal surgery. The VA examiner found that the Veteran's condition did not require a colostomy. The VA examiner also found an asymptomatic nontender nonpainful superficial midline abdominal scar measured at 1.35 centimeters by 0.8 centimeters from the January 1991 surgery. The VA examiner found the Veteran's diverticulitis was asymptomatic at the time of the examination. The VA examiner found that the Veteran did not have any residuals from his sigmoid resection for perforated diverticulitis, incidental appendectomy, and incidental splenectomy. The VA examiner also found no functional impact on the Veteran's work from his disability. In May 2014, the RO issued a DRO decision granting service connection for scar, status post appendectomy and colectomy, with a noncompensable rating, effective November 22, 2008, as secondary to the Veteran's service-connected diverticulitis, status post colectomy. During the November 2015 Board hearing, the Veteran testified that his in-service surgery relating to his diverticulitis was successful and that he currently was not experiencing any residuals or symptoms related to his diverticulitis. He testified that he had no current symptoms of bleeding or diarrhea. In this regard, he indicated that he had not intended to appeal the initial noncompensable diverticulitis rating. The Veteran and his representative also indicated that the Veteran's spleen, appendix, and a portion of his colon were removed during the in-service surgery relating to his diverticulitis. In summary, the totality of the evidence, including that from the Veteran and VA examiners, shows that the Veteran's diverticulitis has been asymptomatic during the entire appeal period. In this regard, the Veteran has not exhibited frequent episodes of bowel disturbance with abdominal distress sufficient to warrant a 10 percent rating under Diagnostic Code 7319. As noted above, the Veteran reported an instance of diarrhea in a January 2009 treatment note. The January 2010 VA examiner noted that the Veteran reported occasional diarrhea and constipation but not on any regular basis. The January 2010 VA examiner considered the Veteran's reports and found that the Veteran's diverticulitis disability was without any residuals. The August 2013 VA examiner found that the Veteran did not have symptoms of diarrhea or constipation attributable to the Veteran's intestinal surgery. The August 2013 VA examiner also found that the Veteran was asymptomatic. During the November 2015 Board hearing, the Veteran testified that he did not have diarrhea symptoms and that he was not experiencing any residuals or symptoms related to his diverticulitis. The Board acknowledges that Diagnostic Code 7319 provides a noncompensable rating for mild symptoms of bowel function with occasional episodes of abdominal distress. As noted above, the Veteran's January 1991 in-service surgery included repair of enterocolic fistula. As relayed by the Veteran and VA examiners, the surgery was successful. As such, the Board has considered whether a higher rating is warranted for such fistula. In this regard, such is evaluated under the criteria for peritoneal adhesions set forth in Diagnostic Code 7301. See Diagnostic Code 7330. However, the Veteran does not have moderate symptomatology of pulling pain on attempting work or aggravated by movements of the body, or occasional episodes of colic pain, nausea, constipation (perhaps alternating with diarrhea) or abdominal distension, sufficient to warrant a 10 percent rating under Diagnostic Code 7301. While the Veteran has mentioned occasional diarrhea and constipation, he also testified that he did not experience any residuals or symptoms related to his diverticulitis. The Veteran reported a regular diet without problems. Both VA examiners found that the Veteran was asymptomatic. The Board finds the Veteran has not exhibited moderate symptomatology sufficient to warrant a compensable rating under Diagnostic Code 7301. The Board acknowledges that Diagnostic Code 7301 provides a noncompensable rating for mild adhesions of peritoneum. The Veteran also does not have moderate ulcerative colitis with infrequent exacerbations sufficient to warrant a 10 percent rating under Diagnostic Code 7323. As discussed above, the Veteran has asymptomatic diverticulitis and has reported that he has had no further attacks of diverticulitis since service. Because the Veteran's January 1991 in-service surgery included sigmoid resection with end-to-end colocolostomy, the Board has also considered the potential applicability of Diagnostic Code 7329, which provides criteria for the assignment of a rating for disability associated with resection of the large intestine. The Board finds that the Veteran does not have slight symptoms attributable to his in-service intestinal surgery sufficient to warrant a 10 percent rating under Diagnostic Code 7329. The January 2010 VA examiner considered the Veteran's report of occasional diarrhea and constipation and found that there were no residuals of the Veteran's 1991 surgery. The August 2013 VA examiner also found that the Veteran did not have any residuals from his intestinal surgery. During the November 2015 hearing, the Veteran reported that he does not experience any symptoms. In addition, in the July 2013 DRO decision, the Veteran was granted service connection for splenectomy based on evidence showing the removal of the spleen during the Veteran's in-service surgery related to his diverticulitis. The Veteran's splenectomy disability associated with his diverticulitis was separately compensated with a 20 percent rating for the entire appeal period. Pursuant to Diagnostic Code 7706, a 20 percent rating applies for this disability. 38 C.F.R. § 4.118. Complications such as systemic infections with encapsulated bacteria are rated separately. There are no complications to warrant a separate rating and the Veteran has not alleged such. Moreover, in a May 2014 DRO decision, the Veteran was granted service connection for scar, status post appendectomy and colectomy, with a noncompensable rating, effective November 22, 2008, as secondary to the Veteran's service-connected diverticulitis, status post colectomy, under Diagnostic Code 7804, 38 C.F.R. § 4.118. Pursuant to Diagnostic Code 7804, a 10 percent rating applies when there are one or two scars that are unstable and painful. As noted above, the August 2013 VA examiner found an asymptomatic nontender nonpainful superficial midline abdominal scar measured at 1.35 centimeters by 0.8 centimeters. The Veteran has not asserted that the scar is painful or unstable such as to warrant a compensable rating under Diagnostic Code 7804. Therefore, based on the totality of the evidence of record, the Board finds that the Veteran is not entitled to a compensable rating for his diverticulitis. Neither examination revealed any symptomatology that would warrant a compensable rating and the Veteran has reported no symptomatology attributable to his diverticulitis. 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 Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected diverticulitis is inadequate. A comparison between the level of severity and symptomatology of the Veteran's diverticulitis with the established criteria shows that the rating criteria reasonably contemplates the Veteran's disability level and symptomatology. Specifically, the Veteran has testified that he does not experience symptoms related to his diverticulitis and both VA examiners found that the Veteran's diverticulitis was asymptomatic. Furthermore, the Board notes that under 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 the evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. However, in this case, even after affording the Veteran the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there is no additional impairment that has not been attributed to a specific, rated disability. The Veteran is separately service-connected for a scar and splenectomy associated with his diverticulitis disability. The Board finds that the schedular evaluations reasonably contemplate the Veteran's symptomatology, including any symptoms resulting from the combined effects of multiple service-connected disabilities. Accordingly, this is not an exceptional circumstance in which extra-schedular consideration may be required to compensate the Veteran for disability that can be attributed only to the combined effect of multiple conditions. Consequently, the Board finds that the Veteran's diverticulitis symptomatology, or lack thereof, is fully addressed by the rating criteria under which his disability is rated. There are no additional symptoms of his diverticulitis that are not addressed by the rating schedule. The Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected disability, and the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, 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. Thun, supra; 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 due to individual unemployability (TDIU) is part of a rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. In this regard, the Veteran has not contended that his diverticulitis renders him unemployable. Moreover, the August 2013 VA examiner found there were no functional limitations on the Veteran's ability to work resulting from his disability. Therefore, the Board finds that the issue of entitlement to a TDIU due to service-connected diverticulitis has not been raised by the Veteran or the record and need not be further addressed. The Board has also considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claim for an initial compensable rating for diverticulitis, the doctrine is not for application. 38 38 U.S.C.A. § 5107; 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An initial compensable evaluation for diverticulitis is denied. 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 seeks entitlement to service connection for a back disorder, an acquired psychiatric disorder, and alcoholism. Records As an initial matter, the Board finds that a remand is necessary in order to obtain outstanding treatment records. In this regard, the Veteran testified that he was taken to Walson Army Hospital at Fort Dix by ambulance and remained immobile for 10 days in 1985 or 1986 as a result of his back. While the Veteran reported that Walson Army Hospital is closed, a remand is necessary in order to attempt to obtain such clinical records from any appropriate source, to include the National Personnel Records Center (NPRC), keeping in mind that clinical records may be filed under the facility's name rather than the servicemember's name. Review of the claims file reflects treatment records from the Coatesville VA Medical Centers (VAMCs) dated August and September 2000. The claims file also contains an April 2010 treatment note from the Trenton Vet Center. In an August 2013 statement, the Veteran reported that he attended a PTSD support group at the Mount Holly office of the New Jersey Department of Military and Veterans Affairs in 2011. During the November 2015 Board hearing, the Veteran testified that he attended group PTSD sessions for several months at the VA Center in Mount Holly in 2013. Accordingly, any additional VA treatment records should be associated with the claims file, to include the 2011 and 2013 treatment records referenced by the Veteran. So as to ensure a complete record, the Veteran should be given another opportunity to identify any additional relevant medical treatment records not already on file, from either private or VA facilities, which pertain to his claims for service connection for a back disorder and an acquired psychiatric disorder, to include secondary alcoholism. In this regard, the Veteran noted treatment from a chiropractor, Dr. Stefanou, in Marlton, New Jersey, in 1985. All identified records should be obtained. Also, the evidence of record suggests that the Veteran is receiving disability benefits from the Social Security Administration (SSA). A January 2009 SSA Inquiry shows a disability onset date of April 2002 and a date of initial entitlement of October 2002. The Veteran reported a disability of a spinal tumor. See November 2008 Claim. As such materials may be relevant to the Veteran's service connection claim for a back disorder, the AOJ should obtain the complete medical and administrative records related to any application for SSA disability benefits. See Murincsak v. Derwinski, 2 Vet. App. 363, 369-70 (1992) (where VA has actual notice of the existence of records held by SSA which appear relevant to a pending claim, VA has a duty to assist by requesting those records from SSA). Back Disorder The Veteran contends that his back disorder was caused or aggravated by physical training and daily activities in service, to include marching, running, lifting, and carrying backpacks. During the November 2015 Board hearing, the Veteran testified that he first experienced back pain during his first period of service, from 1966 to 1968. He continued to have back pain until he threw out his back in between his first and second periods of active duty. During his second period of active duty, his back pain worsened until he was taken to Walson Army Hospital at Fort Dix by ambulance and remained immobile for 10 days in 1985 or 1986. The Veteran was placed on light duty following his hospital stay. The Veteran testified that his doctors have told him that his back disorder is a congenital condition. The Veteran has continued to experience back symptomatology to the present time. Private treatment records from July 2002 show the Veteran underwent a thoracic laminectomy and excision of tumor. A May 2004 private radiology treatment record shows a diagnosis of disc bulges and mild multilevel cervical spondylosis. An April 2004 treatment note mentions spina bifida occulta. A January 2007 private radiology treatment record also notes a diagnosis of spondylolisthesis. A February 2007 private radiology treatment record notes a diagnosis of thoracic spine ventral extradural defects suggesting small disc herniations, malalignment at the L4-5 and L5-S1 levels, advanced degenerative changes, and bulging discs. The Board notes that the Veteran's February 1966 and October 1980 entrance examinations did not document a back disorder. The Board therefore finds that the Veteran is presumed to have been in sound condition with respect to his back condition upon entrance into both periods of active duty service. See 38 U.S.C.A. § 1111. Clear and unmistakable evidence that the disability existed prior to service and was not aggravated by service will rebut the presumption of soundness. Id.; VAOPGCPREC 3-2003. A pre-existing disease will be considered to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. The Board further notes that the VA's Office of General Counsel has distinguished between congenital or developmental defects, for which service connection is precluded by regulation, and congenital or hereditary diseases, for which service connection may be granted, if initially manifested in or aggravated by service. See VAOPGCPREC 82-90, VAOPGCPREC 67-90. A defect differs from a disease in that the former is "more or less stationary in nature" while the latter is "capable of improving or deteriorating." Quirin v. Shinseki, 22 Vet. App. 390, 394 (2009) (quoting VAOPGCPREC 82-90). VA has a duty to provide a medical examination when it is deemed necessary to make a decision on a claim if the evidence (including lay statements of the appellant) contains competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of the disability; if the evidence indicates that his disability or symptoms may be associated with the appellant's service; and there is not sufficient medical evidence for VA to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). In this case, given the facts above, a VA examination is warranted to determine the nature and etiology of the Veteran's claimed back disorder. Acquired Psychiatric Disorder and Alcoholism During the November 2015 Board hearing, the Veteran testified that he experienced fear of hostile activity while serving in Vietnam. He also reported that his friend was killed during guard duty by a satchel charge and he was assigned to guard duty the next day. The Veteran testified that he feared for his life and his fellow soldiers' lives. He testified that there was racial turbulence among the soldiers. The Veteran further indicated that he had trouble adjusting from the death and disease of the war to life at home. He testified that he internalized his feelings and coped through alcohol abuse. The Veteran's service treatment records note a drinking problem. See January 1991 STR (binge drinking). The Veteran's post-service treatment records show diagnoses of depression, anxiety, alcohol dependence, and substance induced mood disorder. See July 2000 and December 2000 Private Treatment Records. The Veteran underwent a mental health VA examination in May 2010. The VA examiner found the Veteran did not meet the diagnostic criteria for PTSD. The VA examiner diagnosed the Veteran with generalized anxiety disorder, major depressive disorder, and alcohol dependence in partial remission. The VA examiner opined that it was not at least as likely as not that the Veteran's generalized anxiety disorder, major depressive disorder, and alcohol dependence were directly related to his verified stressor event. The examiner explained that the Veteran reported drinking alcohol heavily when he first entered the service, before the stressor event occurred. The examiner opined that the Veteran's depression appeared related to his alcohol issues. The examiner also noted that the Veteran had reported that his anxiety presented approximately twenty to thirty years prior to the examination. Despite the examiner's comments indicating the potential appearance of all three disorders during the Veteran's time in service, the VA examiner did not opine as to whether these disorders had their onset in service or were otherwise related to service, aside from the described stressor. In addition, the VA examiner did not have the benefit of the Veteran's later testimony regarding his fear of hostile activity during his service in Vietnam. Once VA undertakes the effort to provide an examination for a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In light of the deficiencies noted above, the Board finds that a new examination and opinion to address the nature and etiology of the Veteran's acquired psychiatric disorders and alcoholism is necessary. Accordingly, the case is REMANDED for the following action: 1. The AOJ should attempt to obtain any clinical records with regard to the Veteran's hospitalization at Walson Army Hospital at Fort Dix for 10 days in 1985 or 1986 as a result of his back disorder from any appropriate source, to include the National Personnel Records Center (NPRC), keeping in mind that clinical records may be filed under the facility's name rather than the servicemember's name. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. The AOJ shall provide the Veteran with the opportunity to identify any additional relevant medical treatment records not already on file, from either private or federal facilities, which pertain to his back disorder, acquired psychiatric disorder, or alcoholism, to include Mount Holly or Trenton Vet Center treatment records from 2011 and 2013, and records from Dr. Stefanou, in Marlton, New Jersey, in 1985. After obtaining any necessary authorization from the Veteran, all identified records should be obtained. For private treatment records, 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. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. Request that SSA furnish complete copies of any determination on a claim for disability benefits from SSA as well as the medical records that served as the basis for any such determination. All reasonable attempts should be made to obtain any identified records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 4. After obtaining any additional records, schedule the Veteran for an examination to determine the nature and etiology of any currently diagnosed back disorder. It is imperative that the electronic record be made available to the examiner for review in connection with the examination, to specifically include these remand instructions. (A) After reviewing the record and examining the Veteran, the examiner should clearly identify all back disorders present at any time during the claim period (i.e., from November 2008 to the present). (B) For each currently diagnosed back disorder, the examiner should state whether such condition constitutes a congenital or developmental defect or a disease (per VAOPGCPREC 82-90, in general, a congenital abnormality that is subject to improvement or deterioration is considered a disease). (i) If the Veteran's diagnosed back disorder is considered a congenital or developmental defect, was there additional disability due to disease or injury superimposed upon such defect during either period of the Veteran's military service? If so, please identify the additional disability. (ii) If the examiner finds that the Veteran's diagnosed back disorder is a congenital or developmental disease, was it aggravated beyond the natural progression during either period of the Veteran's military service? Aggravation indicates a permanent worsening of the underlying condition as compared to a temporary increase in symptoms. (C) For each currently diagnosed back disorder that is not a congenital or developmental defect or a disease, the examiner is asked to opine as to whether there is clear and unmistakable evidence that the disorder(s) pre-existed either period of the Veteran's military service. (i) If there is clear and unmistakable evidence that the disorder(s) pre-existed either period of the Veteran's military 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 either period of the Veteran's military service, then the examiner is asked whether it is at least as likely as not that the disorder is directly related to service. (D) For any diagnosis of arthritis, the examiner should offer an opinion as to whether it is at least as likely as not (a 50% or higher degree of probability) that the Veteran's arthritis manifested within one year of the Veteran's service discharge in December 1968 or March 1991, and, if so, describe the manifestations. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles. In proffering this opinion, the examiner should consider the Veteran's testimony that his back symptomatology started during service, progressively worsened, and has continued to the present time. 5. After obtaining any additional records, schedule the Veteran for a VA psychiatric examination to determine the nature and etiology of any currently diagnosed acquired psychiatric disorder, to include PTSD. It is imperative that the electronic record be made available to the examiner for review in connection with the examination, to specifically include these remand instructions. (A) After reviewing the record and examining the Veteran, the examiner should clearly identify all psychiatric disorders found to be present at any time during the claim period (i.e., from November 2008 to the present) that meet the 4th edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV). The Board notes that, for cases certified to the Board prior to August 4, 2014, a diagnosis must be in accordance with the DSM-IV. 38 C.F.R. § 4.125(a) (2015). Effective August 4, 2014, VA issued an interim rule amending the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to, among other things, remove outdated references to the DSM and replace them with references to the recently updated DSM-5. See 79 Fed. Reg. 45,093 (Aug. 4, 2014). The aforementioned changes do not apply to this case, as this was certified to the Board prior to August 4, 2014. (B) If the Veteran meets the criteria for a PTSD diagnosis, the examiner is requested to identify the stressor(s) supporting the PTSD diagnosis. The examiner should specifically indicate whether such a diagnosis is based on the Veteran's verified stressor of the death of S. Allsopp who was killed while on guard duty on May 6, 1968 in Vietnam and/or based on a fear of hostile/terrorist activity. If PTSD is not diagnosed, explain why the Veteran does not meet the criteria for such diagnosis. (C) For each currently diagnosed acquired psychiatric disorder other than PTSD, the examiner should offer an opinion as to whether it is at least as likely as not (a 50% or higher degree of probability) that such disorder manifested during his active service or is otherwise related to his military service, to include the death of S. Allsopp who was killed while on guard duty on May 6, 1968 in Vietnam and/or the circumstances of the Veteran's service in Vietnam. (D) The examiner should also offer an opinion as to whether it is at least as likely as not (a 50% or higher degree of probability) that the Veteran's alcoholism is caused or aggravated by any diagnosed acquired psychiatric disorder, to include by way of self-medication. For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles. In proffering these opinions, the examiner should consider the April 2010 PTSD stressor verification, the Veteran's November 2015 testimony regarding fear of hostile activity, the May 2010 VA psychiatric examination, and other pertinent lay and medical evidence. 6. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If any claim remains denied, the 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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