Citation Nr: 1802923 Decision Date: 01/12/18 Archive Date: 01/23/18 DOCKET NO. 13-25 893 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to service connection for a right knee disability. 3. Entitlement to service connection for a left knee disability. 4. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for sleep apnea. 5. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with major depressive disorder, unspecified anxiety disorder, and alcohol abuse claimed as psychosis prior to April 25, 2017. 6. Entitlement to an effective date prior to October 11, 2011 for the grant of service connection for PTSD. 7. Entitlement to a total disability rating based on individual unemployability. REPRESENTATION Appellant represented by: J. Michael Woods, Attorney at Law ATTORNEY FOR THE BOARD J.A. Williams, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1988 to May 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2012, July 2012, September 2015, and June 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In July 2015, the Board granted the Veteran's PTSD claim and remanded the Veteran's claim of entitlement to service connection for the back, bilateral knees, and acquired psychiatric disorder other than PTSD. The Board finds that the RO substantially complied with the remand instructions. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). A September 2015 rating decision effectuated the PTSD grant. The Veteran filed a notice of disagreement with the effective date and evaluation on February 2016. In a June 2017 supplemental statement of the case, the RO assigned a 100 percent rating for PTSD effective April 25, 2017. Despite the increased evaluation, the Court has held that, where there is no clearly expressed intent to limit the appeal to entitlement to a specified disability rating, the RO and Board are required to consider entitlement to all available disability ratings for that condition. See AB v. Brown, 6 Vet. App. 35, 39 (1993). Thus, the issue remains in appellate status. In the September 2015 decision, the Board also remanded the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder other than PTSD. As the medical evidence showed that all the Veteran's mental health diagnoses are related to service, the issue has been recharacterized to reflect that all of his psychiatric disabilities are service-connected. See April 2017 VA Examination; May 2017 Supplemental Statement of the Case. In April 2016, the Board denied the Veteran's claim of entitlement to service connection for sleep apnea. The Veteran did not appeal this decision to the United States Court of Appeals for Veterans Claims (Court), and it became final. See 38 U.S.C. §§ 7104, 7266 (West 2014). The Veteran filed a new claim for sleep apnea in April 2016. In a June 2016 rating decision, the RO declined to reopen the claim. In an August 2017 correspondence, the Veteran, through his attorney, indicated he is unable to work due to his service-connected psychiatric disabilities. As such a claim for a total disability rating based on individual unemployability (TDIU) has been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that a TDIU claim is part of an increased rating claim when it is expressly raised by the Veteran or reasonably raised by the record). The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The evidence is not sufficient to show that the Veteran's lumbar spine disability had its onset in service, manifested to a compensable degree within one year of separation, or is otherwise related to service. 2. The evidence is not sufficient to show that the Veteran's right knee disability had its onset in service or is otherwise related to service. 3. The evidence is not sufficient to show that the Veteran's left knee disability had its onset in service or is otherwise related to service. 4. In an unappealed Board decision, dated April 2016, service connection for sleep apnea was denied. 5. The evidence received since the April 2016 Board decision, is not new and material; in that it does not raise a reasonable possibility of substantiating the claim. 6. Prior to April 25, 2017 the Veteran's PTSD symptoms more nearly approximate the degree of occupational and social impairment contemplated by a 50 percent schedular rating, but no higher. 7. The record evidence shows that the Veteran's original claim of service connection for PTSD was received on October 11, 2011. 8. The earliest effective date for the establishment of service connection for PTSD is October 11, 2011, the date the Veteran first filed his claim. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). 2. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2017). 3. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2017). 4. The April 2016 Board decision denying service connection for sleep apnea is final. 38 U.S.C. § 7104(b) (West 2014); 38 C.F.R. § 20.1100 (2017). 5. New and material evidence has not been received to reopen the claim of entitlement to service connection for sleep apnea. 38 U.S.C. § 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 6. The criteria for an initial evaluation in excess of 50 percent for PTSD with major depressive disorder, unspecified anxiety disorder, and alcohol abuse claimed as psychosis prior to April 25, 2017, are not met. 38 U.S.C. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.126, 4.130, Part 4, Diagnostic Code 9411 (2017). 7. The criteria for an effective date prior to October 11, 2011 for the grant of service connection for PTSD disease are not met. 38 U.S.C. § 5110 (West 2014); 38 C.F.R. §§ 3.114, 3.400, 3.816 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection for Lumbar Spine and Bilateral Knee Disabilities Establishing service connection requires (1) evidence of a current disability; (2) 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 present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Moreover, pursuant to 38 C.F.R. § 3.309, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and a chronic disease, such as arthritis, becomes manifest to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a). In a May 2014 private treatment note, the Veteran was diagnosed with L4-5, L5-S1 herniated nucleus pulposus, degenerative disc disease, facet arthropathy, foraminal stenosis, and chronic lower back pain. VA treatment records indicate a diagnosis of bilateral knee arthralgia. As the evidence is clear that the Veteran has current diagnoses, the issue that remains disputed is whether the Veteran's lumbar spine and bilateral knee disabilities had their onset in service, manifested to a compensable degree within one year of separation or are otherwise related to service. Regarding the lumbar spine, an April 1996 report of medical history indicates that show the Veteran complained of low back pain developed low back pain during exercise and was treated with physical therapy and restrictions. He was back to normal in January 1990 without recurrence. The Veteran also had upper back pain that was relieved by a lipoma excision. In an October 1997 report of medical history, the Veteran denied recurrent back pain. Regarding the Veteran's bilateral knees, in the April 1993 report of medical history, the Veteran indicated that he suffered from swollen or painful joints as well as cramps in his legs. In an October 1997 Report of medical History the Veteran denied "trick" or locked knee and swollen or painful joints. The Veteran's current treatment records (both VA and private) indicate ongoing treatment for his knees and back. An August 2011 VA treatment note indicates that the Veteran complained of back pain and indicated that it started in 2003. The Veteran reported that his back pain began while washing his truck. During August 2011 medical treatment, the Veteran also reported bilateral knee pain. He reported that his knees buckle. He reported the pain has been off and on for the previous 4 years and he denied any injury or trauma. The Veteran was afforded a VA examination in May 2017. The examiner opined that the Veteran's lumbar spine and knee conditions were less likely than not related to service. The examiner cited to the medical evidence of record for his conclusions. He acknowledged that the Veteran endorsed swollen or pain joints and recurrent back pain in his April 1996 report of medical history. The April 1996 report of medical examination did not note any back or bilateral knee conditions. In addition, in early 1989 the Veteran complained of low back pain and was treated with physical therapy and restrictions. He was back to normal in January 1990 with no recurrences. The examiner also cited to a May 2010 VA treatment note in which the Veteran reported bilateral knee pain with some symptoms prior but not particularly disabling. He reported no specific injury but did run track and play basketball in high school. The Veteran reported that he left the military in 1996 and his knees improved over time after leaving the military. The diagnostic impression was mild early osteoarthritis in both knees. The examiner also cited to an August 2011 VA treatment note in which the Veteran complained of back pain with an onset of 2003. The Veteran reported that his pain began while washing his truck. The Board finds that the VA examiner's opinion adequate and highly probative to the question at hand. The examiner possessed the necessary education, training, and expertise to provide the requested opinions. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In addition, the VA examiner provided adequate rationales for the opinions, and the opinions were based on an examination and interview of the Veteran, as well as on a review of the service treatment records, the post-service treatment records and examinations, and the lay statements of the Veteran. The opinions considered an accurate history, were definitive and supported by a detailed rationale that considered the lay and medical evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Significantly, the Veteran has not presented or identified any contrary medical opinion that supports the claim for service connection. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). The Board finds that the most persuasive evidence of record shows that the current knee disability is not related climbing poles in service. The Board has also considered the Veteran's assertions that his current lumbar spine and bilateral knee disabilities were caused by service. The Veteran is competent to testify to facts or circumstances that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). It is also well established that lay persons without medical training, such as the Veteran, are not competent to provide medical opinions on matters requiring medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Whether the Veteran's current lumbar spine or bilateral knee disabilities are related to service requires medical expertise to determine. Thus, the Board finds the VA medical opinions more probative than the Veteran's statements. . The Board has also considered whether service connection is warranted on a presumptive basis. However, the evidence does not show that the Veteran's degenerative joint disease of the lumbar spine symptoms manifested to a compensable degree within 1 year from separation. As previously noted, the Veteran reported that his back pain had its onset in 2003 - approximately 7 years after separation. Thus, service connection on a presumptive basis is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). New and Material Evidence for Sleep Apnea A Board decision is final unless the Chairman of the Board orders reconsideration. See 38 U.S.C. §§ 7103 (a), 7104; 38 C.F.R. § 20.1100(a). The Board denied the Veteran's claim in an April 2016 decision. The Veteran did not appeal this decision to the United States Court of Appeals for Veterans Claims (Court), and it became final. See 38 U.S.C. §§ 7104, 7266. A previously denied claim may be reopened by the submission of new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Evidence is new if it has not been previously submitted to agency decision makers. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Evidence is material if it, either by itself or considered in conjunction with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be cumulative or redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Fortuck v. Principi, 14 Vet. App. 173, 179-80 (2003); Justus v. Principi, 3 Vet. App. 510 (1992). Furthermore, in Shade v. Shinseki, 24 Vet. App. 110, 117 (2010), the United States Court of Veterans Appeals (Court) clarified that the phrase "raises a reasonable possibility of substantiating the claim" is meant to create a low threshold that enables, rather than precludes, reopening. Specifically, the Court stated that reopening is required when the newly submitted evidence, combined with VA assistance and considered with the other evidence of record, raises a reasonable possibility of substantiating the claim. Id. The Veteran has not submitted new evidence relevant to his sleep apnea claim since he requested the claim be reopened. The Veteran's claim was denied because the evidence of record does not show a diagnosis of sleep apnea. Additional private and VA medical records have been associated with the record but do not show a diagnosis of sleep apnea. Notably, the only treatment for sleep impairment is the Veteran's medical treatment records are related to his service-connected PTSD and other acquired psychiatric disorder. As such, the Board finds that there is not new evidence that relates to an unestablished fact necessary to substantiate the claim for service connection for sleep apnea. See Shade, 24 Vet. App. at 117-18. The request to reopen the claim of entitlement to service connection for sleep apnea is denied. Increased Rating for PTSD Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. Part 4 (2017). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran is presumed to be seeking the maximum possible evaluation. AB v. Brown, 6 Vet. App. 35 (1993). Separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). PTSD is evaluated under VA's General Rating Formula for Mental Disorders. Under the formula, a 10 percent rating is warranted when there is 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent 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). 38 C.F.R. § 4.130, DC 9411. A 50 percent rating is warranted when there is 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 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. 38 C.F.R. § 4.130, DC 9411. A 70 percent rating is warranted where 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; 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, DC 9411. The criteria for a 70 percent rating for PTSD are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent rating is warranted when there is 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. 38 C.F.R. § 4.130, DC 9411. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are 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, 442-43 (2002). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). 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. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). The Global Assessment Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996). A score of 31 to 40 reflects 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 score of 41 to 50 is assigned where there are "[s]erious 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)." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV) 47 (4th ed. 1994). A score of 51 to 60 is appropriate where there are "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. A GAF score of 61 to 70 indicates the examinee has some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functions pretty well with some meaningful interpersonal relationships. Id. at 46. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran asserts that his PTSD is more disabling than reflected in his 50 percent initial rating. September 2000 private treatment notes show the Veteran reported recurrent intrusive memories of traumatic experiences in the Gulf War. The Veteran also reported nightmares and flashbacks. The Veteran denied homicidal and suicidal ideation. He denied substance abuse and antisocial behavior. During the assessment the Veteran's affect, mood, and cognitive functions were normal. His thought content was coherent and goal directed. September 2011 VA treatment note indicates that the Veteran presented as visibly anxious and shaky. He reported significant PTSD symptoms including re-experiencing via nightmares, flashbacks, frequently thinking about trauma, avoidance, and hyperarousal such as sleep problems, irritable/angry mood, poor concentration, jumpiness. He reported that 2 to 3 times per night he finds himself curled up on the floor near the edge of the bed feeling frightened and shaken. In 2000 he was detained for 72 hours following placing a threatening called to the mother of his daughter and being observed by family members laying on the ground firing his gun across the field as if in combat. He reported that he did not have memory of these incidents. The Veteran denied suicidal or homicidal intent, ideation, or plan. During a November 2011 VA psychiatric evaluation, the Veteran reported symptoms of insomnia, feeling on edge, decreased appetite, excessive drinking, and nightmares. He reported that he constantly feels someone is out to hurt him. The examiner noted that the Veteran appeared intoxicated. He denied current legal ideation and his symptoms were severe. He reported a good relationship with his wife but indicated their marriage was strained. The Veteran reported that after service he worked as a laborer for eight to nine years. He reported that his relationship with his supervisor and co-workers were good although he worked alone. He reported that there had not been major changes in his daily activities or major social function since his mental condition developed. He reported that he had not worked for the past six months. The Veteran further reported that his unemployment is not due, primarily, to the effects of a mental condition. The Veteran reported alcohol and marijuana use daily. On physical examination the Veteran's orientation was within normal limits. Appearance and hygiene were appropriate. Behavior was grossly inappropriate with examples of paranoia and agitation. He maintained good eye contact. Affect and mood showed findings of intoxication. Communication was within normal limits. Abnormal speech occurred intermittently. It was illogical obscure speech. The Veteran denied panic attacks and hallucinations. The examiner concluded that there was occupational and social impairment with deficiencies in most areas, such as work, school, family, relations, judgment, thinking and/or mood. The Veteran had a GAF score of 40. See also January 2012 Addendum VA Medical Opinion. During March 2013 VA psychiatric treatment the Veteran reported nightmares occurring less frequently. See VA Treatment Records. He also reported hypervigilance and history suicidal thoughts. He denied suicide attempts. He reported having rageful thoughts but denied homicidal ideation. He denied use of illicit substances but reported drinking alcohol. The health care provider indicated the Veteran's appearance was neat and clean. He was alert and oriented. Behavior was appropriate. His mood was anxious. His speech was relevant and coherent. There were no delusions or hallucinations. His memory was adequate. A July 2013 VA treatment note indicates that the Veteran reported recurrent intrusive thoughts, recurrent nightmares, flashbacks, irritability, hypervigilance, and social isolation. In July 2014 the Veteran reported flashbacks and nightmares twice a week. He reported low energy and low motivation. He reported problems falling and staying asleep. He reported feeling depressed that he cannot work or enjoy things he used to enjoy. He reported he does not socialize and often "gets angry at little things." He reported that his wife helps him with his limitations. He also reported attending church and working with the deacons at his church. He denied suicidal and homicidal ideation. He reported that he stopped drinking alcohol. Similarly, a November 2014 VA treatment note indicates the Veteran denied psychotic symptoms. He denied depression, manic symptoms, suicidal ideation, and homicidal ideations. He reported no problems with sleep or appetite. There were no delusions or hallucinations elicited. His mood was euthymic with some constriction of affect. His insight and judgement were not impaired. The medical service provider noted the following protective factors: positive future plans, positive social support, sense of responsibility to family/significant other, cultural/religious/spiritual beliefs, reality testing ability, and positive problem-solving skills. A March 2015 VA treatment note indicates the Veteran reported flashbacks and nightmares. He reported that refraining from watching the news and removing reminders of military service helped his symptoms. He further reported attending church and having an uncle who is deacon stop by his home several times a week. He further reported that his family recently celebrated his birthday by having a gathering. He reported an inability to tolerate crowds of people and loud sounds. He reported hyperarousal symptoms of increased started response and hypervigilance. He also reported social isolation, difficulty dealing with significant others, and irritability. The medical service provider indicated that the Veteran's PTSD symptoms have been present in varying intensity for many years and have caused significant impairment in social, occupational and interpersonal spheres. The medical service provider reported that he has had to deal mostly with anger, anxiety, irritability, and sleep issues. The Veteran denied psychotic symptoms, suicidal ideation, and homicidal ideation. In November 2015 the Veteran, the Veteran reported that he was "doing pretty good." He indicated that he helps take care of his granddaughter. He reported that he and his wife recently celebrated a 13 year anniversary. He reported that his avoidance and re-experiencing symptoms were less frequent. Based on the forgoing evidence the Board concludes that the Veteran's PTSD manifestations prior to April 25, 2017 are insufficient in severity to produce the level of social and occupational impairment contemplated by a rating in excess of 50 percent, nor could one conclude that existing psychiatric symptoms would have been best approximated by a 70 percent or 100 percent rating. Mauerhan v. Principi, 16 Vet. App. at 442-43. The record shows that the Veteran consistently reported effective relationships with his wife and other family members. He also reported involvement with his church. He reported that prior to discontinuing work in 2011 he maintained good relationships with his supervisor and coworkers. Further, the Veteran's treatment records were silent for panic attacks, obsessional rituals which interfere with routine activities. There was also no evidence of intermittently illogical obscure or irrelevant speech except when the Veteran appeared to be intoxicated during the November 2011 VA examination. There is also no evidence of unprovoked irritability with periods of violence, spatial disorientation, or neglect of personal appearance and hygiene. The April 2017 VA examination noted a worsening the Veterans PTSD symptoms to warrant a 100 percent rating. The Board finds that April 25, 2017, the date of the Veteran's most recent VA examination, is the earliest date upon which it is factually ascertainable that the Veteran experienced a worsening of symptoms to warrant a 100 percent rating. In sum, an initial rating in excess of 50 percent for the Veteran's PTSD with major depressive disorder, unspecified anxiety disorder, and alcohol abuse claimed as psychosis is not warranted as the preponderance of the evidence is against the claim. Earlier Effective Date for Grant of Service Connection for PTSD The Veteran has claimed entitlement to an effective date prior to October 11, 2011 for the grant of entitlement to service connection for Parkinson's disease. Generally, the effective date of an award of disability compensation based on an original claim shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a) (West 2014); 38 C.F.R. § 3.400 (2017). If the claim is received within one year after separation from service, the effective date of an award of disability compensation shall be the day following separation from active service. 38 U.S.C. § 5110(b)(1) (West 2014); 38 C.F.R. § 3.400(b)(2)(i) (2017). Unless specifically provided, the effective date will be assigned on the basis of the facts as found. 38 C.F.R. § 3.400(a) (2017). Here, the evidence shows the Veteran filed his claim on October 11, 2011- almost 15 years after separation. There is no evidence indicating that the Veteran's PTSD claim was received prior to October 2011. Thus, there is no legal basis to establish an effective date prior to October 11, 2011 for PTSD. ORDER Entitlement to service connection for a lumbar spine disability is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability is denied. The appeal to reopen the Veteran's claim of entitlement to service connection for sleep apnea is denied. Entitlement to an effective date prior to October 11, 2011 for the grant of service connection for PTSD with major depressive disorder, unspecified anxiety disorder, and alcohol abuse claimed as psychosis is denied. Entitlement to an initial rating in excess of 50 percent for PTSD with major depressive disorder, unspecified anxiety disorder, and alcohol abuse claimed as psychosis prior to April 25, 2017 is denied. REMAND As previously stated, the issue of entitlement to TDIU has been raised by the record but it has not been developed or adjudicated by the RO. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, on remand the RO should send the Veteran a VA Form 21-8940 to assist in developing his claim. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with appropriate notice regarding the TDIU claim and request that she complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. Explain what is needed to establish entitlement to TDIU due to his service-connected disabilities. Ask the Veteran to submit any additional evidence in support of a TDIU claim, to specifically include information on his work history, salary, and educational history. 2. The RO/AMC should again contact the Veteran and his representative and request that he complete and submit a VA Form 21-8940, and associate the form with the claims file. The form should be completed for the years 2004 nthrough 2016. Ask the Veteran to provide IRS tax returns from 2004 through 2016 and a statement that the copy is an exact duplicate of the return filed with the IRS. Provide the Veteran with an IRS Form 4506-T "Request for Transcript of Tax Return" which may also be found at https://www.irs.gov/pub/irs-pdf/f4506t.pdf so that the Veteran may request tax returns from 2011 thru 2017 and submit them to VA. Tell the Veteran that if he does not have copies of his tax returns for the requested years, he may use the IRS form cited to above. 3. Obtain any available records from the Social Security Administration that address whether the Veteran has filed for disability benefits or is in receipt of same. 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 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). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs