Citation Nr: 1751099 Decision Date: 11/08/17 Archive Date: 11/17/17 DOCKET NO. 13-20 946 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). 3. Entitlement to service connection for coronary artery disease (CAD) and cardiac arrhythmia as secondary to PTSD. 4. Entitlement to service connection for a central nervous system (CNS) disability as secondary to CAD and cardiac arrhythmia. 5. Entitlement to service connection for hypertension as secondary to PTSD. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Juliano, Counsel INTRODUCTION The Veteran served on active duty in the Air Force from October 1962 to October 1966. These matters come before the Board of Veterans' Appeals (Board) on appeal from September 2010, September 2013, and March 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In February 2009, the RO granted service connection for PTSD and assigned a 30 percent rating, effective October 2008. The Veteran expressed timely disagreement with the initial rating in March 2009, and the RO issued a statement of the case in September 2009 with instructions on how to perfect an appeal. In May 2010, the Veteran submitted a statement referring to a pending appeal for a higher initial rating. In July 2010, the RO received a VA Form 9 dated September 30, 2009 which he contended was a timely perfection of an appeal. In September 2010, the RO issued a decision finding that the VA Form 9 was not a timely perfection of an appeal for a higher initial rating for PTSD and provided the Veteran with instructions on how to disagree with the finding. The next communication from the Veteran relevant to this issue was received in July 2013 and was not timely as a notice of disagreement. Therefore, the issue of an increased initial rating for PTSD from the date of service connection in October 2008 is not on appeal. A November 2016 Board decision denied the claims for service connection for CAD and cardiac arrhythmia, and service connection for CNS, and the Board remanded the remaining claims for further development. The remanded claims are now returned to the Board for further review. A July 2017 Order of the Court of Appeals for Veterans Claims (Court) granted a joint motion by the parties to partially vacate the November 2016 Board decision to the extent the Board denied the claims for service connection for CAD and cardiac arrhythmia, and for CNS. Therefore, these claims are now returned to the Board for further appellate review. The Board acknowledges that after the appeals were certified to the Board, some additional VA treatment records were associated with the VBMS claims file. As none of those records are relevant to the appeals claims, the Board finds that a remand for consideration by the agency of original jurisdiction (AOJ) is not required. The issues of entitlement to service connection for coronary artery disease (CAD) and cardiac arrhythmia, a CNS disability, and hypertension, are addressed in the REMAND portion of the decision below and are REMANDED to the agency of original jurisdiction (AOJ). FINDINGS OF FACT 1. For the entire period on appeal, resolving all doubt in the Veteran's favor, his PTSD is manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as anxiety, depressed mood, insomnia, mild memory loss (such as forgetting names, directions or recent events), impaired impulse control (such as unprovoked irritability with periods of violence), difficulty in adapting to stressful circumstances (including work or a work-like setting), and flattened affect. 2. The Veteran has been awarded service connection for PTSD (70 percent), bilateral hearing loss (noncompensable prior to July 31, 2012, and 20 percent thereafter), and tinnitus (10 percent); his combined rating is 70 percent effective May 18, 2010, and 80 percent effective July 31, 2012. 3. The Veteran is not shown to be unable to secure and follow all forms of substantially gainful employment due to service-connected disability. CONCLUSIONS OF LAW 1. For the period from May 18, 2009, to May 17, 2010, the criteria for a 70 percent evaluation for PTSD are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2016); 38 C.F.R. §§ 3.400(o)(2), 4.3, 4.130, Diagnostic Code 9411 (2016). 2. For the entire period on appeal, the criteria for an evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2016); 38 C.F.R. §§ 4.3, 4.130, Diagnostic Code 9411 (2016). 3. The criteria for entitlement to a TDIU have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.150, 3.155, 3.160, 3.340, 3.341, 4.16, 4.25, 4.26 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) With regard to the Veteran's claim for an increased rating for his PTSD and for a TDIU, the Board finds that VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5102, 5103(a), 5103A, 5106 (West 2014); 38 C.F.R. §§ 3.159, 3.326(a) (2016). The Board finds that a July 2010 and March 2014 notice letters fully satisfied VA's duty to notify the Veteran. See 38 U.S.C.A. § 5103(a). The Board also finds that VA's duty to assist has been satisfied. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The Veteran's VA treatment records, private treatment records, and Social Security Administration (SSA) records are all in the claims file. The Veteran has not identified any outstanding records for VA to obtain. VA's duty to assist generally includes the duty to provide a VA examination or obtain a VA medical opinion when necessary to make a decision on a claim. See 38 C.F.R. § 3.159(c)(4) (2016). The Veteran was afforded VA examinations relating to his PTSD rating claim in July 2010 and February 2017, and in September 2013 relating to his service-connected bilateral hearing loss and tinnitus (and they relate to his claimed TDIU). There is no evidence indicating that there has been a material change in the severity of the Veteran's disabilities since the last VA examinations. See 38 C.F.R. § 3.327(a) (2016). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. VAOPGCPREC 11-95. The July 2010 VA examination report (PTSD) shows the Veteran was not cooperative with the examination, as explained in greater detail below, and that no constructive information was able to be obtained. The Board finds the subsequent February 2017 VA examination report (PTSD), and the September 2013 VA examination report (audio) to be thorough and adequate upon which to base a decision with regard to the Veteran's claims. The examiner personally interviewed and examined the Veteran and provided the information necessary to evaluate the Veteran's PTSD under the applicable rating criteria and to consider the TDIU claim. In November 2016, the Board remanded the PTSD claim to provide the Veteran one more opportunity for a VA examination for his PTSD, so that his more recent VA treatment records could be associated with the claims file, and to ask the Veteran to identify any other relevant outstanding records. The Veteran was afforded the new VA examination in February 2017, which answered all the questions posed by the Board. His more recent VA treatment records were associated with the claims file, and in December 2016, the AMC requested that the Veteran identify any outstanding treatment records (but none were identified). Therefore, the Board finds that there was substantial compliance with the Board's remand directives. The Veteran has not identified any shortcomings in fulfilling VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Therefore, for the above reasons, the Board finds the duties to notify and assist have been met, all due process concerns have been satisfied, and the appeal may be considered on the merits. II. Analysis A. PTSD The Veteran served on active duty in the Air Force from October 1962 to October 1966 and attained the rank of Senior Airman. He claims entitlement to an evaluation in excess of 70 percent for his service-connected PTSD. Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2016). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7 (2016). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2016). When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. See 38 U.S.C.A. § 5107(b) (West 2014). Where service connection has already been established and an increase in the disability rating is in issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability in issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's service-connected PTSD is evaluated under Diagnostic Code 9411. The regulations establish a general rating formula for mental disabilities. 38 C.F.R. § 4.130 (2016). Ratings are assigned according to the manifestation of particular symptoms. Notably, the term "such as" in 38 C.F.R. § 4.130 precedes lists of symptoms that are not exhaustive, but rather serve as examples of the type and degree of symptoms and their effects that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F. R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA will consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM V). The criteria for a 30 percent rating are as follows: 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, mild memory loss (such as forgetting names, directions, recent events). The criteria for a 50 percent rating are as follows: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are as follows: 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); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2016). The criteria for a 100 percent rating are as follows: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score is, of course, just one part of the medical evidence to be considered and is not dispositive. The same is true of any clinician's statement as to the severity of a disability. It remains the Board's responsibility to evaluate the probative value of any clinician's opinion in light of all the evidence of record. GAF scores from 51 to 60 represent moderate symptoms, such as flat affect and circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school function (such as few friends, conflicts with peers or coworkers). GAF 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). Scores ranging from 31 to 40 reflect 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; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting oneself or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasional failure to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. 38 C.F.R. § 4.130 (incorporating by reference VA's adoption of the DSM-IV for rating purposes). The Board notes, however, that the DSM-V no longer utilizes GAF scores. The DSM-V is applicable for cases certified to the Board on or after August 4, 2014. In this case, the appeal was certified in August 2015. The Veteran was afforded VA examinations in July 2010 and February 2017. As noted in the VCAA section above, the July 2010 VA examination report shows the examiner noted that the Veteran was not cooperative with the examination, and that no constructive information was able to be obtained. The examiner noted: He complained about my questions, cursed at me, refused to answer questions, and complained that I was not examining him properly again. I attempted to examine him repeatedly dealing with his insults, comments, and raised voice. At one point when asked a question, he stated "that's none of your god damned business." At another point he stated "Whose exam is this . . . yours or mine. . . I ask the questions not you . . . ! You are not here to help me . . . you are the adversary . . . and here you go again asking me questions. . . !" At one point I asked him to lower his voice or security would be called. The exam was ended due to the Veteran's behavior and fear of acting out behavior/violent behavior in the meeting due to his escalating agitation increased confrontation and refusal to allow me to ask questions of him. The February 2017 VA examination report shows the Veteran reported that he remained married to and lived with his wife of 50 years, and that they have a good relationship and he spends a time helping her with tasks such as shopping and cooking meals because she has arthritic knees. He reported watching television, playing games, and engaging in Facebook in his leisure time. He reported he was independent in his daily functioning, and the examiner noted the Veteran drove to the examination by himself. Regarding his occupational history, the Veteran reported that he worked in security at from 1966 to 1998 at the Kennedy Space Center, and from 2002 to 2009 at Cape Canaveral Air Force station, and retired in September 2009 because the Air Force was changing security from a private contractor to Department of Defense security officers, and because he was able to obtain disability income (from a private insurance policy) due to polyneuropathy of the feet. He did, however, report that he had preferred to work alone because of his anger and irritability, and he reported that typically, his interpersonal interactions were hostile with anger and irritability, which he attributed to his PTSD. The Veteran reported that he was not receiving any mental health treatment, and that he had no history of mental health treatment. When asked whether he should be in mental health treatment, he replied "I don't think so." He denied any history of psychiatric hospitalizations or suicidality. The February 2017 VA examiner noted that the DSM-V criteria for PTSD were met, with symptoms including irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects, as well as hypervigilance. The examiner noted that the Veteran actively had PTSD symptoms of anxiety, mild memory loss, such as forgetting names, directions or recent events, flattened affect, and difficulty in adapting to stressful circumstances, including work or a work-like setting. The examiner noted that the Veteran's appearance was notable insofar as he appeared older than his stated age. The examiner noted that the Veteran's overall thinking was based in reality. The examiner opined that the Veteran's level of occupational and social impairment due to his PTSD was best summarized as follows: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Board acknowledges April 2009 and July 2013 private psychological evaluation reports by Dr. W.A. In the 2013 report, the Veteran reported engaging in social media on Facebook and "venting frustration," including political banter, but denied arguing with people in person or any physical fighting. He also reported he stopped arguing with his wife, and noted she was wiser than him. He reported he rarely left home due to his wife's condition. He reported working out at a fitness center three tunes per week, and going out on weekends. He reported difficulties with re-experiencing, social distancing and estrangement, a restricted range of affect, insomnia, hypervigilance, concentration problems, exaggerated startle responses, and irritability. Mental status examination revealed impaired impulse control, including a history of irritability, normal speech, thought content within normal limits, no apparent psychosis or suicidality or homicidality, his mood was down, affect was blunted, he was oriented to all three spheres, and his attention, concentration, immediate and remote memory were all within normal limits. Judgment and insight appeared to fall below normal limits. Troubles with visual spatial functioning, as well as with abstract verbal reasoning and with delayed auditory verbal recall were noted, but his functioning was noted as otherwise "quite normal." A history of a stroke had also been noted. A GAF score of 47 was recorded. The examiner noted that a GAF score ranging from 41 to 50 is based on the presence of serious symptoms or any serious impairment in social, occupational, or school functioning, and that the Veteran reported serious symptoms of PTSD and depression accompanied by a pattern of social distancing and isolation. While a history of occupational difficulties was noted as apparent, the examiner noted that the Veteran explained that those difficulties calmed after he left work (in 2009, prior to the filing of his claim), except that ongoing troubles with irritability were still noted. The Veteran's other private treatment records, VA treatment records, and his SSA records have all been reviewed, which do not show any other treatment for his service-connected PTSD during the period on appeal, which is consistent with his report to the February 2017 VA examiner that he had not received any mental health treatment. The Board finds that the preponderance of the evidence is against finding that the criteria for a rating in excess of 70 percent for the Veteran's PTSD have been met or approximated. The Board finds the VA examiner's opinion regarding the overall level of severity of the Veteran's PTSD to be particularly persuasive based on the level of detail in that report, which opinion was that the overall severity of the Veteran's PTSD was best summarized as: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. This level of severity described by the VA examiner is contemplated by the 30 percent rating criteria, not the presently assigned 70 percent rating. The next higher, 100 percent rating criteria contemplate total social and occupational impairment, which is clearly not shown. The above July 2013 private evaluation and the February 2017 VA examination report show the Veteran remained married to and living with his wife of 50 years, he reported engaging in social media (Facebook), he reported that he was able to help his arthritic wife by doing the household shopping and meal preparation, he reported he remained independent in his activities of daily living, he drove himself to the examination, he goes to the gym three times per week, and that he goes out on weekends. He reported that he stopped working in 2009 as a security officer (after working in security for around 29 years) due to a loss of a government contract and due to his polyneuropathy of the feet, not due to his PTSD. Dr. W.A. noted that the Veteran's attention, concentration, and immediate and remote memory were all within normal limits, and assigned a GAF score of 47, which the Board finds is consistent with the Veteran's 70 percent rating. The Veteran has not shown symptoms such as, or of a level of severity akin to, gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation as to time or place, or memory loss of names of close relatives or his own name. In light of all of the above, the Board concludes that the greater weight of the evidence is against finding that the Veteran's PTSD is so severe as to result in total social and occupational impairment as contemplated by the next higher rating (100 percent) criteria. While the Board acknowledges that the April 2009 and July 2013 evaluations by Dr. W.A. note a history of irritability and anger at work and resultant homicidal thoughts or ideation, that was noted as having ceased with his decision to stop working in September 2009, which was prior to the filing of his claim for an increase in May 2010. In that regard, the Board has considered whether entitlement to an increased rating is shown at any time during the one-year period prior to the filing of his claim for an increase in May 2010. See 38 C.F.R. § 3.400(o)(2) (2016). The Veteran's PTSD is rated as 30 percent disabling prior to May 18, 2010 (the claim date), and 70 percent thereafter. An April 2009 evaluation report by Dr. W.A. shows the Veteran reported he stopped working in security in 2009 when Cape Canaveral changed its security from a private contractor to the Department of Defense, and that he was unable to pass a physical test due to his polyneuropathy of the feet. His impulse control was noted as below normal, his frame of thought and thought content was normal, he did not report suicidal ideation and instead reported he needed to be there for his wife, he denied homicidal ideation, he reported his mood was a little down or depressed, his affect was somewhat blunted, he was oriented to all three spheres, his attention and concentration was within normal limits, including tracking the topic of conversation, and ability to recollect two of three items from a list subsequent to an inference task, his immediate memory was within normal limits, as evidenced by his providing the correct spelling of the word "house" both forwards and backwards, memory for recent events was within normal limits, remote memory was intact, intelligence and fund of information appeared to fall within the average range, judgement and insight were below normal limits. Dr. W.A. recorded diagnoses including PTSD, and a GAF score of 39. Dr. W.A. provided an explanation for the GAF score, noting a marked pattern of social isolation, a history of problems with employment functioning consistent with difficulties with authority figures, a history of arguments with those individuals that formed the basis of past homicidal ideations (which were noted in the report as having ceased with his decision to stop working), problematic family relationships including conflict within his marriage and with his son, and a history of irritability and verbal angry outbursts. As shown above, the April 2009 evaluation by Dr. W.A. shows the Veteran's symptoms included a depressed mood, social isolation, and irritability, including in the workplace with resultant homicidal ideations until he retired in September 2009. His GAF score was 39, which reflects "major impairment" in several areas (see DSM-IV), and which score is slightly less than his GAF score in July 2013. Overall, his symptoms appear to be the same if not slightly worse during the one-year period prior to the filing of his claim for an increase on May 18, 2010, particularly in light of his symptoms prior to his retirement in September 2009. Therefore, the Board finds that entitlement to the current 70 percent rating is shown dating back to the one-year period prior to the filing of his claim, i.e., effective May 18, 2009, to May 17, 2010. The Board finds, however, that the preponderance of the evidence is against finding entitlement to the next higher 100 percent rating for the same reasons as described above regarding the remaining period on appeal. As explained in greater detail above, total social and occupational impairment have not been shown. While the Board again acknowledges that the Veteran reported homicidal thoughts prior to retiring in September 2009, the Board finds that this symptom is not enough to bring the Veteran's overall disability picture to more nearly approximate the next higher rating. He remained married to his wife of over 50 years, and reported he wanted to be there for her, albeit family conflicts and irritability with angry outbursts were noted. His attention, concentration, and memory were all within normal limits. He was not shown to have symptoms such as, or of a level of severity akin to, gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation as to time or place, or memory loss of names of close relatives or his own name. The Board adds that the Veteran's wife reported on a January 2010 SSA Functional Report - Third Party, that the Veteran helped with house chores, visited with and helped his neighbors, and enjoyed playing with his grandchildren and reading. See SSA-831 records, March 2010 at p.5 of 16. In light of the above, and also for the same reasons as described above regarding the remainder of the period on appeal, the Board finds that entitlement to the next higher rating is not shown. In this case, the Veteran has not contended, and the evidence does not suggest, that he has experienced symptoms outside of those listed in the schedular criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (Board is not obligated to analyze whether remand for referral for extraschedular consideration is warranted if "§ 3.321(b)(1) [is] neither specifically sought by [the claimant] nor reasonably raised by the facts found by the Board") (quoting Dingess v. Nicholson, 19 Vet.App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007)). In summary, the Board concludes that entitlement to a 70 percent rating for the period from May 18, 2009, to May 17, 2010 is shown; but a preponderance of the evidence is against finding entitlement to an evaluation in excess of 70 percent for PTSD for the entire period on appeal; the benefit of the doubt rule is not for application. See 38 U.S.C.A. § 5107(b). B. TDIU A total rating based on unemployability may be granted if a veteran is "unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities." 38 C.F.R. § 4.16 (2016); see also 38 C.F.R. §§ 3.340(a), 3.341(a) (2016). If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16(a) (2016). To meet the requirement of "one 60 percent disability" or "one 40 percent disability," the following will be considered as one disability: (1) disability of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from one common etiology; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; and (5) multiple disabilities incurred as a prisoner of war. Id. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). In determining whether unemployability exists, consideration may be given to a veteran's level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2016). Medical examiners are responsible for providing a full description of the effects of disability upon the person's ordinary activity, while the rating agency is responsible for interpreting reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of the disability present. See Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). The Veteran claims entitlement to a TDIU. In his June 2015 substantive appeal, the Veteran alleges he is unable to work due to his service-connected hearing loss and tinnitus and "other" service-connected disabilities, i.e., his PTSD. He did not mention heart, vascular, or neurological disorders. The Veteran is service-connected for PTSD (70 percent), bilateral hearing loss (noncompensable prior to July 31, 2012, and 20 percent thereafter), and tinnitus (10 percent). His combined rating is 70 percent effective May 18, 2009, and 80 percent effective July 31, 2012 (factoring in the increased rating for PTSD granted herein effective May 18, 2009). As such, the schedular criteria for a TDIU of having one service-connected disability rated as 60 percent disabling or greater are met for the entire period of the appeal. See 38 C.F.R. § 4.16. As noted above, the Veteran was afforded a February 2017 VA examination relating to his PTSD. The Veteran reported to that examiner that he retired in September 2009, after a career of about 29 years of working in security at Kennedy Space Center and Cape Canaveral, due to the loss of a government contract by his employer, and due to his polyneuropathy of the feet. The Board notes the Veteran is not service-connected for polyneuropathy of the feet. Regarding the Veteran's occupational impairment due specifically to his PTSD, the examiner opined that it was best summarized as follows: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Board also acknowledges the April 2010 and July 2013 private evaluation reports by Dr. W.A. discussed in detail above, which show that the Veteran had a history of irritability with angry outbursts, including at work, and a history of homicidal ideation regarding his work until he retired in September 2009. Regarding the Veteran's other service-connected disabilities, his bilateral hearing loss and tinnitus, the Veteran was afforded a September 2013 VA examination (see LCM-VVA file). The September 2013 VA audiological examination report shows pure tone thresholds were as follows: Hertz (decibels) 500 1000 2000 3000 4000 Avg RIGHT 10 10 30 80 95 54 LEFT 85 80 90 105+ 105+ 95 Speech recognition was 94 percent in the left ear, but could not be tested in the right ear. The examiner also noted that the Veteran reported tinnitus, but opined that it did not impact his ordinary conditions of daily life or his ability to work. Regarding occupational impairment due to the Veteran's hearing loss, the VA examiner noted that the Veteran reported he had difficulty hearing what people were saying. The Board has also reviewed all of the other VA and private treatment records, as well as the Veteran's SSA records. A March 2010 SSA Disability Determination (SSA-831) shows the Veteran was found to be disabled for SSA purposes since September 2009 due to diabetic neuropathy, peripheral neuropathy, and other unspecified circulatory disease, none of which are service-connected disabilities. In June 2015 correspondence, the Veteran admits that when his employer's security contract was set to end at Cape Canaveral in September 2009 and be transferred to the Department of Defense (DoD), he applied for a civilian security position with the DoD and was accepted for a police officer position contingent upon passing a physical fitness test (PFT), but his physician put limitations on running on his PFT because of foot neuropathy, and he was ultimately rejected when his PFT was reviewed by the DoD. In light of all of the evidence of record, the Board finds that the preponderance of the evidence is against finding that the Veteran has been unable to secure or follow substantially gainful employment as a result of his service-connected disabilities. As shown above, the Veteran reported to the February 2017 VA examiner that he stopped working in 2009 due to his polyneuropathy of the feet, not due to service-connected disability. This is consistent with the fact that the Veteran is in receipt of disability from the SSA due to his diabetic neuropathy and polyneuropathy, and it is consistent with the Veteran's report in his June 2015 statement that he would have worked directly for the DoD in security, having been conditionally offered a position when they took over security at Cape Canaveral, but for the fact that the Veteran's physician put running restrictions on his PFT which formed the basis of his ultimate rejection for the position. Also, the Veteran has admitted that he was able to obtain other disability income relating to private insurance around that time. As noted above, the February 2017 VA examiner only found the Veteran's PTSD to be of a level of severity best described as resulting in an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. While the Board acknowledges the Veteran is shown to have significant hearing loss, and while the Board acknowledges his service-connected tinnitus, his hearing loss and tinnitus are not shown to preclude maintaining substantially gainful employment. Rather, the evidence as a whole shows the Veteran stopped working in September 2009 due to his running restriction due to his diabetic neuropathy and polyneuropathy, neither of which are service-connected disabilities. The Board acknowledges that in his June 2015 correspondence, the Veteran asserted that his PTSD was taken into consideration by the SSA, but just did not form the basis of the disability award. While that may be so, regardless, none of the medical or clinical evidence of record tends to indicate that the Veteran is unable to secure and maintain substantially gainful employment due to his PTSD. Moreover, the Veteran himself admits that he would have maintained employment after September 2009 but for his running restriction in the DoD physical fitness test required for his police officer job offer. Therefore, in summary, the Board concludes that the aggregate of lay and medical evidence weighs against entitlement to a TDIU, and that the benefit of the doubt rule is not for application. See 38 U.S.C.A. § 5107 (b). ORDER For the period from May 18, 2009, to May 17, 2010, entitlement to a 70 percent evaluation for PTSD is granted. For the entire period on appeal, entitlement to an evaluation in excess of 70 percent for PTSD is denied. Entitlement to a TDIU is denied. REMAND A. CAD and Cardiac Arrhythmia The Veteran claims he has CAD and cardiac arrhythmia as secondary to his service-connected PTSD. The basis for the joint motion by the parties to partially vacate the November 2016 Board decision was the fact that the Board relied in part on a July 2013 VA examiner's opinion, with a January 2015 addendum, in which the examiner opined in part that there was no medical literature supporting any causal relationship between CAD and PTSD, but at the same time, the examiner reasoned that the CAD "results from a combination of genetic predisposition, aging, dietary habits, sedentary lifestyle, and obesity." (Emphasis added). See CAPRI (LCM-VVA), received March 2014 at p.27 and 52 of 53. The parties noted in the JMR that in October 2012, the Veteran had submitted articles in support of his claim, including one stating that "with PTSD, we have stress and depression as factors . . . which can lead to not only risk markers of their own but also unhealthy lifestyle habits." (Emphasis added). See Article, PTSD Linked to Increased Risk of Death - Cardiovascular Disease, received October 3, 2012 at p.6 of 7. Another more recent article regarding PTSD and heart disease was submitted by the Veteran in October 2013. The Board acknowledges that the Veteran alleges that his PTSD causes a "lack of control of eating and drinking habits." See, e.g., Brief, July 2017. Therefore, in light of all of the above, the Board finds that this matter should be remanded to obtain a new VA medical opinion to address whether the Veteran's CAD is caused or aggravated by unhealthy lifestyle habits, including an unhealthy diet, due to the Veteran's service-connected PTSD. B. Hypertension The Veteran also claims that he has hypertension as secondary to his service-connected PTSD. In November 2016, the Board remanded the claim for a VA examination. In the Board remand directive, the Board noted that the Veteran alleged that his hypertension was due to a lack of control of eating and drinking habits due to his PTSD. See, e.g., Briefs, July 2017. Subsequently, a January 2017 VA examination was performed. The VA examiner opined in part that the Veteran's hypertension was not caused or aggravated by his PTSD. The examiner reasoned there was "no documented medical evidence to support the above claim that the Veteran's hypertension [was] caused or aggravated by the service connected PTSD." As shown above, however, and as noted by the parties in their joint motion for remand, the Veteran submitted three articles in October 2012, including one entitled: PTSD Linked to Increased Risk of Death - Cardiovascular Disease, which article noted that "with PTSD, we have stress and depression as factors . . . which can lead to not only risk markers of their own but also unhealthy lifestyle habits." (Emphasis added). See Article, received October 3, 2012 at p.6 of 7. Another more recent article regarding PTSD and heart disease was submitted by the Veteran in October 2013. Therefore, the Board finds that this matter should be remanded for a new VA medical opinion to address whether the Veteran's CAD is caused or aggravated by unhealthy lifestyle habits, including an unhealthy diet, due to his PTSD. C. CNS The Veteran also claims that he has a CNS disability as secondary to his claimed CAD and cardiac arrhythmia. The parties noted in their joint motion for remand that the claimed CNS disability is intertwined with the claimed CAD and cardiac arrhythmia that is being remanded herein for further development. Therefore, the Board defers decision on the claimed CNS. Accordingly, the case is REMANDED for the following action: 1. Obtain a VA medical opinion to clarify whether the Veteran's a) CAD and history of cardiac arrhythmia, and b) hypertension, are "at least as likely as not" (a 50-50 probability) caused or aggravated by an unhealthy lifestyle, such as a lack of control of eating or drinking if so indicated in this Veteran's case, due to his service-connected PTSD. Please direct the VA examiner's attention to the article submitted by the Veteran in October 2012 entitled: PTSD Linked to Increased Risk of Death - Cardiovascular Disease , ("PTSD . . . can lead to not only risk markers of their own but also unhealthy lifestyle habits"). Also note the more recent article submitted by the Veteran in October 2013. Request that the examiner provide an opinion on the degree of peer acceptance in the relevant medical community of the research and conclusions and how they apply in this Veteran's case including whether PTSD or other non-service-connected factors and their relative weight contribute to unhealthy lifestyle, if any. Any opinion must be accompanied by a complete rationale. 2. Then, readjudicate the Veteran's claims. If any claim remains denied, the Veteran should be provided a Supplemental Statement of the Case (SSOC). The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of 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). ____________________________________________ J.W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs