Citation Nr: 1605961	
Decision Date: 02/17/16    Archive Date: 03/01/16

DOCKET NO.  06-00 165A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Muskogee, Oklahoma


THE ISSUES

1.  Entitlement to service connection for a lung disability, to include chronic obstructive pulmonary disorder (COPD), pneumonia and asthma.  

2.  Entitlement to service connection for sleep apnea, to include as secondary to service-connected disabilities including posttraumatic stress disorder (PTSD) and diabetes mellitus.  

3.  Entitlement to service connection for cataracts, to include as secondary to diabetes mellitus.  

4.  Entitlement to a compensable evaluation for erectile dysfunction as due to diabetes mellitus.  

5.  Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD).

6.  Entitlement to an evaluation in excess of 20 percent for peripheral vascular disease (PVD) of the left lower extremity.
7.  Entitlement to an initial compensable evaluation for bilateral eye retinopathy.  

8.  Entitlement to an initial compensable evaluation for tinea pedis and onychomycosis.  

9.  Entitlement to an initial rating in excess of 10 percent for hypothyroidism.  

10.  Entitlement to a disability rating in excess of 20 percent for peripheral neuropathy of the right lower extremity.

11.  Entitlement to a disability rating in excess of 20 percent for peripheral neuropathy of the left lower extremity.

12.  Entitlement to an earlier effective date than June 2, 2006 for the grant of special monthly compensation based on loss of use of a creative organ.  

13.  Entitlement to a total disability rating based on individual unemployability (TDIU) from April 29, 2013.   

14.  Entitlement to TDIU prior to April 29, 2013.   


REPRESENTATION

Veteran represented by:	Jeany Mark, Esquire


ATTORNEY FOR THE BOARD

N.K., Associate Counsel




INTRODUCTION

The Veteran had active service from July 1969 to February 1977. 

These matters initially came or have come to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Muskogee, Oklahoma Regional Office (RO) of the Department of Veterans Affairs (VA).

In July 2013, the Board remanded the sleep apnea claim to obtian an opinion as to whether the Veteran's sleep apnea was related to his service-connected diabetes mellitus and remanded the bilateral retinopathy claim for the claim for readjudication by the Agency of Original Jurisdiction (AOJ).  The AOJ was also directed to issue a statement of the case (SOC) pertaining to the Veteran's increased rating claims concerning his peripheral vascular disease of the left lower extremity, hypothyroidism, and PTSD as well as his service connection claim concerning cataracts pursuant to Manlincon, supra.  Thereafter, the Veteran was provided a VA examination for his sleep apnea, and his bilateral retinopathy claim was readjudicated by the AOJ in a February 2015 supplemental statement of the case (SSOC).  He was also issued a SOC as to his cataracts, PTSD, hypothyroidism, and peripheral vascular disease of the left lower extremity disabilities.  Accordingly, the Board's remand instructions have been complied with regarding the Veteran's sleep apnea, bilateral retinopathy, cataracts, PTSD, hypothyroidism, and peripheral vascular disease of the left lower extremity claims.  See Stegall v. West, 11 Vet. App. 268, 271 (1998).  

In the July 2013 decision, the Board also denied the Veteran's claims of entitlement to service connection for a lung disability and entitlement to an initial compensable evaluation for tinea pedis and onychomycosis.  The Veteran appealed the Board's denial of these issues to the United States Court of Appeals for Veterans Claims (Court).  In a December 2014 memorandum decision, the Court vacated the Board's decision and remanded these matters to the Board for development and readjudication.  Of note, the Veteran abandoned any challenge of the issues of service connection for a left knee disability, a back disability, rashes or boils, or a jaw disability, or increased ratings for hypertension or for left or right lower extremity peripheral neuropathy. 

By rating action dated September 2014, the RO increased the disability ratings for the Veteran's peripheral neuropathy of the right and left lower extremities to 20 percent effective April 29, 2013.  In a statement from the Veteran dated September 2015, he expressed disagreement with the awards of the 20 percent ratings.  A statement of the case (SOC) has not been submitted addressing these issues.  In Manlincon v. West, 12 Vet. App. 238 (1999), the United States Court of Appeals for Veterans Claims (the Court) held that where a notice of disagreement (NOD) is filed but a SOC has not been issued, the Board must remand the claim to the agency of original jurisdiction so that a SOC may be issued.

The issues of entitlement to an effective date earlier than June 2, 2006 for the award of service connection for peripheral vascular disease of the left lower extremity and entitlement to a separate compensable disability rating for hypertension were raised by the Veteran in a statement dated November 2014.  See VA Form 9 dated November 2014.  These issues have not been adjudicated by the Agency of Original Jurisdiction (AOJ).  Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action.  38 C.F.R. § 19.9(b) (2015). 

The issues of entitlement to service connection for a lung disability as well as entitlement to increased disability ratings for tinea pedis and onychomycosis and peripheral neuropathy of the right and left lower extremities and entitlement to TDIU prior to April 29, 2013 are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ.


FINDINGS OF FACT

1.  The evidence of record is at least in equipoise as to whether the Veteran's current sleep apnea is related to his service-connected PTSD.  

2.  The Veteran's currently diagnosed cataracts are not related to his military service and are not due to or aggravated by his service-connected diabetes mellitus, type II.

3.  For the period on appeal, the Veteran's PTSD caused occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of the inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior.  

4.  The Veteran's erectile dysfunction does not result in loss of the glans of the penis or more than half the penis, or any deformity of the penis.

5.  Throughout the pendency of the appeal, the Veteran's hypothyroidism has been manifested by fatigability and required continuous medication for control.

6.  The Veteran's peripheral vascular disease has manifested by claudication on walking more than 100 yards, and diminished peripheral pulse of left/ankle brachial index of more than .9.

7.  Prior to August 15, 2013, the Veteran's service-connected bilateral retinopathy was manifested by corrected visual acuity of no worse than 20/40 in both eyes, without any evidence of visual field loss, pain, rest requirements, impairment of muscle function, or incapacitating episodes.

8.  From August 15, 2013, the Veteran's service-connected bilateral retinopathy was manifested by incapacitating episodes of at least 6 weeks; it was also manifested by corrected visual acuity of no worse than 20/40 in both eyes, without any evidence of visual field loss, pain, rest requirements, or impairment of muscle function.

9.  There was no claim, formal or informal, of entitlement to special monthly compensation for loss of use of a creative organ filed before June 2, 2006.
 
10.  The Veteran was first diagnosed with erectile dysfunction on January 13, 2006. 

11.  From April 29, 2013, the Veteran was service-connected for cardiomyopathy with septal hypokinesis with a 100 percent disability rating and he was eligible for special monthly compensation based on the award of a disability rating at 100 percent and additional service-connected disabilities independently ratable at least 60 percent and was awarded such in a rating decision dated September 2014; an award of TDIU from April 29, 2013 can result in no further benefit, and there remains no case or controversy concerning whether the Veteran is entitled to any benefits that may be inferred from his claim from this date.


CONCLUSIONS OF LAW

1.  The criteria for service connection for sleep apnea have been met.  38 U.S.C.A. §§ 1101, 1110, 1131 (West 2014); 38 C.F.R. § 3.310 (2015).

2.  The criteria for service connection for cataracts, to include as secondary to service-connected diabetes mellitus, type II, have not been met.  38 U.S.C.A. §§ 1101, 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2015).

3.  The criteria for an initial disability rating in excess of 30 percent for PTSD have not been met.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015).

4.  The criteria for an initial compensable disability rating for erectile dysfunction have not been met.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R § 4.115b, Diagnostic Codes 7520, 7521, 7522 (2015).

5.  The criteria for an initial disability rating in excess of 10 percent for hypothyroidism have not been met.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. 
§ 4.119, Diagnostic Code 7903 (2015).

6.  The criteria for an initial rating in excess of 20 percent for peripheral vascular disease of the left lower extremity have not been met.  38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.62, 4.104, Diagnostic Codes 7111, 7114, 7115 (2015).

7.  Prior to August 15, 2013, the criteria for an initial compensable rating for bilateral retinopathy were not met.  38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. 
§§ 4.76a, Diagnostic Code 6006 (2008), 4.79, Diagnostic Code 6006 (2015).

8.  From August 15, 2013, the criteria for a 60 percent disability rating, and no higher, for bilateral retinopathy have been met.  38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.79, Diagnostic Code 6006 (2015).

9.  The criteria for an effective date earlier than June 2, 2006, for the grant of special monthly compensation based on loss of use of a creative organ have not been met.  38 U.S.C.A. §§ 1114(k), 5101, 5110, 7105; (West 2014); 38 C.F.R. 
§ 3.151, 3.400, 3.350 (2015).

10.  From April 29, 2013, there is no question of law or fact involving the award of entitlement to special monthly compensation based on award of TDIU; the appeal is moot.  38 U.S.C.A. § 7105(d)(5) (West 2014); 38 C.F.R. § 4.16  (2015).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Duties to Notify and Assist

Under applicable criteria, VA has certain notice and assistance obligations to claimants.  See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a).  In this case, required notice was provided.  Additionally, neither the Veteran, nor his representative, has either alleged, or demonstrated, any prejudice with regard to the content or timing of VA's notices or other development.  See Shinseki v. Sanders, 129 U.S. 1696 (2009).  Thus, adjudication of his claim at this time is warranted. 

With respect to the issues of an increased initial evaluation for service-connected tinea pedis and onychomycosis, peripheral vascular disease of the left lower extremity, PTSD, bilateral retinopathy, hypothyroidism, and erectile dysfunction, for initial rating claims or claims for an earlier effective date, where, as here, service connection has been granted and the initial rating and effective date have been assigned, the claim of service connection has been more than substantiated, as it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled.  Once a claim for service connection has been substantiated, the filing of a notice of disagreement (NOD) with the rating or the effective date of the disability does not trigger additional 38 U.S.C.A. § 5103(a)  notice.  See Dingess v. Nicholson, 19 Vet. App. 473, 490-491; Dunlap v. Nicholson, 21 Vet. App. 112   (2007). 

With respect to the service connection issues on appeal, the RO provided notice to the Veteran in a January 2004 letter, prior to the date of the issuance of the appealed January 2005 rating decision.  The January 2004 letter explained what information and evidence was needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. 

A June 2008 letter also provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). 

With regard to the duty to assist, the claims file contains the Veteran's service treatment records, private and VA treatment records, Social Security Administration  records, and reports of VA examinations.  Additionally, the claims file contains the Veteran's statements in support of his claims.  The Board has carefully reviewed such statements and concludes that he has not identified further evidence not already of record.  The Board has also reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. 

Additionally, the Veteran was offered the opportunity to testify at a hearing before the Board, but he declined.

The Veteran has also been provided with a number of VA examinations in this case (the reports of which have been associated with the claims file), which the Board finds to be adequate for rating purposes.  See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  

Thus, based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claims.  Essentially, all available evidence that could substantiate the claims has been obtained.

As described, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose.  See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994).  Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. 

Entitlement to Service Connection for Sleep Apnea

The Veteran seeks entitlement to service connection for sleep apnea, to include as secondary to service connected disabilities including PTSD and diabetes.  However, since his claim is being granted based on a secondary service connection theory of entitlement, in particular his sleep apnea secondary to his service-connected PTSD, no further discussion is required regarding the direct service connection theory.

Service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability.  See 38 C.F.R. § 3.310(a) (2015); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993).  Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a).  See Allen v. Brown, 7 Vet. App. 439, 448 (1995). 

For secondary service connection to be granted, generally there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability.  See Wallin v. West, 11 Vet. App. 509, 512 (1998).  When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition.  38 C.F.R. § 3.310 (2015); see Harder v. Brown, 5 Vet. App. 183, 187 (1993).  Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a).  See Allen v. Brown, 7 Vet. App. 439, 448 (1995).  

With respect to element (1), current disability, the competent medical evidence of record indicates a diagnosis of sleep apnea.  See, e.g., the July 2014 VA examination report.  Accordingly, element (1), current disability, is satisfied.  
Element (2) has been met; the Veteran is service-connected for PTSD.

Turning to element (3), nexus, the Board finds that the competent and probative evidence demonstrates that the Veteran's currently diagnosed sleep apnea is at least as likely as not related to his service-connected PTSD.  A competent and probative medical opinion is of record concerning the issue of nexus for the Veteran's sleep apnea in the form of a February 2015 treatment report from Dr. Ali, M.D.

Specifically, Dr. Ali documented the Veteran's history of snoring at night, difficulty sleeping, and his problems of irritability, nervousness, and depression from his PTSD.  She further noted medical literature suggesting that combat veterans with PTSD almost universally experience sleep problems, including more cases of sleep apnea than might otherwise be expected.  Specifically the study looked at a group of 135 young, and otherwise healthy combat veterans who, despite their relatively young age (35) and slightly overwieght physique, 54 percent of the PTSD who underwent polysomnography were diagnosed with obstructive sleep apnea, compared with approximately 20 percent of the general population.  She also reported that sleep apnea is associated with a higher prevalence of psychiatric comorbid conditions in Veterans Health Administration beneficiaries, and this association suggests that patients with psychiatric disorders and coincident symptoms suggesting sleep-disordered breathing should be evaluated for sleep apnea.  Based on a review of this medical literature and the Veteran's medical history, Dr. Ali concluded that it is more likely than not that the Veteran's sleep apnea is secondary to his service-connected PTSD.  

The opinion of Dr. Ali was based upon a thorough analysis of the Veteran's history and current medical condition.  See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion").  

Based on the total record, the Board finds that there is sufficient competent medical evidence to indicate that the Veteran's sleep apnea is at least as likely as not related to his service-connected PTSD.  The Board also notes that there is no medical opinion of record which suggests that the Veteran's sleep apnea is not related to his PTSD.  The Board therefore finds that the benefit of the doubt rule is for application.  See 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015).  Element (3), and therefore all elements, is satisfied.  

In summary, the Veteran has met all requirements needed to establish service connection for sleep apnea and the claim is granted.  

Entitlement to Service Connection for Cataracts

The Veteran contends that he has cataracts that are related to his military service or are alternatively the result of his service-connected diabetes mellitus.  In May 2015, the Veteran's representative argued that the Veteran's cataracts were the result of his diabetes mellitus, noting that medical literature suggested that diabetes along with long-term use of Simvastatin accelerates cataract formation.  The representative noted that the Veteran was service connected for diabetes mellitus and was taking Simvastatin for treatment of his cholesterol.

The law and regulations pertaining to service connection on a secondary basis have been set forth above.  Additionally, service connection will generally be granted for disability or injury incurred in or aggravated by active military service.  See 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2015).  To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service."  Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167(Fed. Cir. 2004).  The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value.  See Baldwin v. West, 13 Vet. App. 1, 8 (1999).

As noted above, in order for service connection to be granted, three elements must be present:  (1) a current disability; (2) in-service incurrence of disease or injury; and (3) nexus.  See Shedden, supra.

As to element (1), the competent and probative evidence of record documents diagnoses of cataracts.  See, e.g., a VA examination report dated January 2011.  Shedden element (1) is therefore satisfied.

Turning to crucial element (2), in-service incurrence of an injury or disease, to the extent that the Veteran contends that his cataracts are related to his military service, the Board finds that the competent and probative evidence of record outweighs these contentions.  Crucially, his service treatment records indicate no suggestion of treatment for cataracts.  On the contrary, the earliest document showing a history of a diagnosis or symptoms consistent with cataracts is more than 25 years after his separation from service.  See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the veteran); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (noting that it was proper to consider the veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised).    

The Board observes that lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person (e.g. any evidence not requiring that the proponent has specialized education, training, or experience).  38 C.F.R. § 3.159(a)(2).  As such, the Veteran can competently testify about symptoms he experienced in service.  However, competency must be distinguished from weight and credibility.  The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Layno v. Brown, 6 Vet. App. 465, 469 (1994).  In the present case, the Board finds that the Veteran's history of cataracts since service is outweighed by the objective evidence of record in light of both the lack of any post service treatment or complaints of this disability until more than 25 years after his separation from service.       

Accordingly, to the extent that the Veteran contends that his cataracts manifested during service, this contention is at odds with the remainder of the record, which is devoid any indication that any injury or disease occurred during service or for more than 25 years thereafter.  As such, the Veteran's statements are lacking probative value.  See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence).

In short, there is no objective indication of an in-service diagnosis of cataracts or symptomatology attributed therewith.  Element (2) for direct service connection is therefore not met, and the Veteran's claim fails on this basis.
  
For the sake of completeness, the Board will discuss element (3), nexus.  See Luallen v. Brown, 8 Vet. App. 92, 95-6 (1995), citing Holbrook v. Brown, 8 Vet. App. 91, 92 (1995) (the Board has the fundamental authority to decide a claim in the alternative).  There is no competent and probative evidence of record that establishes a direct causal relationship between the Veteran's currently diagnosed cataracts and his military service.  

In relevant part, 38 U.S.C.A. 1154(a) (West 2014) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits.  Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).  "Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional."  Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("(T)he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence").

The Board notes that the Veteran, while entirely competent to report his symptoms both current and past, has presented no clinical evidence of a nexus between his cataracts and his military service.  The Board finds that the Veteran as a lay person is not competent to associate any of his claimed symptoms to his military service.  That is, the Veteran is not competent to opine on matters such as the etiology of his current cataracts.  Such opinion requires specific medical training in the field of eye disabilities and is beyond the competency of the Veteran or any other lay person.  In the absence of evidence indicating that the Veteran has the medical training in the field of eye disabilities sufficient to render medical opinions, the Board must find that his contention with regard to a nexus between his cataracts and military service to be of minimal probative value and outweighed by the objective evidence of record which is absent a finding of such.  See 38 C.F.R. § 3.159(a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions).  Accordingly, the statements offered by the Veteran in support of his own claim are not competent evidence of a nexus.

With regard to the Veteran's cataracts, the Board is aware of the provisions of 38 C.F.R. § 3.303(b) relating to chronicity and continuity of symptomatology.  However, the Federal Circuit has held that section 3.303(b) applies only to those chronic conditions specifically listed in 3.309(a).  See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).  The Veteran's cataracts are not such a listed disease entity.  Therefore, establishment of service connection on the basis of continuity of symptomatology is not warranted as to this claim.

Accordingly, element (3) is not met, and the Veteran's claim also fails on this basis.

Turning to whether service connection can be granted on a secondary basis, as discussed above, with respect to element (1), current disability, the competent medical evidence of record indicates diagnoses cataracts.  See, e.g., a VA examination report dated January 2011.  Accordingly, element (1), current disability, is satisfied.  Additionally, the Veteran is currently service-connected for diabetes mellitus, type II.  Element (2) is therefore also satisfied.    

Turning to crucial element (3), nexus, the Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that the weight of the competent and probative evidence of record is against a finding that the Veteran's current cataracts is either due to or aggravated by his diabetes.

Specifically, the Veteran was afforded a VA examination in January 2011.  After examination of the Veteran and review of his claims folder, the VA examiner diagnosed the Veteran with cataracts and concluded that it was less likely than not that the Veteran's cataracts were caused by his diabetes.  The examiner explained in an addendum dated February 2012 that while there is a specific type of cataract that is linked to diabetes, a posterior subcapsular cataract, the Veteran does not have this type of cataract.  On the contrary, the Veteran has a nuclear sclerosis cataract which is age-related.  The Board also notes that another VA examiner concluded in an August 2013 report following examination of the Veteran and consideration of his medical history that the Veteran's diagnosed cataracts are not related to his diabetes.      

The January 2011 VA examination report with February 2012 addendum were based upon thorough examination of the Veteran and analysis of his entire history.  See Bloom, supra.  

The Board observes that the Veteran has submitted a medical article dated November 2014 indicating a possible relationship between cataracts and diabetes.  The Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence.  See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses).  However, the article submitted by the Veteran is of a general nature and does not contain any information or analysis specific to the Veteran's case.  Moreover, the article did not actually link the development of cataracts to diabetes mellitus or to statin use, but rather indicated that further study on the subject to the laws and regulations governing the award of monetary benefits. was encouraged.  Additionally, the Court has held that medical evidence which is speculative, general, or inconclusive in nature cannot support a claim.  See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996).  

Here, multiple opinions have been obtained to address the specifics of the Veteran's disability.  As discussed in detail above, the January 2011 VA examiner reviewed the Veteran's medical history, considered his complaints, and conducted an examination of the Veteran, and thereafter concluded that the Veteran's current cataracts is not related to his diabetes.  The Board has therefore placed great probative value on the findings of the VA examiner.  While the medical article submitted by the Veteran is of probative value, such value is outweighed by the examiner's opinion which focused on the specifics of the Veteran's case.  

The Board notes that the Veteran, while entirely competent to report his symptoms both current and past, has presented no probative clinical evidence of a nexus between his cataracts and service-connected diabetes.  The Board finds that the Veteran as a lay person is not competent to associate any of his claimed symptoms to his service-connected diabetes.  That is, the Veteran is not competent to opine on matters such as the etiology of his current cataracts.  Such opinion requires specific medical training in the field of eye disabilities and is beyond the competency of the Veteran or any other lay person.  In the absence of evidence indicating that the Veteran has the medical training in the field of eye disabilities sufficient to render medical opinions, the Board must find that his contention with regard to a nexus between his cataracts and service-connected diabetes to be of minimal probative value and outweighed by the objective evidence of record which is absent a finding of such.  See 38 C.F.R. § 3.159(a)(1), supra.  Therefore, the statements offered by the Veteran in support of his own claim is not competent evidence of a nexus.

As described, when weighing the evidence, the negative VA medical opinion is afforded greater weight than either the Veteran's assertions or the non-specific medical articles.  The examiner addressed the specifics of the Veteran's claim, including the type of cataract he had and explained why such was not the result of diabetes mellitus.  Conversely, the Veteran is not competent (medically qualified) to determine the etiology of his cataracts and the medical literature that was provided only suggests the possibilty of a link between diabetes mellitus and cataracts.  As such, the VA medical opinion is found to be the most probative evidence and therefore the weight of evidence is against a finding that the Veteran's cataracts were caused by his service connected diabetes mellitus.  

The Board notes that evidence has not been submitted suggesting that the Veteran's cataracts were in any way aggravated by his diabetes mellitus. 
 
As discussed, the criteria for service connection for cataracts have not been met and the Veteran's claim is denied.

Entitlement to an increased rating for PTSD

In an October 2011 rating decision, the Veteran was awarded service connection for PTSD and a 30 percent disability rating was assigned effective July 26, 2004.  The Veteran submitted a timely notice of disagreement with the rating decision, disagreeing with the assigned disability rating and perfected an appeal as to this issue.  As this is an initial claim, the Veteran's appeal period goes back to June 26, 2004, his date of claim.  

Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule).  38 U.S.C.A. § 1155; 38 C.F.R. §§  4.1, 4.2, 4.10 (2014).  

In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition.  The Board has a duty to acknowledge and consider all regulations that are potentially applicable.  Schafrath v. Derwinski, 1 Vet. App. 589 (1991).  The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required.  38 C.F.R. §§ 4.1, 4.2, 4.10.  

Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating will be assigned.  See 38 C.F.R. § 4.7.  Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor.  38 C.F.R. § 4.3.  

When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found.  Such separate disability ratings are known as staged ratings.  See Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007).   

VA is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence that does so.  Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996).  The reasonable doubt doctrine dictates that all symptoms be attributed to the veteran's service-connected disability.  See Mittleider, 11 Vet. App. at 181.  

PTSD is evaluated under the General Rating Formula for Mental Disorders.  See 38 C.F.R. § 4.130, Diagnostic Code 9411.  Under the General Rating Formula for Mental Disorders, a 100 percent rating is assigned when PTSD causes 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; or memory loss for names of close relatives, own occupation, or own name.  Id. 

A 70 percent rating is assigned when PTSD causes occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); or inability to establish and maintain effective relationships.  Id.

A 50 percent rating is assigned when PTSD causes occupational and social impairment with reduced reliability and productivity, due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing effective work and social relationships.  Id.

A 30 percent rating is assigned when PTSD causes occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational 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, or mild memory loss (such as forgetting names, directions, recent events).  

The criteria set forth in the rating formula for mental disorders do not constitute an exhaustive list of symptoms, but rather are examples of the type and degree of the symptoms, or their effects, that would justify a particular rating.  Mauerhan v. Principi, 16 Vet. App. 436 (2002).  Nevertheless, the Veteran must demonstrate the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.  Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013) (also explaining that VA intended the General Rating Formula to provide a regulatory framework for placing veterans on the disability spectrum based upon their objectively observable symptoms).

A Global Assessment of Functioning (GAF) score is a quantifiable assessment of overall functioning used by mental health clinicians that reflects an individual's "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness."  See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (both citing the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), p. 32 (1994)).  

Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated Fifth Edition (DSM-5).  See 79 Fed. Reg. 149, 45094.  The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014.  Id.  VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that were certified for appeal to the Board or were pending before the Board as of August 4, 2014.  See 80 Fed. Reg. 53, 14308 (March 19, 2015).  The RO certified the Veteran's appeal to the Board in February 2014, and therefore the claim is governed by DSM-IV.

The Board notes that the use of GAF scores has been abandoned in the DSM-5 because of, among other reasons, "its conceptual lack of clarity" and "questionable psychometrics in routine practice."  See Diagnostic and Statistical Manual for Mental Disorders, Fifth edition, p. 16 (2013).  In this case, however, the Veteran's claim is governed by DSM-IV and DSM-IV was in use at the time the medical entries of record were made.  Thus, the GAF scores assigned remain relevant for consideration in this appeal.

GAF scores ranging between 61 and 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships.  See Diagnostic and Statistical Manual for Mental Disorders, Fourth edition, p. 46 (1994).  

Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).  Id. at p. 47.  

Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).  Id. 

Scores ranging between 31 and 40 are assigned 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 (e.g., depressed man avoids friends, neglects family, and is unable to work).  Id. 

In May 2004, the Veteran was seen by VA psychiatry.  It was noted that the Veteran had a difficult life with a mentally retarded and behavoirally challenged son and a wife with medical problems.  The Veteran was depresed and anxious.  He had difficulty sleeping, and was irritable and very anxious.  However, was not suicidal.  A GAF of 60 was assigned.  At a second visit, the Veteran was alert and oriented and was noted to be active in an email campaign to obtain assistance for his son.  The Veteran stated that his current stressors (apparently family and financial) were causing difficulty sleeping.  The Veteran did not want to be overmedicated.

In July 2004, the Veteran was noted to have been offered a volunteer position as the head of fundraising with his church and he stated that it felt good to be recognized by others as being capable.  The Veteran was alert and oriented with normal thought processes.

In August 2004, the Veteran reported experiencing nightmares but noted that he was sleeping better.  He was alert and oriented with no suicidal ideation or homicidal ideation and no evidence of delusions or hallucinations.  The Veteran was noted to be managing his stress.

In January 2008, the Veteran had nervousness, angry outbursts and irritability.  He had a normal appearance with normal speech and thought process.  His memory was grossly intact and his insight and judgment was good.  His affect was depressed and anxious, but he denied any suicidal ideation or homicidal ideation.

In October 2009 and February 2010 the Veteran was assigned a GAF of 55.

In March 2010, the Veteran was in a PTSD support group where he was able to interact with others, identify positive aspects of his life, take action to reduce effects of anxiety, express emotions, among other things.  The Veteran was noted to be attentive with clear thought processes and appropriate dress.  He was calm.

In January 2011 the Veteran was afforded a VA examination for his PTSD.  At that examination the Veteran presented with ongoing nightmares two to three times a week of traumatic experiences he had while in Vietnam and of Vietnamese children who were killed.  He avoided thoughts and feelings associated with such events including watching war movies and watching the news.  He noted that he had diminished participation in social activities, and that in the past he had his wife had been actively involved in the church.  He noted that since moving to Oklahoma in 2002 he had limited his social activities to just being with his wife, children and grandchildren.  He struggled with insomnia, sleeping only two to three hours a night and also with irritability.  The Veteran noted that he participated in an anxiety and depression support group.  He found the group beneficial to him, and he reported no other ongoing mental health treatment.  

The Veteran reported a history of being born and raised in Connecticut by both parents.  He noted that he was an only child and had a high school degree.  The Veteran had been married to his wife for almost 41 years at the time of the examinations with three children.  The Veteran reported getting along well with his children and his wife and having "great relationships" with his grandchildren.  The Veteran reported being unemployed since 2001, but stated that following his military career he worked with computers.  He noted an inability to secure employment since 2002 but was able to maintain personal hygiene and basic activities of daily living.  He stated that he spent most of his time taking care of his wife and son and also would play solitaire and work on the computer.  

On examination the Veteran was well-groomed with good personal hygiene.  His affect appeared restricted and his mood was mildly depressed.  His attention, concentration and memory were within normal limits and he could not recall the names of his medications.  He had poor sleep and had lost weight due to his dieting but denied suicidal or homicidal ideations or intent.  There was no evidence of a thought disorder in terms of derailment and he denied hallucinations or delusions.  The examiner diagnosed the Veteran with Axis I PTSD and assigned a GAF score of 70.  

In January 2013, Dr. Riebeling wrote a letter asserting that she was of the belief from a review of the record that the Veteran's PTSD rendered him unemployable since at least November 2004.  She noted that the Veteran's resume documented an unambiguous trend of career success in information technology with positions of increasing responsibility, including supervisory authority and managing budgets.  She suggested that the Veteran's GAF scores did not adequately convey the Veteran's degree of dysfunction, noting that the medical professionals who had treated him repeatedly noted the Veteran's irrational and debilitating belief in a conspiracy and his impaired judgment.  She then quoted from a number of treatment records from March 2004 to November 2004.

In July 2013 the Veteran was afforded a VA psychiatric examination.  At that evaluation the Veteran reported symptoms of efforts to avoid thoughts, feelings or conversations associated with his traumatic events in service, markedly diminished interest or participation in significant activities, difficulty falling or staying asleep, irritability outbursts of anger and hypervigilance.  The Veteran also reported that he attended PTSD group therapy which he benefitted from.  The examiner acknowledged the Veterans prior diagnosis of PTSD and found that the Veteran appeared to have occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of the inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation.  The examiner also noted symptoms of depressed mood and anxiety associated with the PTSD, and that the Veteran did not appear to pose any threat of danger or injury to self or others.  The examiner confirmed the Veteran's diagnosis of PTSD and assigned him a GAF score of 58.  

As briefly discussed above, VA treatment records dated during the course of the appeal document the Veteran's treatment for his PTSD.  These treatment records indicate that the Veteran's PTSD symptoms consist of anxiety, nightmares associated with his military service, difficulty with falling asleep and maintaining a regular sleep pattern, hypervigilance, obsessive thinking, and irritability.  A November 2004 treatment record indicated that he was trying to "find justice" for his family which impaired his judgment to manage his anxiety.  However, the VA treatment records document the Veteran's participation in group therapy and repeatedly document the absence of suicidal and homicidal ideation as well as his appropriate grooming and appearance, orientation, speech, memory, judgment, eye contact, motivation, impulse control, and absence of delusions.  Notably, a June 2008 psychiatric evaluation notes his statement that his family is very important to him.  Although his affect was noted as being between worry and angry, the evidence does not demonstrate a flattened affect.  The Board further notes in a January 2013 statement, Dr. Riebeling., PhD. opined that the Veteran's PTSD rendered him unemployable due to the Veteran's impaired judgment as he believed that he was being targeted by the government in a conspiracy.

Based on the evidence, the Board concludes that throughout the rating period, no more than a 30 percent rating is warranted for the Veteran's service-connected PTSD, as the preponderance of the evidence is against a finding that the Veteran's symptoms have resulted in occupational and social impairment with reduced reliability and productivity or greater occupational and social impairment.  The Board acknowledges that some VA treatment records have indicated that the Veteran's judgment is impaired.  However, there is no evidence of impaired speech, panic attacks more than once a week, disturbances of motivation or mood, flattened affect, difficulty in understanding complex commands, or impaired abstract thinking.  Although the Veteran was not able to recall the names of all of his medications, his memory has been consistently reported to be within normal limits.  

With regard to difficulty in establishing effective work and social relationships, the Veteran has reported that he has not worked since 2002 and that his participation in social activities has diminished due to his PTSD.  Although the evidence of record indicates social impairment, the Veteran has maintained multiple social relationships.  Specifically, he has consistently indicated a positive relationship with his wife, children, and grandchildren.  Moreover, he attended PTSD group therapy on a regular basis which he found beneficial.  Indeed, the January 2011 VA examiner reported mild impairment with regard to social functioning.  As such, the Board finds that the Veteran has been able to establish multiple effective relationships.  

The Board also observes that the Veteran has been assigned GAF scores between 55 and 70, which indicate mild to moderate impairment with a GAF of 58 at his most recent VA examination.  While Dr. Riebeling suggested that the assigned GAF scores were not indicative of the Veteran's true level of impairment, there is no indication that she ever met the Veteran, and the multiple medical professionals who did personally meet the Veteran clearly reached a different conclusion than Dr. Riebeling.  That is, they did not suggest that the Veteran's PTSD rendered him unemployable.  The Veteran was even provided with a VA examination following the receipt of Dr. Riebeling's letter, but even then the GAF score that was assigned was in the moderate range.

In light of the foregoing, the Board concludes that the evidence of record does not show that the Veteran's overall level of severity more closely approximates the criteria for a 50 percent disability rating under 38 C.F.R. § 4.130.  See Mauerhan v. Principi, supra (the specified factors for each incremental rating are examples rather than requirements for a particular rating; analysis should not be limited solely to whether the claimant exhibited the symptoms listed in the rating scheme).  Rather, the Veteran's overall level of functioning is greater than that contemplated by the 50 percent rating category.  The Board finds that the evidence as whole indicates that the Veteran's PTSD is most accurately manifested by nightmares, anxiety, difficulty adapting to stressful circumstances, hypervigilance, irritability, and chronic sleep impairment.  These criteria are most accurately reflected in the currently assigned 30 percent disability rating.  

The Board also notes that the competent and probative evidence of record does not demonstrate criteria warranting a 70 percent rating for the Veteran's PTSD for any portion of the appellate period.  In this regard, the Board notes that the Court of Appeals for the Federal Circuit (Federal Circuit) recently held in Vazquez-Claudio, supra that "in the context of a 70 percent rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas."  

The Board notes that the Veteran has arguably evidenced some difficulty adapting to stressful circumstances.  However, the evidence does not show that the Veteran has occupational and social impairment with deficiencies in most areas.  Specifically, the evidence fails to demonstrate such symptomatology as suicidal ideation; obsessional rituals to the extent that they interfere with routine activities; near-continuous panic or depression; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; neglect of personal appearance and hygiene; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; or other symptoms on par with the level contemplated here.  Moreover, as discussed above, although the Board acknowledges that the Veteran has some social functioning impairment, the evidence of record does not indicate an inability to establish and maintain effective relationships.  Furthermore, there are no other factors which would lead the Board to conclude that a 70 percent disability rating is warranted.  See Mauerhan, supra.  

The Board has also determined that the criteria approximating a 100 percent rating for any portion of the appellate period have not been met.  While the Board accepts that the Veteran's PTSD affects his functioning, the lay and medical evidence of record does not demonstrate both total occupational and social impairment.  The evidence does not demonstrate gross impairment in thought process or communication, persistent delusions or hallucinations, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of personal hygiene), disorientation to time or place, memory loss for names of close relatives or own name, or other symptoms on a par with the level of severity exemplified in these manifestations.  Rather, the Veteran has repeatedly been found to be oriented, maintains normal hygiene, and has not endorsed suicidal or homicidal ideation.  There is nothing in the record that supports a finding that the Veteran has symptoms whose severity cause total occupational and social impairment.  As such, the Board finds that the record as a whole does not support the existence of symptoms such that there is total occupational and social impairment.  The fact remains that the Veteran has been commendably married to his spouse for more than 40 years and continues to report good interaction with his children and grandchildren, as such he is not totally socially impaired.

Based on all of the above, the Board finds that a disability rating greater than 30 percent is not warranted at any time during the period under review.  The Veteran's application for a higher schedular rating for his service-connected PTSD is denied.

Entitlement to a compensable rating  for Erectile Dysfunction

The Veteran is service connected for erectile dysfunction for which an initial 
noncompensable disability rating has been assigned by an October 2011 rating decision under Diagnostic Code 7599-7522 effective June 2, 2006.  The Veteran filed a notice of disagreement to this rating decision and perfected an appeal as to this issue in October 2012.  

The rating schedule provides three codes for penile impairment.  Removal of half or more of the penis is rated as 30 percent disabling, or is to be rated based on voiding dysfunction.  38 C.F.R. § 4.115b, Diagnostic Code 7520.  Removal of the glans of the penis is rated as 20 percent disabling, or is to be rated based on voiding dysfunction.  38 C.F.R. § 4.115b, Diagnostic Code 7521.  Deformity of the penis with loss of erectile power is rated as 20 percent disabling.  38 C.F.R. § 4.115b, Code 7522.  In every instance where the schedule does not provide a zero percent evaluation for a Diagnostic Code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met.  38 C.F.R. § 4.31.

There is no schedular rating for loss of erectile power alone.  In other words, loss of erectile power without penis deformity does not warrant a compensable rating (aside from the special monthly compensation, which has already been granted in this case).  38 C.F.R. § 4.115(b), Diagnostic Code 7522.

In July 2013 the Veteran was afforded a VA examination for his erectile dysfunction.  At that examination the Veteran reported having been diagnosed with erectile dysfunction and having taken Viagra to treat it.  The Veteran did not report having a voiding dysfunction,  or chronic epididymitis or prostatitis.  He also did not report a history of recurrent symptomatic urinary tract or kidney infections.  The examiner noted that the Veteran was not able to achieve an erection sufficient for penetration and ejaculation even with medication.  The examiner noted that the Veteran was not examined per his request, so the examiner was unable to report whether the Veteran's penis or testes appeared normal.  However, the Veteran reported a normal anatomy with no penile deformity or abnormality.  With respect to his testes, the Veteran also requested to not be examined, but reported a normal anatomy with no testicular deformity or abnormality.  

The Board notes that there are no findings in the remainder of the competent and probative evidence of record that are contrary to the findings of the July 2013 VA examination.  As such, the competent evidence does not indicate that any portion of the penis or the glans of the penis has been removed.  Indeed, there is no clinical evidence of any deformity of the Veteran's penis. 

In relevant part, 38 U.S.C.A. 1154(a) (West 2014) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits.  Davidson, supra.  "Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional."  Jandreau and Buchanan, both supra.

The Board notes that the Veteran, while entirely competent to report his symptoms both current and past (including difficulty achieving an erection), has presented no clinical evidence that his penis exhibits any form of physical deformity.  The Board finds that the Veteran as a lay person is not competent to opine on such matters.  That is, the Veteran is not competent to opine on matters such as whether his penis exhibits any form of physical deformity.  Such opinion requires specific medical training in the field of genitourinary disabilities and is beyond the competency of the Veteran or any other lay person.  In the absence of evidence indicating that the Veteran has the medical training in this field to render medical opinions, the Board must find that his contention with regard to his claim that his penis is physically deformed such that an increased rating is warranted for his erectile dysfunction to be of minimal probative value and outweighed by the remainder of the objective evidence of record which is absent a finding of such.  See also 38 C.F.R. § 3.159(a)(1), supra.  Accordingly, the statements offered by the Veteran in support of his own claim are not competent evidence of a deformity of the penis.

Consequently, the Board finds that the weight of the probative evidence is against a finding that the Veteran has a deformity of the penis at any point during the course of the appeal period.  Accordingly, the criteria for a compensable evaluation under Diagnostic Codes 7520, 7521 or 7522 are not met, and the claim for a compensable initial disability rating for erectile dysfunction is denied.  

Entitlement to a higher evaluation for Hypothyroidism

A December 2011 rating decision awarded the Veteran service connection for hypothyroidism and assigned a 10 percent disability rating effective January 10, 2007.  The Veteran contends that he is entitled to a disability rating in excess of 10 percent, and perfected an appeal as to this issue.

The Veteran is rated 10 percent disabling for hypothyroidism under 38 C.F.R. 
§ 4.119, Diagnostic Code 7903.  Under Diagnostic Code 7903, a 10 percent rating is assigned for hypothyroidism with fatigability, or; when continuous medication required for control.  A 30 percent rating is assigned when hypothyroidism causes fatigability and mental sluggishness.  A 60 percent rating is assigned when hypothyroidism causes muscular weakness, mental disturbance, and weight gain.  A 100 percent rating is assigned for hypothyroidism with cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness.  38 C.F.R. § 4.119.

At a January 2011 VA examination the Veteran reported that he had been diagnosed with a thyroid condition in 2004.  He noted that he had been taking medication for it since then.  He reported a history of fatigability, but denied any change in his mental condition secondary to his thyroid problems.  The Veteran denied any other systematic symptoms as a result of his thyroid disorder, and denied any surgery secondary to the condition.  The Veteran reported a cold sensitization of his lower extremities and no heat intolerance.  He reported a history of weight gain of over 10 pounds over the five years prior to the examination.  He reported that his thyroid condition did not affect his activities of daily living, recreational activities or employment.  He reported that he did not have any eye or visual conditions secondary to his thyroid, and noted no muscle weakness or tremors.  Upon examination the examiner found that the Veteran's vital signs and general systems within normal limits.

In July 2013 the Veteran was afforded a VA examination for his hypothyroidism a second time.  At that examination the examiner noted the Veteran's history of hypothyroidism and use of Synthroid for treatment.  The examiner noted that the Veteran's thyroid condition required continuous medication, but that the Veteran had not had radioactive iodine treatment or surgery for his condition.  The Veteran experienced fatigue as a symptom of his thyroid disorder but did not have any pressure on adjacent organs or scars in the area or areas of the neck that were pigmented or had abnormal texture.  With respect to the Veteran's hypothyroidism, the only symptom that the VA examiner noted was fatigability.  Pertinently, the examiner did not report constipation, mental sluggishness, muscular weakness, mental disturbance, weight gain, cold intolerance, or bradycardia.  The examiner further noted that the Veteran's thyroid condition affected his ability to work by causing him to become tired easily.  

In May 2015, the Veteran's representative asserted that the Veteran had reported cold sensitivity and numbness in the lower extremities bilaterally, and purplish discoloration was noted in the toes.  The representative also suggested that the Veteran had experienced weight gain and fatigability that had been attributed to his hypothyroidism, but did not provide any citation to where such information was being derived from.  As such, the representative suggested that a 30 percent rating was warranted.  The Board disagrees.

As an initial point, the 30 percent rating requires both fatigability and mental sluggishness.  However, neither examination for the Veteran's hypothyroidism found sluggishness to be present.  Likewise, he has not been shown to have weight gain for VA purposes so as to justify a 60 percent rating.  For example, at the most recent examination no weight gain was noted within the context of hypothyroidism.

The Board notes that the medical treatment records have not shown findings contrary to the VA examination reports during the period under consideration with regard to the Veteran's hypothyroidism symptomatology.  Therefore, the Board finds that a disability rating in excess of 10 percent is not warranted at any time.  The clinical evidence indicates that the Veteran's hypothyroidism is manifested by fatigability and requires continuous medication during the pendency of the appeal.  In particular, the Board finds the January 2011 and July 2013 VA examination reports deserve substantial probative value with respect to the specific symptoms attributable to the Veteran's hypothyroidism.  As such, the Board finds the evidence does not demonstrate competent, credible symptoms of constipation or mental sluggishness to warrant a 30 percent disability rating, nor is there competent evidence of muscular weakness, mental disturbance, and weight gain attributable to hypothyroidism upon which to base a 60 percent disability rating.  38 C.F.R. § 4.119, Diagnostic Code 7903.

The Board acknowledges the Veteran's competent lay statements describing his symptoms and their effects on his daily life.  Jandreau, 492 F.3d at 1377; Layno, 6 Vet. App. at 469 ; see also Buchanan, 451 F.3d 1331.  Here, the Board has based the decision on the lay statements as well as the objective medical evidence, as it demonstrates consideration of the Veteran's statements and the information necessary to rate the Veteran's disability under the rating criteria.  The Veteran reported his symptoms to multiple VA examiners, who did not attribute any additional symptoms to his hypothyroidism that would warrant an increased disability rating.  

For these reasons, the Board finds the criteria for a disability rating in excess of 10 percent for hypothyroidism have not been met at any time during the pendency of the appeal.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.119, Diagnostic Code 7903.

Entitlement to a Higher evaluation for peripheral vascular disease of the left lower extremity

In a September 2010 decision, the Board granted service connection for peripheral vascular disease of the left lower extremity.  The rating was effectuated by an October 2011 rating decision that assigned a 20 percent disability rating effective June 2, 2006 under 38 C.F.R. § 4.104, Diagnostic Code 7199-7115 (thrombo-angiitis obliterans (Buerger's Disease)).  38 C.F.R. §§ 4.20, 4.27(when an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" by using the first two digits of that part of the rating schedule which most closely identifies the part, or system, of the body involved and adding "99" for the unlisted condition).   The Veteran submitted a notice of disagreement to the disability rating in October 2012, and perfected an appeal as to this issue.

Although peripheral vascular disease is not specifically listed in the Rating Schedule, when a disability is not specifically listed in the Rating Schedule, it may be rated under a closely related injury in which the functions affected and the anatomical localization and symptomatology are closely analogous.  38 C.F.R. § 4.20.  In this case, the Board finds that the Veteran's primary symptomatology associated with his left leg compartment syndrome is claudication, pain, and lack of stamina caused by vascular impairment, and these symptoms are most comparable to the rating criteria for rating the vascular disorders of the limbs.  

Under Diagnostic Codes 7111, 7114, and 7115, a 40 percent rating requires claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour, and; trophic changes (thin skin, absence of hair, dystrophic nails) or ankle/brachial index of 0.7 or less.  Claudication on walking more than 100 yards, and diminished peripheral pulses or ankle/brachial index of 0.9 or less warrants a 20 percent rating.  38 C.F.R. § 4.104, Diagnostic Codes 7111, 7114, 7115.

The ankle/brachial index is the ratio of the systolic blood pressure at the ankle (determined by Doppler study) divided by the simultaneous brachial artery systolic blood pressure.  The normal index is 1.0 or greater.  38 C.F.R. § 4.104, Diagnostic Codes 7111, 7114, 7115, Note (1).

Claudication is defined as "limping or lameness," and intermittent claudication is "a complex of symptoms characterized by pain, tension, and weakness in a limb when walking is begun."  Dorland's Illustrated Medical Dictionary 369 (32nd ed. 2012).  

At a VA examination in January 2006, the examiner noted that the Veteran's diabetes affected his arteries resulting in the problem of leg cramps.  This problem had been present for 2 years, and the Veteran reported experiencing intermittent claudication after walking 10 yards on level ground at 2 miles per hour.  The Veteran also reported calf pain at rest and persistent coldness of the extremities.  On examination, there were signs of skin disease at the bottom of the feet.  There were atrophic skin changes with thin skin, absence of hair, and dystrophic nails.  Peripheral vascular disease was not specifically diagnosed.  A Doppler Arterial flow study in February 2006 showed right PVD with a ration of 1.06 and nothing on the left.

In January 2007 the Veteran was afforded a VA examination for his peripheral vascular disease, of the left lower extremity.  The examiner noted that the Veteran had been suffering from diabetes for approximately three years, reporting that he had intermittent claudication after walking 2 yards on level ground.  There was calf pain at rest and the Veteran reported feeling persistent coldness of the extremities.  The ability to perform daily functions during flare-ups was alleviated  by the Veteran sitting down, elevating his legs and taking medication.  His current treatment was hydrocodone once daily.  From this condition he experienced pain, swelling and his leg turned black and purple from knee to ankle.  The examiner noted that the Veteran had signs of PVD, including shiny skin and decreased hair of the feet.  On examination the Veteran was well developed, well nourished and in no acute distress.  Examination of the extremities revealed persistent coldness, ischemic limb pain at rest, atrophic skin changes with thin skin and with absence of hair and diminished monofilament sensation to plantar surfaces of both feet.  Doppler test results showed an ankle/brachial index of 1.4 on the right and 1.0 on the left, both of which the examiner explained were within normal limits, and showed that there was good blood flow to the extremities, but the examiner added that the physical signs of peripheral vascular disease were still present.  

In June 2007 the Veteran was afforded another VA examination for his PVD.  He noted that he was diagnosed with diabetes in 2003, and that he began to have pain in his lower extremities prior to 2003.  He reported that he had lower extremity symptoms, including swelling and discoloration that he described as red and black.  He noted that if he was on his feet standing or walking for a prolonged period of time he would feel as though his feet were giving way and stated that he had cramping in his legs that was most prevalent at night.  He described cramping in his lower calf, ankle and foot when walking.  He reported treating his disability by taking Lortab 7.5 mg ever six hours and etodolac twice daily and stated that it provided him some relief.  He denied any side effects of the medication and denied a persistent coolness to his feet, but did report that they sweat frequently.  He denied having undergone any lower extremity surgery for his vascular condition.  

Upon examination, the examiner found that the Veteran had decreased hair growth over his calves and that his extremities were warm to the touch with no ulcers present.  The skin was not atrophic and there was no discoloration noted.  There was a trace amount of edema present bilaterally.  The examiner noted that the Veteran had a history of bilateral claudication, but no history or either ulcers or rest pain.  An ankle/brachial index showed 1.19 and 1.12 on the right at the calf and ankle respectively, and 1.05 and 1.08 on the left at the calf and ankle respectively.  These were found to be normal, and the examiner stated that there was no evidence of peripheral arterial disease at that time.

At a VA respiratory examination in January 2011, the Veteran stated that he had a history of cold sensitization in the bilateral lower extremities, right worse than left. He also reported swelling on the right ankle and purplish discoloration of his toes.  The Veteran denied any claudication symptoms or pain in the lower legs or calf muscles associated with standing or walking.  The Veteran reports he experiences pain in the knee joints and feet with standing and walking.  The Veteran denied any venous stasis ulcers or any pigmentation on the bilateral lower extremity.  The Veteran stated that his peripheral arterial disease does not affect his activities of daily living, recreational activities, or employment.  The veteran reports the knee and feet pain affects his ability to do prolonged standing and walking.  On examination, the Veteran was well-developed, well-nourished and in no acute distress.  His skin was warm and dry.  There was no evidence of varicosities, or ulceration, and edal pulses were palpable.  There was mild red discoloration of the tips of the toes bilaterally, but no diabetes ulcer, or venous stasis ulcer.  The Veteran's feet were warm to touch and there was no coolness noted.  There was decreased hair growth noted on the lower bilateral lower extremities, although this was not attributed to any particular condition.

At a VA examination in January 2011, the Veteran denied any claudication symptoms.  He also You do not report pain in the lower legs or calf muscles associated with standing or walking. You have knee and feet pain. Upon examination of the feet they are warm to the touch. There is no coolness, but there is decreased hair growth in the lower two thirds of the lower extremities. The pulses are 1+ and 2+. There is no edema noted in the left lower extremity. There is no atrophy of the skin. The ankle brachial index testing dated February 18, 2011 is noted to be negative for peripheral arterial disease. The examiner notes there is no evidence of peripheral arterial disease per your present history on the objective ankle brachial index tests on January 11, 2007, June 22, 2007 or February 18, 2011.

The Veteran was provided another VA examiner in July 2013.  He reported that he used a walker for ambulation.  Notably, the VA examiner reported that the Veteran's peripheral vascular disease of the left lower extremity was manifested by claudication on walking more than 100 yards.  The disability was not manifested by ischemic limb pain at rest, persistent coldness of the extremity, trophic changes, or ischemic ulcers.  Moreover, the Veteran was not diagnosed with an aortic aneurysm.  Left ankle/brachial index testing revealed 1.14 and right ankle/brachial index was 1.14.  The examiner documented the pulse testing as normal.  The examiner concluded that while the Veteran had previously been diagnosed with peripheral vascular disease of the right and left lower extremities, the examiner stated that there was no evidence on examination of peripheral vascular disease in either extremity as the ABI was normal and pulses were normal.

In May 2015, the Veteran's representative argued that the VA examination in January 2006 had shown an abnormal ankle/brachial index in the right lower extremity, and stated that the Veteran experienced intermittent claudication after walking 10 yeards on level ground at two miles per hour and persistent coldness of the bilateral lower extremities.  She also noted that atrophic skin changes such as thin skin, absence of skin and absence of hair had also been observed, and she suggested that a 60 percent rating was warranted for both lower extremities.  She acknowledged that the Veteran had not been shown to have an ankle/brachial index of .5 or less, but noted that a 60 percent rating could be assigned with claudication on walking less than 25 yards with persistent coldness of the extremity.

As an initial point, the issue of an increased rating for peripheral vascular disease of the right lower extremity is not on appeal.  To the extent that the Veteran wishes to appeal the rating that is assigned for that disability, a claim should be filed.

During the course of the Veteran's appeal, a series of ankle/brachial index tests were conducted, but the tests were repeatedly normal and would not support a compensable rating.  As such, the Board must consider other factors listed in the rating schedule to determine whether a higher rating is warranted.

There are no medical findings of record that are contrary to the VA examiners' reports.  As such, the Board finds that the competent and probative evidence does not demonstrate that the Veteran's peripheral vascular disease of the left lower extremity results in claudication on walking between 25 and 1000 yards on a level grade at 2 miles per hour; and with trophic changes or ankle/brachial index of .7 or less.  Accordingly, the Board finds that a higher 40 percent rating is not warranted for the Veteran's peripheral vascular disease of the left lower extremity at any time during the period on appeal.  The clinical evidence indicates that the Veteran's peripheral vascular disease is manifested by claudication on walking more than 100 yards, and ankle/brachial index of over 1.0.  The Board finds the VA examination reports deserve substantial probative value with respect to the specific symptoms attributable to the Veteran's peripheral vascular disease of the left lower extremity.  As such, the Board finds the evidence does not demonstrate evidence of claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour, and; trophic changes (thin skin, absence of hair, dystrophic nails) or ankle/brachial index of 0.7 or less to warrant a 40 percent disability rating, nor is there competent evidence of persistent coldness, ischemic limb pain at rest, or deep ischemic ulcers upon which to base 60 or 100 percent ratings.  38 C.F.R. § 4.104, Diagnostic Code 7115.

The Board acknowledges the Veteran's competent lay statements describing his symptoms.  Jandreau, 492 F.3d at 1377 ; Layno, 6 Vet. App. at 469 ; see also Buchanan, 451 F.3d 1331.  Here, the Board has based the decision on the lay statements as well as the objective medical evidence, as it demonstrates consideration of the Veteran's statements and the information necessary to rate the Veteran's disability under the rating criteria.  The Veteran reported his symptoms to multiple VA examiners, who did not attribute any additional symptoms to his hypothyroidism that would warrant an increased disability rating.  For these reasons, the Board finds the criteria for a disability rating in excess of 20 percent for peripheral vascular disease of the left lower extremity have not been met at any time during the pendency of the appeal.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.104, Diagnostic Code 7115.

Extraschedular considerations

The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis for his service connected disabilities.  Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical.  See Fisher v. Principi, 4 Vet. App. 57, 60 (1993).

According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards.  See 38 C.F.R. § 3.321(b)(1).  An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards.  See Fanning v. Brown, 4 Vet. App. 225, 229 (1993).

Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating.  First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate.  Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms."  Third, if the rating schedule is inadequate to evaluate a veteran'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 extraschedular rating.

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 evaluations for the service-connected PTSD, hypothyroidism, peripheral vascular disease of the left lower extremity, and erectile dysfunction.  A comparison between the level of severity and symptomatology of these disabilities with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology.  

The Veteran's PTSD is manifested by signs and symptoms such as avoidance of certain activities, irritability, anxiety, and chronic sleep impairment, among others.  The Diagnostic Code in the rating schedule for mental disorders provides disability ratings for the Veteran's exact symptoms.  Moreover, even if psychiatric symptoms were experienced that were not specifically enumerated in the schedular rating criteria, Vazquez-Claudio directed the Board to consider all of the Veteran's psychiatric symptomatology and to determine how these symptoms impacted his occupational and social functioning.  As such, the schedular rating that is assigned has considered all of the psychiatric symptomatology.

The Veteran's hypothyroidism is manifested by symptoms such as fatigability which is a symptom contemplated by Diagnostic Code 7903.  It also assesses symptoms such as claudication which is contemplated by Diagnostic Code 7115.  

His erectile dysfunction is manifested by loss of erectile power which is contemplated by Diagnostic Code 7522.  

The Veteran has simply not described symptoms of the disabilities above that are not specifically enumerated.  As such, referral for extraschedular consideration is not warranted in this case.

Finally, the Board notes that a veteran may be awarded an extraschedular 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 service-connected disabilities experienced.  Johnson v. McDonald, 762 F.3d 1362 (2014).  In this case, the Veteran has not alleged, nor does the evidence indicate, that the combined effects of the Veteran's service-connected disabilities require extraschedular consideration.

Further, there is no medical evidence indicating that the Veteran's service-connected disabilities combine or interact either with each other, either separately or together, in such a way as to result in further disabilities, functional impairment, or additional symptomatology not accounted for by the rating criteria applicable to each disability individually.  Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions.

In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology.  The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted.

Earlier effective date than June 2, 2006 for the grant of SMC based on loss of use of a creative organ

The Veteran contends he is entitled to an earlier effective date than June 2, 2006 for his award of special monthly compensation for loss of use of a creative organ.  

Unless specifically provided otherwise in the statute, the effective date of an award based on an original claim for compensation benefits shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400.

A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C.A. § 5101(a); 38 C.F.R. § 3.151(a).  The term "claim" or "application" means a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit.  38 C.F.R. § 3.1(p).  Any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA, from a veteran or his representative, may be considered an informal claim.  An informal claim must identify the benefit sought.  If a formal claim is received within one year of an informal claim, it will be considered filed as of the date of receipt of the informal claim.  38 C.F.R. § 3.155.

To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). 

Under 38 C.F.R. 3.157(b), once a claim for compensation has been allowed, receipt of a VA outpatient or hospital examination or admission to a VA hospital pertaining to the service-connected disability will be accepted as an informal claim for increased benefits.  See Servello v. Derwinski, 3 Vet. App. 196, 199 (1992).  The date on the VA outpatient or hospital examination report will be accepted as the date of claim.  38 C.F.R. 3.157(b).

The Veteran's claim seeking service connection for erectile dysfunction and special monthly compensation for loss of use of a creative organ was received on June 2, 2006.  A review of the Veteran's claims file reveals no other applications or statements on the part of the Veteran filed prior to June 2, 2006 that can be interpreted as an informal claim for benefits concerning this issue.

In an October 2011 rating decision, the Veteran was awarded service connection for erectile dysfunction as secondary to the service-connected diabetes mellitus.  He was also awarded special monthly compensation based on the loss of use of a creative organ, effective June 2, 2006, the date VA received a claim of entitlement to service connection for erectile dysfunction.  

The Veteran contends that he should be granted an earlier effective date than June 2, 2006 for special monthly compensation.  See the Veteran's notice of disagreement dated November 2012.  

In May 2015, the Veteran's representative noted that the April 2006 VA examination concluded that the Veteran's erectile dysfunction was a complication of his service connected diabetes mellitus, and asserted that the effective date for SMC based on loss of use of ac reative organ should be October 24, 2005 since the erectile dysfunction was diagnosed in conjunction with the adjudication of a diabetes claim.
 
Crucially, however, the record does not reveal any indication of the Veteran filing a claim for this benefit until June 2, 2006.  The Board acknowledges the January 2006 VA examination noting a diagnosis of erectile dysfunction.  However, "(t)he mere existence of medical records generally cannot be construed as an informal claim; rather, there must be some intent by the claimant to apply for a benefit."  Criswell v. Nicholson, 20 Vet. App. 501, 504.  As the Veteran's claim for special monthly compensation is dated after the date entitlement arose, the Board will assign the later of the two dates.  Therefore, the Board has no basis upon which to assign an earlier effective date for special monthly compensation based on loss of use of a creative organ. 

Accordingly, entitlement to an effective date prior to June 2, 2006 for the award of special monthly compensation for loss of use of a creative organ is not warranted. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule is inapplicable.  See 38 U.S.C.A. § 5107(b). 

Entitlement to TDIU from April 29, 2013

VA will grant a TDIU when the evidence shows that a veteran is precluded, by reason of his service-connected disabilities, from obtaining or maintaining "substantially gainful employment" consistent with his education and occupational experience.  38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91.

In June 1999, VA's General Counsel  (OGC) issued VAOPGCPREC 6-99 addressing questions of whether a claim for a TDIU may be considered when a schedular 100 percent rating is already in effect for one or more service-connected disabilities.  Essentially, that OGC precedent opinion held that receipt of a 100 percent schedular rating for a service-connected disability rendered moot any pending claim for a TDIU, requiring dismissal of the TDIU claim.  See also Green v. West, 11 Vet. App. 472, 476 (1998); Vettese v. Brown, 7 Vet. App. 31, 34-35   (1994); and Smith v. Brown, 10 Vet. App. 330, 333-34 (1997) (dismissal is the proper remedy to employ when an appeal has become moot).

In Bradley v. Peake, 22 Vet. App. 280 (2008), the Court, taking a position contrary to the one reached in VAOPGCPREC 6-99, held that, although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of TDIU predicated on a single disability may form the basis for an award of special monthly compensation.  See Bradley v. Peake, 22 Vet. App. 280 (2008) (holding that there could be a situation where a veteran has a schedular total rating for a particular service-connected disability, and could establish a TDIU rating for another service-connected disability in order to qualify for special monthly compensation (SMC) under 38 U.S.C. § 1114(s)  by having an "additional" disability of 60 percent or more ("housebound" rate)); see 
38 U.S.C.A. § 1114(s)  (West 2014).  In view of the issuance by the Court of its decision in Bradley, which recognized that it was possible for a veteran first to be awarded TDIU based on a single disability and subsequently receive schedular disability ratings for other conditions that would not duplicate in the count of disabilities for special monthly compensation purposes (that is, separate disabilities that could combine for a 60 percent disability rating), in November 2009 the VA General Counsel  partially withdrew VAOPGCPREC 6-99 to the extent it was inconsistent with Bradley.

VA has a "well-established duty" to maximize a claimant's benefits.  See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Bradley v. Peake, 22 Vet. App. 280 (2008).  This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to special monthly compensation under 38 U.S.C.A § 1114.  See Bradley, 22 Vet. App. at 294 (finding that special monthly compensation "benefits are to be accorded when a veteran becomes eligible without need for a separate claim").  Indeed, as noted in Bradley, VA must consider a TDIU claim despite the existence of a schedular total rating and award SMC under 38 U.S.C.A. § 1114(s) if VA finds the separate disability supports a TDIU independent of the other 100 percent disability rating.  See id.  
Special monthly compensation is payable at the housebound rate where the veteran has a single service-connected disability rated as 100-percent disabling and, in addition, (1) has a service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability, and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i).

Subsection 1114(s) requires that a disabled veteran whose disability level is determined by the ratings schedule must have at least one disability that is rated at 100 percent in order to qualify for the special monthly compensation provided by that statute.  The Court declared, however, if a veteran were awarded a TDIU based on multiple underlying disabilities and then later receives a schedular disability rating for a single, separate disability that would, by itself, create the basis for an award of a TDIU, that the order of the awards was not relevant to the inquiry as to whether any of the disabilities alone would render him unemployable and thus entitled to a TDIU based on that condition alone.  Buie v. Shinseki, 24 Vet. App. 242, 250 (2010).

In this case, the Veteran has contended that he is unemployable due to service-connected disabilities, in particular his PTSD.  From April 29, 2013, the Veteran has a 100 percent schedular evaluation for cardiomyopathy with septal hypokinesis. Further, the Veteran also is service connected for PTSD, evaluated as 30 percent disabling; diabetes mellitus with hypertension, tinea pedis and onychomycosis, and retinopathy, evaluated as 20 percent disabling; peripheral vascular disease of the right lower extremity associated with diabetes, evaluated as 20 percent disabling; peripheral vascular disease of the left lower extremity associated with diabetes, evaluated as 20 percent disabling; peripheral neuropathy of the right lower extremity associated with diabetes, evaluated as 20 percent disabling; peripheral neuropathy of the left lower extremity associated with diabetes, evaluated as 20 percent disabling; hypothyroidism associated with diabetes, evaluated as 10 percent disabling; and erectile dysfunction, evaluated as noncompensable; and a bilateral hearing loss disability, evaluated as noncompensable.  These evaluations combine to 80 percent during the rating period on appeal.  38 C.F.R. § 4.25.  Thus, the Veteran is already entitled to SMC and indeed, in a January 2014 rating decision, the RO awarded SMC based on this criteria effective April 29, 2013.  38 U.S.C.A. 
§ 1114(s); 38 C.F.R. § 3.350(i).  The Veteran did not appeal the assigned effective date of SMC . 

It follows that as the reasoning of Bradley is that TDIU must still be considered even if a veteran has already been awarded a separate 100 percent evaluation for a disability in order to potentially make the veteran eligible for special monthly compensation, and as the Veteran in this appeal has already been awarded SMC  based on the 100 percent evaluation for cardiomyopathy with septal hypokinesis and separate evaluations combined to 80 percent for his remaining service connected disabilities, then consideration of TDIU no longer serves any useful purpose.  As there remains no case or controversy concerning whether the Veteran is entitled to the benefit sought, the appeal with respect to the claim for TDIU is moot and must be dismissed.  Sabonis v. Brown, 6 Vet. App. 426(1994).


ORDER

Service connection for sleep apnea is granted.  

Service connection for cataracts, to include as secondary to diabetes mellitus is denied.  

A compensable evaluation for erectile dysfunction as due to diabetes mellitus is denied.  

An initial evaluation in excess of 30 percent for PTSD is denied.

An evaluation in excess of 20 percent for peripheral vascular disease of the left lower extremity is denied.

Prior to August 15, 2013, entitlement to an initial compensable evaluation for bilateral eye retinopathy is denied.  

From August 15, 2013, entitlement to a 60 percent disability rating for bilateral eye retinopathy is granted, subject to controlling regulations applicable to the payment of monetary benefits.

An initial compensable evaluation for tinea pedis and onychomycosis is denied.  

Initial rating in excess of 10 percent for hypothyroidism is denied.  

A disability rating in excess of 20 percent for peripheral neuropathy of the right lower extremity is denied.

A disability rating in excess of 20 percent for peripheral neuropathy of the left lower extremity is denied.

An earlier effective date than June 2, 2006 for the grant of special monthly compensation based on loss of use of a creative organ is denied.  

The appeal for TDIU from April 29, 2013 is dismissed.





REMAND

With respect to the Veteran's claim of entitlement to service connection for a lung disability, as discussed above, in July 2013, the Board denied this claim.  The Veteran appealed this denial to the Court of Appeals for Veterans Claims (Court).  In December 2014, the Court issued a Memorandum Decision that set aside the July 2013 Board decision and remanded the claim.  The case has been returned to the Board for compliance with the directives contained in the December 2014 Memorandum Decision.
 
The Court's June 2013 Memorandum Decision indicated that the Board failed to provide adequate reasons or bases for its finding that VA satisfied its duty to assist the Veteran with regard to obtaining a medical opinion as to the etiology of the Veteran's lung disability in January 2011.  In this regard, pursuant to a Board remand in October 2010, the Veteran underwent a VA examination in January 2011.  He reported a history of COPD which was diagnosed in 2004.  He further indicated that he used to smoke a pack of cigarettes a day for 15 years and quit smoking about 15 years previously.  He also reported being hospitalized for pneumonia while in the service in 1969.  He denied any other episodes involving a lung condition in the military.  He was discharged in 1977 and did not have any treatments for a lung condition until 1995 when he was diagnosed with reactive airway disease.  After examination of the Veteran, the examiner diagnosed the Veteran with COPD.  The examiner noted that the service treatment records showed that the Veteran was treated for an acute upper respiratory infection in the military and that the infection resolved with treatments with antibiotics.  Further, there was no diagnoses of COPD in the military or evidence that the Veteran was treated for a lung condition until 1995 when he was diagnosed with reactive airway disease.  She further noted that there was no evidence that the Veteran was treated for a lung condition within 10 years of discharge from the military and that the Veteran smoked 1 pack a day for 15 years.  Moreover, the examiner noted that smoking is an independent risk factor for COPD.  The examiner concluded that it was less likely than not that the Veteran's lung condition was secondary to his treatments in the military.

In finding the January 2011 VA opinion to be inadequate for evaluation purposes, the Court noted that the examiner simply recited several facts as to the Veteran's medical history before providing her conclusion and did not relate the data to her conclusion, nor did she determine that the nature and etiology of the Veteran's current lung disability was related to his history of smoking as the Board had indicated in the July 2013 decision.  As such, the Court found that the Board clearly erred when it concluded that the VA examiner provided an adequate medical nexus opinion and that remand was required for clarification of the examiner's opinion or a new opinion.

The Board observes that since the July 2013 Board decision denying the Veteran's claim, there has been no additional medical opinion associated with the record that addresses the etiology of the Veteran's lung disability.  In light of the inadequate findings of the January 2011 VA examiner, and the December 2014 memorandum decision, the Board finds that an additional opinion should be obtained that addresses the etiology of the Veteran's lung disability.  See Charles v. Principi, 16 Vet. App.  370 (2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 C.F.R. § 3.159(c)(4)(holding a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient medical evidence to decide the claim).

With regard to the claim of entitlement to an initial compensable disability rating for tinea pedis and onychomycosis, the Board reiterates that this claim involves a memorandum decision by the Court dated December 2014.  The memorandum decision indicated that the Board failed to provide adequate reasons or bases for its finding that a compensable disability rating was not warranted for the Veteran's skin disability.  In particular, the Board failed to address a January 2007 VA examiner's notation that the Veteran's skin lesion covered 5 percent of his body as well as evidence showing that he had been prescribed triamcinolone acetonide (a corticosteroid).  As this evidence appeared to be material and favorable to the Veteran's claim, the Court determined that this evidence should have been addressed.  Further, because the record contained varying descriptions of the severity of the Veteran's recurrent skin condition, the Board was required to reconcile the various reports into a consistent picture so that the current rating may accurately reflect the elements of the disability present and provide an adequate statement of reasons or bases address the applicability of staged ratings.    

The Board observes that the Veteran was most recently afforded a VA examination for his skin disability in July 2013.  A review of the record reveals that his disability has worsened since the VA examination.  Specifically, recent medical evidence documents the Veteran's use of the corticosteroid triamcinolone acetonide for his skin disability.  See, e.g., a VA treatment record dated .  Notably, a review of the July 2013 VA examination does not document the use of corticosteroids for treatment.  Further, it is unclear as to how frequently the Veteran uses corticosteroids for treatment.  In light of these ambiguous findings, to include the findings of the December 2014 memorandum decision, the Board finds that the Veteran should be provided a VA examination to determine the current severity of his tenia pedis and onychomycosis.   See Snuffer v. Gober, 10 Vet. App. 400 (1997) (a veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination).  

As was described in the Introduction above, by rating action of September 2014, the RO increased the disability ratings for the Veteran's right and left lower extremities to 20 percent effective April 29, 2013.  As stated above, the Veteran expressed disagreement with those assigned ratings.   A SOC has not been submitted addressing these issues.  In Manlincon, supra, the Court held that where a NOD is filed but a SOC has not been issued to the issue that the Veteran expressed disagreement with, the Board must remand the claim to the agency of original jurisdiction so that a SOC may be issued.  Thus, the agency of original jurisdiction must issue a SOC as to the Veteran's claims of entitlement to increased disability ratings for peripheral neuropathy of the right and left lower extremities.

Finally, with regard to the issue of entitlement to TDIU prior to April 29, 2013, the Board notes that further development and adjudication of the Veteran's lung disability and skin disability claims could have an impact upon the claim for a TDIU prior to April 29, 2013; thus, the claim for a TDIU is inextricably intertwined with the claims being developed.  See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991).  As appellate consideration of the claim for a TDIU would, thus, be premature at this juncture, remand of this matter also is warranted. 

Additionally, the Board remanded the issue of TDIU in July 2013 in part for the Veteran to be provided a VA examination in order to determine the effect of his service-connected disabilities, in particular his PTSD, on his employability.  In this regard, the Board noted the January 2013 letter from the Veteran's VA psychologist indicating that his PTSD rendered him unemployable.  A review of the claims folder reveals that although the Veteran was provided a VA examination for his PTSD in July 2013, an opinion as to the effect of his PTSD on his employability was not obtained.  Therefore, the Board finds that an opinion for such must be obtained in compliance with the July 2013 Board remand.  See Stegall, supra.

Accordingly, the case is REMANDED for the following action:

1. The Veteran should be afforded a VA examination by 
the appropriate specialist to determine the nature and etiology of any current lung disability. All lung conditions should be identified. All necessary tests should be performed. The examiner should be requested to furnish an opinion as to whether it is at least as likely as not that the Veteran has a lung disability that is related to any incident of service, to include his documented upper respiratory infection. The rationale for all opinions expressed should be set forth. The claims folder should be made available to the examiner in conjunction with the examination. 

2. Arrange for a dermatological examination of the Veteran to determine the current severity of his tinea pedis and onychomycosis.  The examiner must review the entire record in conjunction with the examination and must be provided a copy of the criteria for rating the skin disability.  Findings reported should be sufficient to allow for rating under all applicable criteria.  The examiner should specifically note whether or not the Veteran currently has a skin disability, the type, the anatomical areas of involvement, the percentage of the Veteran's entire body and exposed areas affected, and the types and extent of treatment required for the disability in the preceding 12-month period, to include use of corticosteroids.  

All opinions must include a complete rationale.

3. Refer the Veteran's claims folder to a medical professional with the appropriate level of expertise for an opinion as to the functional impairment of the Veteran's service-connected disabilities, in particular his PTSD, as to his employability prior to April 29, 2013.  The claims folder must be made available for review by the examiner should note such review in the report.

The examiner should determine the Veteran's employability prior to April 29, 2013 with consideration only of the Veteran's service-connected disabilities, to include PTSD, and without consideration of nonservice-connected disabilities or the Veteran's age. 

The examiner should provide the rationale for all opinions expressed.

4. Issue a SOC pertaining to the issues of entitlement to disability ratings in excess of 20 percent for peripheral neuropathy of the right and left lower extremities.  The Veteran should be notified that a timely substantive appeal must be filed in order to perfect the appeal of these issues.  

5. Review the claims file to ensure that all of the foregoing 
requested development is completed, and arrange for any additional development indicated.  Then readjudicate the claims of entitlement to service connection for a lung disability and entitlement to an initial compensable disability rating for tinea pedis and onychomycosis as well as entitlement to TDIU prior to April 29, 2013.  If the benefits sought remain denied, issue an appropriate supplemental statement of the case and provide the Veteran and his attorney with the requisite period of time to respond.  The case should then be returned to the Board for further appellate review, if otherwise in order.  

The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded.  See Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment.  The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner.  See 38 U.S.C.A. §§ 5109B, 7112 (West 2014).




______________________________________________
MATTHEW W. BLACKWELDER
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs