Citation Nr: 1751996 Decision Date: 11/14/17 Archive Date: 11/22/17 DOCKET NO. 07-13 046 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for degenerative arthritis of the skeletal system, to include as a result of exposure to herbicides. 2. Entitlement to service connection for a prostate disability, to include as a result of exposure to herbicides. 3. Entitlement to service connection for hypertension, to include as a result of exposure to herbicides. 4. Entitlement to service connection for gastrointestinal disability, to include as a secondary to service-connected posttraumatic stress disorder (PTSD). 5. Entitlement to service connection for a sleep disorder, to include as a secondary to service-connected PTSD. 6. Entitlement to service connection for a fungal infection or jungle rot of the feet. 7. Entitlement to an initial compensable rating for left ear hearing loss. 8. Entitlement to an increased rating in excess of 50 percent for PTSD, between January 23, 2012, and January 31, 2013. 9. Entitlement to an earlier effective date prior to January 23, 2012, for a rating in excess of 30 percent rating for PTSD. REPRESENTATION Appellant represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD Zi-Heng Zhu, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1967 to March 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2006, November 2008, and December 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran's claims were previously remanded by the Board in October 2010 and August 2012. The issues of entitlement to service connection for degenerative arthritis of the skeletal system, hypertension, a gastrointestinal disability, and a prostate disability, and entitlement to a compensable rating for left ear hearing loss, are REMANDED to the Agency of Original Jurisdiction. FINDINGS OF FACT 1. The preponderance of evidence is against a finding that the Veteran has any sleep disability separate from currently service-connected PTSD. 2. The preponderance of evidence is against a finding that any bilateral foot disability condition is etiologically related to any aspect of active service, to include exposure to herbicide agents. 3. From January 23, 2012, and prior to January 23, 2012, the Veteran's PTSD manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as: stereotyped speech; panic attacks more than once a week; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 4. VA received the Veteran's claim of entitlement to an increased rating for PTSD, on January 23, 2012. There is no evidence of record, either formal or informal, of a claim for increased rating for PTSD before that date subsequent to the most recent final assignment of a rating. CONCLUSIONS OF LAW 1. The criteria for service connection for a sleep disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2017). 2. The criteria for service connection for a bilateral foot disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2017). 3. The criteria for entitlement to a rating in excess of 50 percent for PTSD, between January 23, 2012, and January 31, 2013, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. Part 4, including § 4.7 and Code 9411 (2017). 4. The criteria for an earlier effective date for a 30 percent rating for PTSD have not been met. 38 U.S.C.A. § 5110 (West 2014); 38 C.F.R. §§ 3.400, 3.816 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 3.159 (2017); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from any notice error. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing an error is harmful or prejudicial falls on party attacking agency decision); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and representative suggest actual knowledge of the elements necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by claimant or representative that demonstrate awareness of what is necessary to substantiate claim). Thus, VA has satisfied the duty to notify the appellant and had satisfied that duty prior to the adjudication in the January 2017 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has obtained an examination with respect to the claims. Thus, the Board finds that VA has satisfied the duty to assist. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Generally, service connection may be granted for disability or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2017). In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection is also warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2017). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107 (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Sleep Disorder The Veteran claims that he has a sleep disorder secondary to PTSD. However, competent medical evidence of record does not demonstrate a separate sleep disorder that is medically distinct from the Veteran's already service-connected PTSD. Therefore, as there is no medical evidence of a current disability, the Board finds that service connection for a sleep disorder is not warranted, and the Veteran's claim must be denied. The threshold consideration for any service connection claim is the existence of a current disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). A close review of the medical evidence of record, to include post-service treatment records and a VA examination from February 2012, shows no diagnosis of a separate sleeping disorder caused or aggravated by PTSD. The service medical records show no medical incidents in service regarding sleep disorders, and a review of post-service records notes no formal diagnosis of a separate sleep disorder. At a February 2012 VA psychiatric examination for PTSD and sleeping conditions, the VA examiner opined that, while the Veteran did have sleep disturbances, those were only secondary manifestations of PTSD, and not a separate disability or mental disorder. Therefore, the Veteran's sleep condition was only a function or symptom of PTSD, and not a disability itself. In arriving at that conclusion, the examiner noted a comprehensive review of the Veteran's sleep impairment, to include nightmares, nocturnal awakening, hypervigilance, and its effect on the Veteran's daytime activities. Therefore, as the Veteran's sleep disturbance/impairment is only considered a symptom of his PTSD, and not a separate disability, the Board finds that the threshold requirement of a current disability remains in want. The Board acknowledges that the Veteran believes that he has a sleep disability, and that disability is related to active service. The Board notes that the Veteran is competent to speak to factual matters of which he has first-hand knowledge and experiences through his senses, such as symptoms like not being able to fall sleep or awaking in the middle of the night. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). However, formally diagnosing such a complex disability such as a sleep condition, which may be multifaceted in its etiology across many different medical fields and practices, is outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, although the Board has carefully considered the lay contentions of record, the Board must finds that such evidence is not competent as the Veteran is not shown to have the required training to diagnose such a complex condition or opine as to its etiology. To the extent those statements may be competent, the Board ultimately assigns the greater probative weight to the medical evidence of record. That evidence was provided by trained medical professionals whose medical opinions are found to be more probative than the opinion of a layperson. The Board finds the February 2012 VA examination to be most probative evidence. The Board notes that the VA opinion provided a comprehensive opinion regarding why the Veteran's sleep impairment was only a symptom of his PTSD, and not a separate disability. The VA examiner took into account of the Veteran's claim that such condition arose during service, with an inability to sleep more than a few hours, and awaking at night, and his current sleep impairment to include nightmare, waking up at night, and hypervigilance. The Board notes that sleep disturbance is among the symptoms used to assign ratings for mental disorders. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2017). Therefore, the Board finds that the threshold requirement for substantiating a claim for service connection is not met, as the evidence does not show a current sleep disability. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Consequently, as the preponderance of evidence is against the finding of a current disability, the claim for service connection for a sleep disability must be denied. 38 U.S.C.A. § 5107 (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990) Foot Disability The Veteran contends that a currently diagnosed foot disability, to include nummular dermatitis and onychomycosis, is etiologically related to claimed "jungle rot" or a foot condition he development while in active service in Vietnam. However, a review of the medical evidence of record, to include a January 2012 VA examination and a January 2017 addendum opinion, show that the Veteran's current foot condition is not etiologically related to the claimed condition during active service. Therefore, as the preponderance of evidence is against the finding that the Veteran's foot condition is related to active service, the Veteran's claim for service connection must be denied. The Board notes that there is a current disability and an in-service injury or incurrence. Specifically, medical evidence, to include a January 2012 VA examination demonstrates a clear diagnosis for nummular dermatitis and onychomycosis. Likewise, the Board, in its last remand, acknowledges the Veteran's competency to identify observable symptoms such as a fungal infection of the foot during service. Finding the Veteran both competent and credible to report those symptoms, in-service symptomatology is conceded. However, the Board finds that the competent medical evidence of record is against a finding that any current foot disability is related to service. The Board notes that the Veteran was provided an examination in January 2012, which diagnosed a current foot and skin disability. The examiner provided an inadequate opinion noting that any conclusion with regard to the etiology of that condition would be mere speculation. The examiner noted that the Veteran's claims file and medical history were not available for review. In January 2017, the VA obtained an addendum opinion with regard to the etiology of any foot disability. After a documented review of the claims file and medical history, the examiner ultimately concluded that the foot condition was not etiologically related to the Veteran's claimed active service fungal infection or jungle rot. The examiner noted that even considering the Veteran competent to report jungle rot during active service, there was no evidence that such condition proceeded after separation from service. The examiner noted that no such condition was reported at separation from active service, or for nearly three and a half decades after service. The initial evidence of a diagnosis for that condition was in 2007. The examiner opined that even considering the Veteran's lay statements that he had jungle rot during active service, that condition must have been acute and resolved during service. Additionally, the examiner noted that the Veteran's currently diagnosed condition of nummular dermatitis and onychomycosis were medically disparate conditions from that of jungle rot, and therefore, there was no etiological nexus between the current condition and active service. The Board also acknowledges that the Veteran believes, and has continuously asserted, that his foot condition is related to service. The Board notes that the Veteran is competent to provide testimony concerning factual matters of which he has first-hand knowledge and experiences through his senses. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Further, under certain circumstances, lay statements may support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, as to the etiology of a particular claimed disability, the issue of causation of a medical condition is a medical determination outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, although the Board has carefully considered the lay contentions of record suggesting that the Veteran's current foot/skin condition is related to service, but the Board finds that evidence is not competent as the Veteran is not shown to have the required training to diagnose respiratory disabilities and opine as to their etiology. To the extent those statements may be competent, the Board ultimately assigns the greater probative weight to the medical evidence of record. That evidence was provided by trained medical professionals whose medical opinions are found to be more probative than the opinion of a layperson. The Board finds the VA examination and addendum opinion to be most probative evidence when compared to that of the Veteran's lay statements. The Board notes that the VA opinion provided a far more comprehensive opinion regarding why the current disability is not etiologically related to his active service. The VA examiner took into account of the acute nature of those in-service symptoms for claimed jungle rot, and the fact that the Veteran was asymptomatic for decades after service. The Board also notes that, for certain chronic diseases, listed in 38 C.F.R. § 3.309(a), a continuity of symptomatology is required when the condition noted during service is not shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b) (2016); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, the Veteran's foot condition is not a chronic disease listed under 38 C.F.R. § 3.309(a), and, therefore, does not qualify for any presumptions or any analysis under continuity of symptomology. Consequently, the claim is denied on a presumptive basis. Accordingly, the Board finds that the claim of entitlement to service connection for a foot condition must be denied because the preponderance of the evidence is against the claims. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2017). Increased Ratings Disability ratings are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2017). Where there is a question as to which of two 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. 38 C.F.R. § 4.7 (2017). In order to rate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). This review undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran's service-connected PTSD has been rated under the provisions of Diagnostic Code 9411. A 0 percent rating is warranted when a mental condition has been diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent rating is warranted when the Veteran experiences occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent disability rating is warranted when there is 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). A 50 percent is warranted if the Veteran experiences 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. A 70 percent is warranted when the Veteran experiences occupational and social impairment, with deficiencies in most area, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2017). The symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet.App. 436 (2002). Considerations in rating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2017). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2017). From January 23, 2012, to January 31, 2013 For the relevant period between January 23, 2012, and January 31, 2013, the Veteran's PTSD has been assigned a 50 percent rating. The Veteran, through his representative, asserts that his condition during the relevant period was worse than that contemplated by the 50 percent rating. Specifically, he contends that the Veteran's current effective date, for the 50 percent rating, was set by the RO to reflect the date the Veteran noted he had stopped working due to PTSD. However, the representative asserts that the Veteran was actually only partially employed, or employable, since 2008, due to PTSD. Therefore, the Veteran contends that his 100 percent rating should be effective much earlier than the current 50 percent rating prior to January 31, 2013. As a preliminary matter, the Board notes that the relevant period applicable here is between January 31, 2013, the date the Veteran's current 100 percent rating is effective, and January 23, 2012, the date the Veteran's filed a claim for increased rating. The effective date for the increased rating of 50 percent remains January 23, 2012. The Board finds that during the relevant period, between January 2012 and January 2013, the Veteran was provided VA examinations in February 2012 and March 2012. In the February 2012 VA examination report, the examiner, after reviewing the Veteran's medical history and conducting an in person interview, ultimately concluded that the Veteran's PTSD manifestations only amounted to occupational and social impairment with reduced reliability and productivity. Specifically, the examiner noted that the Veteran's PTSD manifestations amounted to symptoms of depressed mood, anxiety, sleep impairment, mild memory loss, lack of motivation and difficulty establishing social and occupational relationships. At the time of the examination, the examiner noted that the Veteran was on time, oriented, and dressed appropriately, with no distress and neutral mood. The examiner noted the Veteran made appropriate eye contact and was cooperative, with normal speech. During the examination, the Veteran also denied any suicidal or homicidal ideations or thoughts, with claims of issues with anger and irritation. The Veteran noted that he retired in June 2011 when he turned 62, in part due to his inability to deal with customers and employees due to his irritations and agitation. The Veteran stated that since then, the PTSD symptoms had gradually increased, which he attributed to being retired and less engaged. The Veteran remained married and lives with his wife, and has children and grandchildren, with no indication of estrangement, to include with his siblings and parents, who were still living. The examination report also noted that the Veteran reported an active social life of going out to bars, meeting up with other Marines, and participating at the VFW. After reviewing the applicable information, the VA examiner ultimately assigned a GAF score of 60 for the Veteran, again noting that the Veteran's condition only amounted to occupational and social impairment with reduced reliability and productivity. In a March 2012 VA psychiatric examination, the Veteran was again formally diagnosed with an Axis I diagnosis of PTSD. The examiner noted symptoms such as sleep impairment, mild memory loss, disturbances in mood, difficulty in relationships, difficulty in adapting to stress, and an inability to maintain effective relationships. The examiner also noted the Veteran's report of leaving his company because of increasing frustration with interactions with employees and customers. However, the Veteran was noted to having a great relationship with his wife and family, with regular interaction with his children. The examination report noted no indication of suicidal or homicidal ideation, or an overall inability to generally function around others. Overall, the examiner noted a GAF score of 63. In order to warrant a rating in excess of 50 percent, the Veteran's PTSD must be manifested by occupational and social impairment, with deficiencies in most area, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. The Board notes that the Veteran is involved in group therapy for PTSD and he relates well to the other group members. While there is some indication that his manifestations of frustration, irrigation, and anger may take a toll on his social relationships, the Veteran remains married and his relationship to his wife and family is good, as noted in both examinations. Additionally, during the February 2012 examination, the Veteran was noted to participate in social activities at the VFW, engage with fellow Marines, and go out with his wife. While evidence suggests some tension between some family members, such as his sister, he remains in contact with his sibling and living parents. Furthermore, at the examinations, the Veteran was noted to be articulate, verbal, and generally cooperative. His thought process was logical, coherent, and relevant. Reasoning and judgment were fair. His affect was somewhat irritable; and he complained of some declining concentration and short-term memory; but stated that he is still able to function. There is no indication that the Veteran would not be able to maintain personal hygiene, and he was fulling oriented during the examinations. The Board finds that the Veteran endorses few of the symptoms enumerated under the criteria for an increased rating, and that his overall disability picture does not more nearly approximate deficiencies in most areas. While there is evidence of irritation and anger, the Veteran seems to be able to maintain effective social relationships with his wife, children, parents, and some friends. The Board acknowledges that the crux of the Veteran's contention is that his PTSD, specifically his frustration and irritability with customers and employees, forced him to essentially retire from his company. However, even if that is the case, the Board notes that it is only one facet of the multitude of factors that must be met to warrant a higher 70 percent rating. Under the diagnostic code, a 70 percent rating required the Veteran's condition to amount to impairments in most areas such as work, family relationships, judgement, thinking and mood, to include: suicidal ideation; obsessional rituals; illogical speech; near-continuous panic or depression affecting the ability to function independently; impaired impulse control; spatial disorientation; neglect of personal hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. While the Board finds that the Veteran may fulfill one or two of those factors for the criteria, that cannot be considered sufficient to warrant a higher rating. The evidence does not show deficiencies in family relationships, judgment, or thinking. Additionally, the Veteran has been assigned GAF scores of 60 and 63, in his February 2012 and March 2012 VA examinations. The Board notes that a GAF score of 61 to 70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social/occupational functioning, but generally functioning pretty well with some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates moderate symptoms or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) (Fourth Edition); 38 C.F.R. § 4.130 (2017). The Board notes that while GAF scores are not, in and of themselves, determinative, or dispositive of a claim, such can be used as indicator and factors to be considered while evaluating the severity of the Veteran's PTSD. Here, those scores align with the written evaluations by the VA examiner noting that the Veteran only has generally mild-moderate impairment from PTSD, to include some occupational impairment, but generally functioning, with meaningful relationships. The Board finds that his disability is most appropriately rated at 50 percent, and that a preponderance of the evidence is against the assignment of any higher rating. As the preponderance of the evidence is against this claim, the claim for a rating in excess of 50 percent for PTSD, for the relevant period must be denied. Gilbert v. Derwinski, 1 Vet. App 49 (1990). Extraschedular Consideration The Board finds that the record does not present such an exceptional or unusual disability picture as to make impractical the application of the regular rating schedule standards. 38 C.F.R. § 3.321(b)(1) (2017). The evidentiary record in this case persuasively shows that the Veteran's symptoms match the type and degree of the examples set forth under the criteria for the current schedular ratings. Consideration of an extraschedular ratings under 38 C.F.R. § 3.321(b)(1) is not appropriate in such a case where the rating criteria reasonably describe the Veteran's disability level and symptomatology. Thun v. Peak, 22 Vet.App. 111 (2008). Here, the Board finds that criteria for PTSD reasonably describe the level of disability and symptomatology noted by the record. Therefore, referral for extraschedular consideration under is not warranted. Effective Dates The Veteran seeks an effective date earlier than January 23, 2012, for the assignment of a 50 percent rating for PTSD. The effective date for an award of disability compensation based on an original claim for direct service connection is the day following separation from active service or the date entitlement arose if a claim is received within one year after separation from service. Otherwise, the effective date is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(b)(1) (West 2014); 38 C.F.R. § 3.400(b)(2)(i)(2017). If the claims is based on a claim which has been finally denied and subsequently reopened by the receipt of new and material evidence, the effective date is the date of receipt of the new claim, or the day entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a) (West 2014); 38 C.F.R. § 3.400(q),(r)(2017). For increases in disability compensation the effective date shall be the earliest date as of which it is factually ascertainable that an increase in disability occurred f a claim is received within one year from that date. Otherwise, the effective date for increase will be the date of the claim for increase. 38 C.F.R. § 3.400(o)(2017). A rating decision becomes final if an appeal is not timely perfected. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 3.104 (a), 3.160(d), 20.200, 20.302, 20.1103 (2017). A Board decision is final unless an exception applies. 38 U.S.C.A. §§ 7103,7104(a) (West 2014); 38 C.F.R. §§ 20.1100, 20.1104(a) (2017). Previous determinations that are final will be accepted as correct in the absence of a collateral attack showing the decision involved clear and unmistakable error (CUE). 38 C.F.R. § 3.105 (a)(2017). A review of the evidence shows that no correspondence, formal or informal, submitted between October 2010 and January 23, 2012, can be construed as a claim for increased rating for PTSD. In January 2012, the Veteran filed a new claim for increased rating for service-connected PTSD. A March 2013 rating decision assigned a 50 percent rating for PTSD, effective from the date of his claim, January 23, 2012. 38 C.F.R. § 3.400(o) (2017). The Board finds that effective date for the 50 percent rating was appropriate and an earlier effective date is not warranted. The Board acknowledges that while the Veteran previously filed for an increased rating of prior to January 23, 2012, that claim was finally denied by the Board in an October 2010 decision, and not vacated by any subsequent appeal to the United States Court of Appeals for Veteran Claims. Therefore, the Board finds that decision for an increased rating became final. Final determinations will be accepted as correct in the absence of CUE. In order for the Veteran to be awarded an effective date based on that earlier claim, he would have to show CUE in the prior denial of that claim. Flash v. Brown, 8 Vet. App. 332 (1995). A close review of the evidence of record shows that there has been no allegation of CUE here. A s the Board is not deciding a CUE motion, there will be no prejudice to the Veteran if he brings such a motion in the future. The Veteran's contends that his condition was worse than represented by the 30 percent rating prior to January 23, 2012. Specifically, the Veteran, through the representative, asserts that the Veteran's PTSD was just as bad as during the time prior to January 2012, as it affected his ability to maintain substantial employment. A review of the record shows that, even considering a year prior to the Veteran's January 23, 2012 claim, there is no evidence that the severity of PTSD rose to the level warranting a higher rating in excess of 30 percent. The Board notes that no additional evidence, lay or medical, was submitted in the year directly prior to the Veteran's claim that can be construed as demonstrating a psychiatric condition not fully contemplated by the 30 percent rating or showing a change in level of disability during the year prior to the filing of the claim such that it is factually ascertainable that a higher rating was warranted. Therefore, as there is no evidence supporting an earlier claim or that the Veteran's condition factually warranted a higher rating within a year prior to his January 23, 2012, claim, the Board must find that the effective date for the 50 percent rating to be adequate and proper. The Board notes that the Veteran is raising an argument based on equity. While the Board is quite sympathetic to the Veteran's argument, the Board is bound by the law and is without authority to grant benefits on an equitable basis. 38 U.S.C.A. §§ 503, 7104 (West 2014); Harvey v. Brown, 6 Vet. App. 416 (1994). Therefore, this appeal for an earlier effective date must be denied. ORDER Entitlement to service connection for a sleep disability is denied. Entitlement to service connection for a bilateral foot disability is denied. Entitlement to an increased rating in excess of 50 percent for PTSD, between January 23, 2012, and January 31, 2013, is denied. Entitlement to an earlier effective date prior to January 23, 2012, for a 50 percent rating for PTSD is denied. REMAND Further development is necessary prior to adjudication of the claims for service connection for degenerative arthritis of the skeletal system, hypertension, a gastrointestinal disability, and a prostate condition, and the claim for an increased rating for left ear hearing loss. With regard to the claim for degenerative arthritis of the skeletal system the Board finds that the VA examinations provided to the Veteran on record are incomplete. Specifically, the Board notes that the Veteran was provided extensive examinations with regard to that claim in January 2013, December 2016, and provided any addendum opinion in January 2017. The January 2013 examiner offered no opinion with regard to the etiology of the diagnosed arthritis in his hands, feet, neck, back, hip, and knees. The examiner's report also noted no access to the claims file as part of the examination processes, and therefore, could not offer any conclusion with regards to etiology or nexus without resorting to mere speculation. The December 2016 examination report is equally incomplete as it only spoke to one of the arthritic conditions, of the back, and the Veteran has been diagnosed with arthritis of other joints. An addendum opinion was acquired in January 2017 from a VA examiner. While that report explicitly noted a review of the claim file, the Board finds that the examiner's negative conclusion is ultimately considered incomplete as it is based on an inadequate factual premise and rationale. Specifically, as a rationale for the opinion, the VA examiner noted explicitly that the Veteran's arthritic conditions were not due to any aspects of the Veteran's service as there was no evidence of trauma during service, and that development of a degenerative condition at such a young age without a traumatic event was highly unlikely. However, that rationale seem to not consider the Veteran's continuous and consistent contentions that the conditions were caused by trauma during service when drill instructors walked on the backs of the trainees while they did push-ups, and other activities. As the examiner's opinion did not address the lay contentions, the Board finds that opinion to be incomplete. VA's statutory duty to assist the Veteran includes the duty to conduct a thorough examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). Assistance by VA includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). When the medical evidence is incomplete, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). With regard to the claims for service connection for hypertension, a gastrointestinal disability, and a prostate condition, the Board notes that these claims was previous remanded by the Board in August 2012 for further development to include a VA examination. The August 2012 remand explicitly directed that the claims file must be made available to the VA examiner at the examination. However, upon review of the VA examinations provided to the Veteran subsequent to that remand, the VA examiners noted no claims file was made available to for review. The Board notes that a remand confers on the Veteran the right to compliance with the terms of that remand. Stegall v. West, 11 Vet. App. 268 (1998). Therefore, the Board finds the examinations and opinions to be incomplete and remand is required for VA to fulfill the duty to the Veteran. With regard to the claim for an increased rating for left ear hearing loss, the Board notes that the Veteran was last provided a VA examination to assess the nature and severity of left ear hearing loss in February 2015, more than two and half years ago. The Board recognizes that, generally, the mere passage of time is not a sufficient basis for a new examination. Palczewski v. Nicholson, 21 Vet. App. 174 (2007). However, a review of the medical evidence of record shows that the Veteran's hearing in both ears has progressively worsened during the claims period. When available evidence is too old for an adequate evaluation of the current condition, VA's duty to assist includes providing a more current examination. Weggenmann v. Brown, 5 Vet. App. 281(1993). The Board finds that not only is the last examination remote, but the examination appears to no longer indicate the Veteran's current level of disability and functional loss. Consequently, after all outstanding medical records are associated with the claims file, a more contemporaneous examination is needed to rate the Veteran's claims for increased ratings for his right knee, right elbow, and left great toenail. Allday v. Brown, 7 Vet. App. 517 (1995); Caffrey v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). Accordingly, the case is REMANDED for the following action: 1. Obtain copies of any VA clinical records not on file pertaining to treatment of the claimed disabilities. 2. Schedule the Veteran for a VA examination of claimed degenerative arthritis of the skeletal system for the purpose of determining the nature and etiology of arthritis of any joint where it is found. The examiner must review the claims file and should note that review in the report. The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that any degenerative arthritis is causally related to the Veteran's active duty service, to include exposure to herbicides during service. The examiner must consider the claim as pertaining to all joints where arthritis is diagnosed, to include the hands, feet, neck, back, hip, knees, and any other joints shown to have arthritis. Full consideration must be given to the Veteran's claims that during service, he was stepped upon while performing exercises such as push-ups. A rationale should be offered for the opinion. 3. Schedule the Veteran for a VA prostate examination for the purpose of determining the nature and etiology of any prostate disability. The examiner must review the claims file and should note that review in the report. All current prostate disorders should be clearly reported. As to each current prostate disability, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) causally related to active service, to include exposure to herbicide agents during service. A rationale should be offered for the opinion. 4. Schedule the Veteran for a VA hypertension examination for the purpose of determining the nature and etiology of hypertension. The examiner must review the claims file and should note that review in the report. A rationale should be offered for the opinion. (a) The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that hypertension is causally related to active service, to include exposure to herbicide agents during service. (b) The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that hypertension is proximately due to or caused by service-connected PTSD. (c) The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that hypertension has been aggravated (permanently increased in severity beyond the natural progress of the disorder) by service-connected PTSD. 5. Schedule the Veteran for a VA gastrointestinal examination for the purpose of determining the nature and etiology of any gastrointestinal disability, claimed as GERD, hiatal hernia, irritable bowel, constipation, and diarrhea,. The examiner must review the claims file and should note that review in the report. All current gastrointestinal disorders should be clearly reported. A rationale should be offered for the opinion. (a) As to each current gastrointestinal disability, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) causally related to active service, to include exposure to herbicide agents during service. (b) As to each current gastrointestinal disability, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) proximately due to service-connected PTSD. (c) As to each current gastrointestinal disability, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) to have been aggravated (permanently increased in severity beyond the natural progress of the disorder) by service-connected PTSD. 6. Schedule the Veteran for a VA audiological examination to assess the nature and severity of left ear hearing loss. The examiner must review the claims file and should note that review in the report. The examiner should conduct audiometric findings and should provide word recognition scores using the Maryland CNC test. The examiner should opine regarding any social or industrial impairment due to the left ear hearing loss. 7. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs