Citation Nr: 1753042 Decision Date: 11/17/17 Archive Date: 11/22/17 DOCKET NO. 13-18 413 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial compensable rating for service-connected tinea pedis and tinea unguium. 2. Entitlement to an initial compensable rating for service-connected bilateral hearing loss. 3. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) and depressive disorder. 4. Entitlement to a compensable rating for service-connected tinea versicolor. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD R. Williams, Counsel INTRODUCTION The Veteran served on active duty from August 1965 to May 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision of the U.S. Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran testified before the undersigned during a Board hearing held in February 2016. A copy of the hearing transcript is of record. The Board previously remanded the claims in May 2016. The Board finds that there has been substantial compliance with the remand directives. As such, there is no prejudice for the Board to proceed. See Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that in March 2017, entitlement to a total disability rating by reason of individual unemployability (TDIU) was granted and, as such, that matter is no longer before the Board. Additionally, in the March 2017 Board remand, the claim for entitlement to service connection for a noncompensable dental disorder for the purpose of obtaining VA outpatient dental treatment under 38 C.F.R. § 17.161 was remanded for referral to the appropriate VA Medical Center (VAMC) to determine if the Veteran meets the basic eligibility requirements. While it appears that a July 2016 Routing and Transmittal slip referred the Veteran's dental claim to the VAMC Durham; no determination is of record. The Board does not have jurisdiction over it, and it is referred to the Agency of Original Jurisdiction (AOJ) for appropriate action consistent with the Board's May 2016 remand directives. 38 C.F.R. § 19.9(b) (2017). According to the April 2017 supplemental statement of the case, the Veteran was granted an increased (70 percent) rating for his service-connected PTSD with depressive disorder, effective from May 15, 2009. As the maximum rating has not been assigned, the Veteran has continued his appeal, and the claim has been characterized accordingly. See AB v. Brown, 6 Vet. App. 35 (1993). The issue of entitlement to an initial compensable for service-connected bilateral hearing loss is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's service-connected tinea pedis and tinea unguium affects less than 5 percent of the entire body and does not require systemic corticosteroids for treatment. 2. The Veteran's PTSD and depressive disorder results in occupational and social impairment in most areas; however it does not result in or more nearly approximate total occupational and social impairment. 3. The Veteran's service-connected tinea versicolor affects less than 5 percent of the entire body and does not require systemic corticosteroids for treatment. CONCLUSIONS OF LAW 1. The criteria for an initial compensable evaluation for tinea pedis and tinea unguium have not been met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.10, 4.118, Diagnostic Code 7813 (2017). 2. The criteria for an evaluation in excess of 70 percent for PTSD and depressive disorder have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9432 (2017). 3. The criteria for a compensable evaluation for tinea versicolor have not been met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.10, 4.118, Diagnostic Code 7806 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of the claims in March 2009. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With respect to the claim for a higher initial rating for the service-connected tinea pedis, tinea unguium, and tinea versicolor, in cases such as this, where service connection has been granted and an initial disability rating and effective date has been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess v. Nicholson, 19 Vet. App. 473 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). With regard to the duty to assist, the Veteran's service treatment records, pertinent post-service treatment records, statements, and testimony from the February 2016 Board hearing have been associated with the record. Moreover, the Veteran was afforded VA examinations in December 2009, March 2010, and November 2016. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the December 2009, March 2010, and November 2016 VA examinations are adequate and addressed all the relevant criteria. Pursuant to the May 2016 Board remand, additional VA treatment records and the November 2016 examination reports have been obtained and associated with the record. Therefore, there has been compliance with the Board's prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his claim, and to respond to VA notices. The Veteran has not identified any outstanding evidence that needs to be obtained. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran, and no further action is necessary to assist the Veteran in substantiating this claim. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Disability Ratings Law and Regulations Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4 (2017). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1 (2017). Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2 (2017). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. When, after careful consideration of the evidence, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where the veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased rating claim or in the adjudication of an initial rating when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 506 (2007). The Board must assess the competency, credibility and probative weight of the relevant evidence, both lay and medical, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. See Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The third step of inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, 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 a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The analysis below focuses on the relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122, 128 (2000). Analysis Tinea pedis, Tinea unguium, and Tinea versicolor The Veteran's tinea pedis and tinea unguium are rated as noncompensably disabling under the criteria of 38 C.F.R. § 4.118, Diagnostic Code 7813, while his tinea versicolor is rated as noncompensably disabling under the criteria of Diagnostic Code 7806. During the February 2016 hearing, the Veteran complained of yearly outbreaks and stated that his skin looks blotchy. Under Diagnostic Code 7806 for dermatitis or eczema, a 10 percent rating is warranted for a skin disorder that affects at least 5 percent, but less than 20 percent of the entire body, or of exposed areas affected; or, intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than 6 weeks during the past 12-month period. A 30 percent rating is warranted for a skin disorder that affects 20 to 40 percent of the entire body or 20 to 40 percent of the exposed areas, or that requires systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is warranted for a skin disorder that affects more than 40 percent of the entire body or more than 40 percent of the exposed areas, or that requires constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. Diagnostic Code 7813 pertains to dermatophytosis, which is in turn rated as disfigurement of the head, face, or neck under Diagnostic Code 7800, scars, under Diagnostic Code 7801-7805, or dermatitis, under Diagnostic Code 7806, depending upon the predominant disability. According to the December 2009 VA Skin examination, the Veteran stated that in 1968 his skin got blotchy and he has had trouble getting a tan since then. He claimed his condition was on his back, neck, and arms and gets worse after the first of the year until September/ October. Upon examination, the examiner stated that there was minimal evidence of tinea versicolor on the back, arms, neck and chest. She noted that the total area affected was less than 5 percent of the exposed areas and less than 5 percent of total body area. The Veteran was afforded another VA Skin disease examination in March 2010. At that time it was noted that the Veteran had tinea of the feet. The Veteran noted that when it is severe, it goes up the great toe and into the medial side of his foot and laterally up the side of his foot starting at the 5th digit. He also complained of toenail fungus of his great toes bilaterally. The Veteran noted that he has pain when the skin breaks and has to limp when he has an outbreak of tinea pedis, two or three times a year which lasts one and a half to two weeks. The Veteran reported pouring bleach on his feet to treat it. The examiner noted that treatment was topical and neither a corticosteroid nor an immunosuppressive. Burning was noted to be a side effects of his treatment. Exam findings of the left foot noted include a small area (0.2 cm) of whitish moist looking skin between the third and fourth interdigital space that appeared to be tinea pedis and a small amount (less than 0.5 cm) of scaling between the fourth and fifth interdigital space. The examiner observed no frank macerated skin. However, the Veteran's great toe had a fungal infection of the nail. There was no sign of tinea on other areas of the left foot, including the dorsal and plantar surface. On the right foot, there is a small area of scaling skin (0.2 cm) between the fourth and fifth digit, but there was no evidence of tinea on the remainder of the dorsal or plantar surface of the right foot. It was determined that tinea pedis and tinea unguium affected none of the exposed areas and less than five percent of the total body area. The Veteran was afforded another VA examination in October 2016. The examiner noted that the Veteran was using topical cream and topical shampoo for 6 weeks or more, but not constant. Upon examination, there were no active tinea pedis symptoms and his tinea pedis was noted to be quiescent. He did have tinea versicolor and tinea unguium, with hypopigmented macules to upper back and right later aspect neck, affecting less than 5 percent exposed body area and less than 5 percent of the total body area. He was also noted to have thickened brittle discolored great toe nails with no exposed body area and less than 5 percent of the total body area affected. In a separate opinion regarding functional impact, the examiner noted that the Veteran has mild tinea versicolor and tinea unguium. He noted that there are no physical limitations on exam that affect the Veteran's ability to secure or maintain gainful employment. A review of the record shows that the Veteran receives VA treatment for various disabilities. However, there is no evidence of record in the VA treatment notes indicating that the Veteran has symptoms of tinea pedis worse than those observed in the various VA examination reports of record. More recent VA treatment reports reflect that the Veteran's foot skin color and temperature are within normal limits and the Veteran consistently denied rashes. See VA treatment records dated in 2016 and 2017. Based on the evidence presented, the Board finds against a higher evaluation for tinea pedis and tinea unguium, and tinea versicolor. There is no showing that either skin disability affects at least 5 percent, but less than 20 percent of the entire body covered; or at least 5 percent, but less than 20 percent of exposed areas; or intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs, is required for a total duration of less than six weeks during the past 12-month period. At most, the evidence shows hypopigmented macules, white patches of skin and scaling of the skin along with fungal infection of the toenails affecting well less than 5 percent total body area and requiring no more than use of topical treatment. The above findings do not warrant compensable ratings. The Board has also considered whether the Veteran is entitled to a compensable rating on the basis of scars. However, the evidence reflects that the total area covered by the tinea versicolor or tinea pedis and tinea unguium less than 6 square centimeters, and the affected areas were not tender or unstable on examination. In addition, there are no functional limitations or disabling effects caused by the Veteran's tinea pedis, and as such, consideration under Diagnostic Code 7805 is not warranted. Although the Veteran reported having pain and walking with a limp at times when the skin breaks because of his tinea pedis, no functional effects have been noted by the VA examiners and the October 2016 examiner noted that there are no physical limitations on exam to affect ability to secure or maintain gainful employment. Further, the March 2010 VA examiner noted that the Veteran had injury to the right foot which is unrelated to any rash on either foot. In addition, VA treatment records dated in February 2017 reflect the Veteran complained of pain in his right foot. It was noted that he was seen and treated in the past for Freiberg's Infraction, but pain had increased and he was treated again with orthotics. Thus it appears that the Veteran's complaints of pain are unrelated to his service connected tinea pedis. Given this, and the complete absence of any findings of pain or tenderness at the site of his tinea during the years of the Veteran's pending appeal, the Board does not consider the Veteran's isolated complaint of pain related to his tinea to be credible. Further, while the Veteran was noted to use a topical corticosteroid cream for treatment of his tinea pedis, he did not take intermittent systemic therapy or immunosuppressive drugs for treatment of tinea. The Board acknowledges the Veteran's complaints of a higher severity of his symptoms of tinea. The examinations considered all reported symptoms in making findings and the Board has considered that evidence in considering the appropriate rating. The Board finds that compensable ratings are not warranted. 38 C.F.R. § 4.118, Diagnostic Codes 7806, 7813. Accordingly, compensable ratings for the service-connected tinea pedis and tinea unguium, and tinea versicolor are not warranted. PTSD and depressive disorder The Veteran contends that a higher rating is warranted for his service-connected PTSD and depressive disorder. During the February 2016 Board hearing, the Veteran testified that he was admitted to the psychiatric department at the Durham VA Medical Center (VAMC) and indicated that he may have had suicidal thoughts and symptoms of paranoia. Psychiatric disabilities are rated under the General Rating Formula for Mental Disorders. Multiple ratings for different diagnoses are not available. Rather, all psychiatric symptoms are considered part of the service-connected disabilities, unless there is medical evidence differentiating between symptoms and diagnoses. The Veteran's psychiatric disability is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411, which provides that a 70 percent disability rating is warranted when there is 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation 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 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. The symptoms listed are not intended to constitute an exhaustive list, but rather 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). When evaluating a mental disorder, the rating agency shall consider 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 agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). 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, the VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment See Mauerhan, supra. Within the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994))., 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). While not determinative, a GAF score is probative as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). A GAF score of 31-40 is assigned where there is some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. A GAF of 41 to 50 reflect serious symptoms (e.g. suicidal ideation or severe obsessional rituals), or any other serious impairment in social or occupational functioning. A GAF score of 51 to 60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). A GAF of 61 to 70 is defined as some mild symptoms or some difficulty in social, occupational, or school functioning but generally functioning pretty well, has some meaningful relationships. The Board notes that the DSM-IV has been recently updated with a Fifth Edition (DSM-V). Effective August 4, 2014, VA issued an interim rule amending the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to refer to certain mental disorders in accordance with DSM-V. The provisions of the interim final rule only apply, however, to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014. As the Veteran's claim was certified to the Board in September 2013 (i.e., before August 4, 2014), the DSM-IV applies. Although the recently adopted DSM-V no longer utilizes the GAF scale, the scores remain informative as to how physicians have assessed the Veteran's functionality during the period under review. The Veteran's PTSD with depressive disorder is rated as 70 percent disabling for the period on appeal. The Board has considered whether a 100 percent schedular rating is warranted. The Veteran was afforded VA examinations in connection with his claim. A December 2009 VA examination record reflects that the Veteran complained of sleep interrupted with nightmares. He also complained of having intrusive thoughts and being anxious and easily startled, intolerant of crowds, as well as hypervigilant. He also complained of sporadic temper and appetite, as well as poor concentration. He reported that he tried to stab himself once, however it was not noted when that took place. Upon examination, his behavior was cooperative. Speech was of normal rhythm and pace was slow. There were no lucid dissociation or flight of ideas, and no bizarre motor movements or ticks. His mood was subdued and his affect appropriate. He had no homicidal or suicidal ideation or intent. He also had no impairment of thought processes or communication, delusions, hallucinations, ideas of reference or suspiciousness. He was oriented times 3, and his memory both remote and recent appeared to be adequate, as was insight, judgement, and intellectual capacity. A GAF score of 52 was assigned. The examiner indicated that the Veteran had moderate and persistent symptoms of PTSD with no remissions. The examiner also noted that the Veteran has no friends and does not have a lot of interests, but he does go to church. Lastly, it was noted that the Veteran takes medication without much relief, and that his psychiatric symptoms result in some impairment of social functioning. The Veteran was afforded another VA Mental Disorder examination in November 2016. The examiner described the Veteran's occupational and social impairment as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported difficulty with his concentration, and complained he lacks initiative and has low self-esteem. He noted he had been highly involved with his children and grandchildren. However, he stated he had no motivation, no initiative, and no finances to do the things he would like to do in retirement. He denied current suicidal ideation, but thought about suicide weekly. Nonetheless, he denied intent to cause himself harm because of his Christian values and church community. Upon examination, his symptoms depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, difficulty in understanding complex commands, disturbances of motivation and mod, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, inability to establish and maintain effective relationships, suicidal ideation. His thought process was logical and linear and he did not describe any unusual thought content. He denied suicidal or homicidal ideation. His insight and judgment were good. He appeared to have adequate attention and concentration and his memory appeared to be intact. VA treatment records throughout the appeal period reflect similar symptoms. In 2011 he presented with suicidal ideations. He reported feeling more depressed, worsening sleep, energy levels, concentration, and interest over the prior few weeks. He was feeling better the next morning and then denied further thoughts of hurting himself. He denied auditory or visual hallucinations and past manic episodes. Upon examination, his attitude was guarded and irritable, but he opened up as the interview progressed. His mood was depressed and affect constricted and guarded, but overall euthymic. He had good judgment and fair insight. The Veteran also denied current hallucinations and violent ideations, and no delusions were evident. Following examination, the examiner determined that the Veteran was at a moderate risk of harm to self, but did not appear imminently dangerous. GAF was reported to be 35 at that time. As noted above, the Veteran was admitted to the hospital in December 2015, in part due to his psychiatric symptoms. He was initially admitted with a diagnosis of rhabdomyolysis due to exertion after leaving the house following an altercation with his wife. At that time, his family implied the Veteran was at his mental baseline and overreacted after the altercation. He subsequently requested to be seen by a psychiatrist and was transferred to psychiatry service. The Veteran denied manic and psychotic symptoms as well as being a danger to himself or others. He did have sadness, guilt feelings, and feelings of worthlessness and hopelessness. His mood and affect were described as depressed. The Veteran specifically denied leaving his house with a plan to harm himself or others, but did feel while walking that he was okay with getting hit by another car or collapsing. Upon examination, he was noted to have mild anhedonia, poor concentration with likely dissociation, and middle insomnia. He also endorsed occasional hopelessness, but denied suicidal ideation, homicidal ideation, audio and visual hallucinations, and paranoia. His wife reported that the Veteran had a history of suicidal ideation, sometimes with a plan. However, the Veteran denied ever attempting suicide and said his thoughts were chronic and intermittent. He was discharged four days later. At that time, though processes were linear with reality based content. The nursing diagnosis was ineffective coping secondary to depression symptoms and PTSD. The status was resolved and the Veteran indicated improvement in mood. The Board finds that the weight of the lay and medical evidence does not demonstrate that the Veteran's symptoms produce total occupational and social impairment. The Veteran does suffer from anxiety, nightmares, sleep impairment, and panic attacks that occur weekly or less often, but these are specifically listed under the criteria for a 30 percent rating. Difficulty in establishing and maintaining relationships and difficulty in understanding complex commands are specifically contemplated in the 50 percent rating criteria. The Veteran's suicidal ideation, inability to establish and maintain effective relationships, and difficulty in adapting to stressful circumstances are contemplated under the 70 percent PTSD rating criteria. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Moreover, the Board notes that the Veteran's GAF scores do not warrant a 100 percent schedular rating. GAF scores throughout the appeal period range from 35 to 52. The severity of the GAF scores throughout the medical record are further evidence of the Veteran's deficiencies in most areas such as psychological, social and occupational functioning, and serve as additional evidence of the degree of the symptoms that warrant an assigned rating of 70 percent. While a GAF score between 31 and 40 indicates some impairment in reality testing or communication or major impairment in several areas, it does not signify total impairment in either occupational or social areas. DSM-IV, 38 C.F.R. §§ 4.125, 4.130. See also, Carpenter, 8 Vet. App. at 242-244. The record does not establish, and the Veteran has not advanced, that his PTSD and depressive disorder picture encompassed symptoms such as gross impairment in thought processes or communication, grossly inappropriate behavior, a persistent danger of hurting himself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to place, and memory loss for names of close relatives, own occupation, or own name. The evidence does not show that the symptoms the Veteran experienced are productive of total occupational and social impairment, given that the Veteran has been able to maintain some personal relationships and attend social activities. The weight of the evidence shows that the Veteran continued to be able to perform activities of daily living. Also, although the Veteran endorsed suicide attempts, he has not demonstrated "persistent danger of hurting self or others" as contemplated by the 100 percent rating criteria. Of note, the Veteran denied suicidal and homicidal ideation during his December 2015 hospitalization. Additionally, VA examination reports reflect no obsessional rituals which interfere with routine activities. Furthermore, the Board finds the Veteran's sleep impairment and depression did not affect his ability to function independently. The Board notes that in December 2015 and January 2016 VA treatment reports, the Veteran complained of visual hallucinations, noting that he sees the first person he shot in Vietnam all the time when he was 19, sometimes daily, or several times a day. While the Veteran may have experienced visual hallucinations at times, the weight of the evidence does not show persistent delusion and hallucinations. Rather additional VA treatment records and examination reports are negative for any hallucinations. Additionally, the Veteran does not have significant social impairment as the Veteran has reported having a good relationship with his wife, children, and grandchildren. He also interacted appropriately with health care providers and VA examiners at all times. Thus, he did not demonstrate total social impairment, as contemplated under the 100 percent rating criteria. In sum, the Board finds that the weight of the lay and medical evidence of record, including the assigned GAF score, demonstrates no more than occupational and social impairment with deficiencies in most areas, due to such symptoms as: suicidal ideation, depression, anxiety, impaired impulse control, and difficulty adapting to stressful circumstances; however, total occupational and social impairment was not shown. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board notes that the September 2016 VA examiner specifically stated that the Veteran's current psychiatric presentation involves occupational and social with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Board observes that the matter of total occupational impairment has been resolved in the Veteran's favor in the granting of a TDIU in a March 2017 rating decision. However, receipt of a 100 percent rating for PTSD requires total occupational AND social impairment due to symptoms of similar severity, frequency, and duration to those that are listed in the 100 percent rating schedule, and such is not demonstrated in this case. Given these findings, a rating in excess of 70 percent is not warranted. 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. As such, the criteria for the maximum, 100 percent rating have not been met, to include on the basis of a staged rating pursuant to Fenderson. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER An initial compensable rating for service-connected tinea pedis and tinea unguium is denied. A rating in excess of 70 percent for PTSD and depressive disorder is denied. A compensable rating for service-connected tinea versicolor is denied. REMAND Bilateral hearing loss On review, the Board finds that additional development is necessary prior to final adjudication of the Veteran's claim for a compensable rating for bilateral hearing loss. Specifically, the Board instructed the AOJ to obtain certain VA treatment records in the May 2016 remand. The AOJ did obtain additional VA treatment records; however, results from a November 2015 audiogram which were requested remain outstanding. Stegall v. West, 11 Vet. App. 268, 270 (1998) (holding that a remand by the Board confers on a veteran, as a matter of law, a right to compliance with the remand instructions, and imposes upon VA "a concomitant duty to ensure compliance with the terms of the remand"). In addition, it appears a June 2009 audiogram is outstanding as well. According to the June 2009 VA treatment notes the audiogram is available on Quasar and the audiometric data was entered in Noah. There is no indication in the claims file that this record is unavailable. As such, the AOJ should attempt to obtain that June 2009 and November 2015 audiograms. Accordingly, the case is REMANDED for the following actions: 1. The AOJ should obtain all updated VA treatment records, to include the June 2009 VA audiogram results identified in the VA treatment record from the same date, which appears to be available in Quasar or Noah based on the notation in the VA treatment record and the November 2015 VA audiogram results. It does not appear that either report was contained in the VA treatment records associated with the file. 2. After completing the above actions and any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs, the claim should be readjudicated by the AOJ on the basis of additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished a supplemental statement of the case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs