Citation Nr: 1803201 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 14-10 938A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Whether new and material evidence has been received to reopen the claim for entitlement to service connection for hypertension. 2. Whether new and material evidence has been received to reopen the claim for entitlement to service connection for hyperlipidemia. 3. Entitlement to service connection for gout. 4. Entitlement to an initial disability rating posttraumatic stress disorder (PTSD) greater than 30 percent for from December 27, 2011, a staged initial rating greater than 50 percent from April 13, 2016, and a staged initial rating greater than 70 percent from January 9, 2017. 5. Entitlement to an initial disability rating greater than 20 percent for lumbar spine spondylosis. 6. Entitlement to an initial disability rating for diabetes mellitus, type II, greater than 10 percent from February 25, 2010, and greater than 20 percent from July 18, 2011. 7. Entitlement to a compensable initial disability rating for allergic rhinitis. 8. Entitlement to an initial disability rating greater than 20 percent for right upper extremity diabetic peripheral neuropathy of the radial nerve, median nerve, and ulnar nerve. 9. Entitlement to an effective date earlier than January 10, 2017 for the grant of service connection for right upper extremity peripheral neuropathy. 10. Entitlement to an effective date earlier than April 13, 2016 for the grant of Dependents' Educational Assistance. 11. Entitlement to an effective date earlier than January 9, 2017 for the grant of special monthly compensation based on housebound status. 12. Entitlement to a total disability rating for compensation based upon individual unemployability (TDIU) prior to April 13, 2016. REPRESENTATION Appellant represented by: Christopher Loiacono, Attorney ATTORNEY FOR THE BOARD M. Katz, Counsel INTRODUCTION The Veteran served on active duty from February 1967 to February 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from August 2010, December 2010, November 2012, January 2014, and May 2017 rating decisions by the Department of Veterans Affairs (VA) Regional Office in Waco, Texas (RO). In the April 2014 substantive appeal, the Veteran indicated that he wanted a hearing before the Board. However, in an August 2017 statement, the Veteran withdrew the request for hearing. Since the RO last considered the Veteran's claim in June 2017, additional evidence has been added to the Veteran's claims file. The additional evidence includes a psychiatric evaluation submitted by the Veteran. Although the Veteran has not provided a waiver of RO consideration of this evidence, a waiver is not needed in this case. An automatic waiver of Agency of Original Jurisdiction (AOJ) consideration applies in this case with respect to the evidence submitted by the Veteran because the Veteran's substantive appeal was received after February 2, 2013, and the Veteran has not requested the Board to remand the case for AOJ consideration of the evidence. See 38 U.S.C. § 7105(e) (2012). Accordingly, although the Veteran has not waived RO consideration of the records submitted in September 2017, no waiver is required. The issues of entitlement to an initial disability rating greater than 20 percent for a lumbar spine disability, entitlement to an increased disability rating for type II diabetes mellitus, entitlement to an initial disability rating greater than 20 percent for right upper extremity diabetic peripheral neuropathy, entitlement to an effective date earlier than January 10, 2017 for the grant of service connection for right upper extremity peripheral neuropathy, entitlement to an effective date earlier than April 13, 2016 for the grant of Dependents' Educational Assistance, entitlement to an effective date earlier than January 9, 2017 for the grant of special monthly compensation based on housebound status, and entitlement to a total disability rating for compensation based upon individual unemployability (TDIU) prior to April 13, 2016 are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In an August 2010 rating decision, the RO denied entitlement to service connection for hypertension and hyperlipidemia. The Veteran did not appeal the August 2010 denial of those issues, and new and material evidence was not received within the one-year appeal period of the August 2010 rating decision. 2. Evidence received since the August 2010 rating decision is new, but does not relate to an unestablished fact necessary to substantiate the claims or raise a reasonable possibility of substantiating the claims for entitlement to service connection for hypertension or hyperlipidemia. 3. Gout is not shown to be casually or etiologically related to any disease, injury or incident in service. 4. Prior to January 9, 2017, the Veteran's PTSD was manifested by symptoms productive of occupational and social impairment with reduced reliability and productivity. 5. From January 9, 2017, the Veteran's PTSD was manifested by symptoms productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. 6. Since the initial grant of service connection, the Veteran's allergic rhinitis has not been manifested by complete obstruction of one side of the nose, or greater than 50-percent obstruction of both nasal passages. CONCLUSIONS OF LAW 1. The August 2010 rating decision is final with respect to the Veteran's claims to establish service connection for hypertension and hyperlipidemia. 38 U.S.C. § 7105(c) (2012), 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). 2. Evidence received since the August 2010 rating decision is not new and material, and therefore the claim for entitlement to service connection for hypertension is not reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156(a) (2017). 3. Evidence received since the August 2010 rating decision is not new and material, and therefore the claim for entitlement to service connection for hyperlipidemia is not reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156(a) (2017). 4. Gout was not incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A (2012); 38 C.F.R. §§ 3.159, 3.303 (2017). 5. Prior to April 13, 2016, the criteria for an initial rating of 50 percent, but no greater, for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2017). 6. From April 13, 2016 to January 9, 2017, the criteria for an initial rating greater than 50 percent have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2017). 7. From January 9, 2017, the criteria for an initial staged rating greater than 70 percent have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2017). 8. The criteria for a compensable initial rating for allergic rhinitis are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.31, 4.97, Diagnostic Code 6522 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With regard to the Veteran's claims to reopen the issues of entitlement to service connection for hypertension and hyperlipidemia, entitlement to service connection for gout, and entitlement to increased ratings for PTSD, and allergic rhinitis, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017). Letters dated in April 2010 and February 2012 satisfied the duty to notify provisions for the claims. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Kent v. Nicholson, 20 Vet. App 1 (2006). With regard to VA's duty to assist, the Veteran's service treatment records, VA medical treatment records, identified private medical treatment records, and Social Security Administration (SSA) records have been obtained. 38 C.F.R. § 3.159(c)(2); Golz v. Shinseki, 590 F.3d 1317, 1320-21 (Fed. Cir. 2010). The Veteran did not undergo a VA examination with regard to his claims to reopen the issues of entitlement to service connection for hypertension or hyperlipidemia. VA is not required to provide a VA examination or obtain a medical opinion in response to a claim to reopen if new and material evidence has not been presented. See 38 C.F.R. § 3.159(c)(4). The Veteran was also not provided with a VA medical examination regarding his claim for service connection for gout. However, a VA examination is not necessary in this case, as the record does not contain any competent evidence suggesting a causal relationship between his currently diagnosed gout and his military service. The Court has held that VA is not required to provide a medical examination when there is no credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Additionally, a mere conclusory generalized lay statement that a service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). For all of these reasons, a VA examination is not required with regard to the Veteran's claim for service connection for gout. McLendon v. Nicholson, 20 Vet. App. 79 (2006). During the time periods pertinent to the current appeal, the Veteran was provided with VA examinations with regard to his claim for an increased rating for PTSD in November 2013, April 2016, and January 2017 and VA examinations for his allergic rhinitis in September 2010, September 2012, and January 2017. Review of the examination reports reflects that the examinations are adequate in this case to determine the severity of the Veteran's PTSD and allergic rhinitis under the pertinent rating criteria during the relevant time periods. The Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding these issues have been met. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). There is no indication in the record that any additional evidence, relevant to the issues adjudicated in this decision, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). I. Hypertension and Hyperlipidemia The Veteran contends that he has submitted new and material evidence sufficient to reopen the claims of entitlement to service connection for hypertension and hyperlipidemia. Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor 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. 38 C.F.R. § 3.156(a). In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the United States Court of Appeals for the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant a claim. In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). In Elkins v. West, 12 Vet. App. 209 (1999), the Court of Appeals for Veterans Claims held the Board must first determine whether the appellant has presented new and material evidence under 38 C.F.R. § 3.156(a) in order to have a finally denied claim reopened under 38 U.S.C. § 5108. Then, if new and material evidence has been submitted, the Board may proceed to evaluate the merits of the claim, but only after ensuring that VA's duty to assist has been fulfilled. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The Court has also held that the law should be interpreted to enable reopening of a claim, rather than to preclude it. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Service connection for hypertension and hyperlipidemia was denied by the RO in an August 2010 rating decision. Notice of that decision was provided to the Veteran that same month. The Veteran did not appeal the August 2010 rating decision's denial of service connection for hypertension or hyperlipidemia, and no evidence was received within the one-year appeal period that would constitute new and material evidence. Thus, the August 2010 rating decision is final with respect to entitlement to service connection for hypertension and hyperlipidemia. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). The August 2010 rating decision denied service connection for hypertension because there was no evidence of in-service incurrence of hypertension, there was no competent evidence demonstrating a relationship between the Veteran's current hypertension and his active duty service, there was no competent evidence showing that hypertension was secondary to service-connected diabetes mellitus, type II, and because there was no evidence that hypertension was diagnosed within one year of service discharge. Service connection for hyperlipidemia was denied because there was no evidence of a diagnosis of a chronic condition or disability manifested by hyperlipidemia, which is a laboratory finding. Thus, in order for the Veteran's claims to be reopened, evidence must be added to the record since the August 2010 rating decision addressing the bases for the August 2010 decisions. Although the RO determined that new and material evidence was not presented to reopen the claim of entitlement to service connection for hypertension and hyperlipidemia, the Board does not have jurisdiction to consider a claim on the merits which was previously adjudicated unless new and material evidence is presented, and before the Board may reopen such a claim, it must so find. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Therefore, the Board must first decide whether evidence has been received that is both new and material to reopen the claims. Consequently, the Board will adjudicate the question of whether new and material evidence has been received, furnishing a complete explanation as to its reasons and bases for such a decision. After a thorough review of the evidence of record, the Board concludes that new and material evidence has not been received to reopen the claims of entitlement to service connection for hypertension and hyperlipidemia. The only pertinent evidence associated with the claims file since the August 2010 rating decision consists of VA treatment records. Although the VA treatment records show diagnoses of benign essential hypertension and hyperlipidemia, they do not indicate that the Veteran's hypertension is related to service or a service-connected disability, or that the Veteran has a disability manifested by hyperlipidemia. Additionally, they do not reflect that hypertension was diagnosed within one year of service discharge. While the new evidence shows diagnoses of hypertension and hyperlipidemia, none of this evidence suggests that the Veteran's hypertension is related to service, or that the Veteran has a disability manifested by hyperlipidemia. The Board acknowledges that the medical evidence received since the August 2010 rating decision is new evidence, as it was not of record at the time of the August 2010 rating decision. However, none of this new evidence is material, as it does not pertain to the etiology of the Veteran's hypertension or show a disability manifested by hyperlipidemia. As the bases of the RO's August 2010 denial of the Veteran's claims for entitlement to service connection for hyperlipidemia was a conclusion that the evidence did not show a disability manifested by hyperlipidemia and that there was no competent evidence showing that hypertension was manifested within one year or service discharge or was related to service or a service-connected disability, the new evidence received since the August 2010 rating decision is not material; accordingly, the issues of entitlement to service connection for hypertension and hyperlipidemia are not reopened. As new and material evidence has not been submitted to reopen the finally disallowed claims of entitlement to service connection for hypertension or hyperlipidemia, the benefit of the doubt doctrine is not applicable. Annoni v. Brown, 5 Vet. App. 463, 467 (1993). II. Gout The Veteran contends that service connection for gout is warranted. Service connection may be established for a disability resulting from disease or injury which was clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran's service treatment records are silent as to any complaints of or treatment for gout. An October 1967 separation examination reflects that the Veteran's lower extremities and feet were normal. In October 1967 and February 1970 reports of medical history, the Veteran denied a history of foot trouble; arthritis or rheumatism; and bone, joint, or other deformity. Private treatment records dated in June 1999 reflect a diagnosis of gout. VA treatment records from 2001 through 2017 show continued diagnoses of and treatment for gout. After a thorough review of the evidence of record, the Board concludes that entitlement to service connection for gout is not warranted, as there is no competent medical or lay evidence showing that the Veteran's gout is related to his military service. The evidence does show diagnoses of gout. Davidson, 581 F.3d at 1316; Degmetich v. Brown, 104 F.3d 1328, 1333 (Fed. Cir. 1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). However, the evidence does not show a link between the Veteran's current gout and his active duty service. The Veteran's service treatment records are negative for any complaints, diagnoses, or treatment for gout, and the Veteran has not provided any lay statements that he experienced gout or symptoms of gout during military service. Further, the first medical evidence of gout is dated in 1999, over 29 years after the Veteran's discharge from military service. See Mense v. Derwinski, 1 Vet. App. 354 (1991) (holding that VA did not err in denying service connection when the Veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of disorder). As the probative evidence of record does not support a finding that the Veteran's gout is causally related to or aggravated by the Veteran's military service, service connection is not warranted. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as discussed above, the preponderance of the evidence is against the Veteran's claim; accordingly, doctrine is not for application. See 38 U.S.C. § 5107(b) (2012);Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Increased Rating Claims The Veteran contends that higher disability ratings are warranted for service-connected PTSD and allergic rhinitis. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2017). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21 (2017); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. 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. VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). a. PTSD The Veteran contends that an initial disability rating greater than 30 percent is warranted for PTSD prior to April 13, 2016, that a staged initial rating greater than 50 percent is warranted for PTSD from April 13, 2016 through January 8, 2017, and that a staged initial rating greater than 70 percent is warranted from January 9, 2017. In January 2014, the RO awarded service connection for PTSD, and assigned a 30 percent rating, effective December 27, 2011, under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411. In May 2014, the Veteran filed a notice of disagreement contesting the rating assigned, and in August 2016, he perfected his appeal. In June 2016, the RO issued a rating decision which awarded an increased rating of 50 percent for PTSD, effective April 13, 2016. In a May 2017 rating decision, the RO assigned an increased rating of 70 percent, effective January 9, 2017. The current regulations establish a general rating formula for mental disorders. 38 C.F.R. § 4.130. 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. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed.Cir.2004); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Entitlement to a specific disability rating, however, requires "sufficient symptoms of the kind listed in the [relevant rating] requirements, or others of similar severity, frequency[,] or duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed .Cir.2013). "Although the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of [occupational and social] impairment." Id. Pursuant to Diagnostic Code 9411, PTSD is rated 30 percent disabling 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), and chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent evaluation 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 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. A maximum 100 percent evaluation is for application 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; and memory loss for names of close relatives, own occupation, or own name. Id. In evaluating the evidence, the Board has considered the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). The Board also notes, however, that the GAF scale was removed from the more recent DSM-V for several reasons, including its conceptual lack of clarity, and questionable psychometrics in routine practice. See DSM-V, Introduction, The Multiaxial System (2013). A GAF score of 61-70 reflects some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 51-60 indicates 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 score of 41-50 reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 31-40 reveals some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). DSM-IV at 46-47. The evidence delineated below does not represent all of the evidence in the claims file, but is representative of the evidence of record and encompasses or is fully representative of evidence that is favorable to the Veteran's claim. VA treatment records dated from December 2010 through April 2016 reflect diagnoses of and treatment for PTSD. The evidence shows that the Veteran reported symptoms including anxiety, insomnia, avoidance of crowds of people, hypervigilance, exaggerated startle response, irritability, concentration and memory problems, nightmares, and feelings of detachment and estrangement from others. In February 2012, he noted that he had a good relationship with his brother. He also indicated that he was married with two daughters. In August 2012, he reported that he was active in his church. A September 2014 record notes that the Veteran interacted well with family and friends, but stayed close to home. The VA treatment records show that the Veteran was regularly alert and oriented. He denied suicidal and homicidal ideation. The Veteran's mood was good, depressed, pleasant, euthymic, or anxious. Affect was congruent with mood. Hygiene was good, eye contact was good, and thoughts were logical and goal-directed. Speech was normal. Memory was intact. The Veteran denied hallucinations. Insight was fair and judgment was good. GAF scores of 51, 55, and 60 were assigned. In November 2013, the Veteran underwent a VA psychiatric examination. The Veteran reported symptoms including depressed mood, anxiety, suspiciousness, irritability, hypervigilance, intrusive thoughts, social isolation, insomnia, and difficulty establishing and maintaining effective work and social relationships. He indicated that he had been married for 45 years and that he lived with his wife. He noted that he got along "fine" with his wife. He explained that he had two daughters and five grandchildren and that he saw his brother once a year. He noted that he had a couple of high school friends that he kept in touch with, but that he mostly kept to himself. He reported that he did not like strangers and did not make friends easily, but that he did have some meaningful long-term relationships. He stated that he attended church and had strong religious beliefs, and that he went to some meetings outside of the church service. He stated that he retired at the age of 64 after working as a water operator. He described a "relatively mild impact of mental health issues on occupational functioning." On mental status examination, the Veteran was casually dressed and well-groomed. He was irritable with some dysthymic affect. Social skills were considered fair to poor. Thought process was logical, coherent, and relevant. Psychomotor functioning was normal. The Veteran was well-oriented with fair reasoning and judgment. Memory and concentration were normal. The Veteran denied suicidal and homicidal thoughts as well as psychosis and mania. The Veteran endorsed significant bizarre experiences including having seen visions, smelling odors that were not there, and seeing things that were not there. The diagnosis was PTSD, and a GAF score of 65 was assigned. The examiner concluded that the Veteran's PTSD symptoms resulted in 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 medication. In an October 2014 lay statement, A.E., the Veteran's friend from childhood, explained that the Veteran exhibited loss of joy of life, bitterness, resentment, and wariness after his return from Vietnam. He noted that the Veteran became anxious and withdrawn in social situations, that he had difficulty sleeping, and that he would not go anywhere where a large crowd was expected. He also indicated that the Veteran always sat with his back to the wall when eating at a restaurant. In a February 2015 PTSD assessment, P.F., a licensed social worker and the Veteran's treating therapist, opined that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood. She reported that the Veteran exhibited symptoms including depressed mood; anxiety; chronic sleep impairment; mild memory loss such as forgetting names, directions, or recent events; disturbances of motivation and mood; difficulty establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; and inability to establish and maintain effective relationships. She noted that the Veteran struggled significantly with alcohol abuse/dependence for 30 years, and that he has been sober for 17 years. She indicated that this substance abuse impacted his interpersonal and occupational experiences, and that alcohol was a way that the Veteran coped with nightmares, sleep issues, and social interactions. She diagnosed PTSD, depression, and anxiety disorder, and assessed a GAF score of 55. In a June 2015 lay statement, the Veteran's wife explained that the Veteran's PTSD was manifested by nightmares, insomnia, difficulty sustaining employment, difficulty getting along with co-workers and supervisors, anxiety, moodiness, lack of trust, and depression. She noted that the Veteran was never able to attend the movies, go to sporting events, or take vacations where he had never been before, and that he was extremely anxious in crowded or strange places. In April 2016, the Veteran underwent another VA psychiatric examination. The VA examiner noted that the Veteran exhibited depressed mood; anxiety; suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss such as forgetting names, directions, or recent events; flattened affect; impaired abstract thinking; and difficulty establishing or maintaining effective work and social relationships. He also reported recurrent intrusive distressing memories, avoidance of trauma-related stimuli, persistent negative emotional state, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbance. The Veteran was fully alert and oriented, and irritable. The examiner noted that the Veteran performed some volunteer work for his church and for a food bank, spending up to 20 hours per week volunteering. He also worked on his vegetable garden for his own therapy. The Veteran stated that he was married for 47 years with two children, five grandchildren, and one great-grandchild. He explained that he avoided most social events and that his wife dealt with his social isolation by going out with their daughters without him. He indicated that he spoke with his brother on a weekly basis and went hunting once or twice a year with a few high school friends. He reported that he slept with a loaded gun under his bed, and that he took the gun outside the previous New Year's Eve when a couple of men drove out on his family property. He explained that he escorted them off of the property. The Veteran reported a history of working as a truck driver before retirement, and noted that he lost previous jobs for "not playing by the company rules." The diagnoses were moderate PTSD and unspecified depressive disorder. The examiner concluded that the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation. VA treatment records from April 2016 through January 2017 reflect continued treatment for PTSD. They show that the Veteran was regularly alert and fully oriented with good eye contact and stable mood. Hygiene was neat. Affect and speech were appropriate. Thought content was goal-directed and concentration and judgment were good. There was no evidence of hallucinations, delusions, or suicidal or homicidal ideation. In January 2017, the Veteran underwent another VA psychiatric examination. The Veteran endorsed symptoms including depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function, chronic sleep impairment, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control, and mild memory loss, such as forgetting names, directions, or recent events. The Veteran reported that he was married for over 45 years. He noted a history of alcohol abuse, but that he had been sober for over 10 years. The Veteran reported that he had considered suicide and that he reported that he was "killing [himself] through drinking so he quit!" The diagnosis was PTSD. The examiner concluded that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. VA treatment records from January 2017 show continued treatment for PTSD with good eye contact, neat hygiene, stable mood, appropriate affect, cooperative behavior, appropriate speech, goal-directed thought content, good concentration, good judgment, and no hallucinations, delusions, or suicidal or homicidal ideation. Additionally, the Veteran was alert and fully oriented. An August 2017 PTSD assessment by P.F., a licensed social worker and the Veteran's treating therapist, reflects current diagnoses of chronic PTSD, recurrent mild depression, generalized anxiety disorder, and alcohol dependence in remission. A GAF score of 55 was assessed. P.F. noted that the Veteran's PTSD disrupted his life in social, occupational, and relational environments, and that depression and anxiety secondarily impacted and complicated his PTSD. She indicated that the Veteran's PTSD resulted in deficiencies in family relations, persistent irrational fears, deficiencies in work or school, depression affecting the ability to function effectively, deficiencies in mood, difficulty adapting to stressful circumstances, intrusive recollections of a traumatic experience, unprovoked irritability, and inability to establish and maintain effective relationships. With regard to work restrictions, P.F. indicated that the Veteran was generally able to perform job requirements, but that the environment needed to include the ability to remove himself if triggered. Also, the type of job had to have limited stimulation and interaction with others, which precluded him from working without having significant incidents of time off for negative responses. After thorough consideration of the evidence of record, the Board concludes that a 50 percent disability rating, but no greater, is warranted prior to April 13, 2016, that a staged initial rating greater than 50 percent is not warranted prior to January 9, 2017, and that a staged initial rating greater than 70 percent is not warranted from January 9, 2017. The Veteran's 30 percent evaluation prior to April 13, 2016 contemplates functional impairment comparable to 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). 38 C.F.R. § 4.130, Diagnostic Code 9411. The 50 percent evaluation from April 13, 2016 through January 8, 2017 contemplates functional impairment comparable to occupational and social impairment with reduced reliability and productivity. Id. The 70 percent rating from January 9, 2017 reflects functional impairment comparable to occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Id. As noted above, GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter, 8 Vet. App. at 242. The Veteran's GAF scores of 51, 55, and 60 show moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM-IV at 46-47. The GAF score of 65 reflects some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. Id. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2017); VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). With consideration of the entire record, the Board finds that the evidence more nearly approximates the criteria for the next higher disability rating of 50 percent prior to April 13, 2016. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2017). In that regard, the evidence shows that the Veteran experienced anxiety, insomnia, avoidance of crowds of people, social withdrawal, hypervigilance, exaggerated startle response, irritability, concentration and memory problems, feelings of detachment and estrangement from others, difficulty establishing and maintaining effective work and social relationships. Although not all of the criteria for a 50 percent rating have been shown, the criteria are simply guidelines for determining whether the Veteran meets the dominant criteria. The dominant criteria for a 50 percent evaluation are occupational and social impairment with reduced reliability and productivity. In this case, the Board finds that the evidence of record demonstrates that this level of functional impairment was met prior to April 13, 2016. Accordingly, based on all the evidence of record, the manifestations of the Veteran's psychiatric disability meet the criteria contemplated for a 50 percent evaluation under the provisions of Diagnostic Code 9411. However, an initial staged rating greater than 50 percent is not warranted for the Veteran's PTSD prior to January 9, 2017. The evidence prior to January 9, 2017 does not more nearly approximate the criteria for a disability rating of 70 percent or higher. Id. While there is evidence of impairment in mood and potentially work, there is no evidence that the Veteran's PTSD caused deficiencies in family relations, judgment, or thinking. In that regard, the evidence prior to January 9, 2017 reflects that the Veteran got along with his wife of over 45 years, and that he spoke on a regular basis with his brother. He also reported that he had a few friends from high school. Additionally, the Veteran was engaged in regular volunteer work with his church and food bank. The medical evidence shows that the Veteran's judgment and thinking were regularly normal. The evidence also shows that the Veteran regularly denied suicidal ideation, and there is no evidence suggesting that he engaged in obsessional rituals which interfere with routine activities. The Veteran's speech was normal, and there is no evidence of near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively. There is no evidence of impaired impulse control, spatial disorientation, or neglect of personal appearance and hygiene. While there is evidence that the Veteran experienced difficulty establishing and maintaining effective relationships, the evidence does not suggest an inability to do so. The Board acknowledges the February 2015 PTSD assessment conducted by P.F. which concluded that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood; however, P.F.'s opinion is not supported by the medical evidence of record prior to January 9, 2017. In particular, her opinion is contracted by the VA treatment records that she authored, which reported that the Veteran interacted well with family and friends, that he was active in his church, that he had a good relationship with his brother, that his judgment was good, and that his thoughts were logical and goal-directed. Accordingly, the Board does not afford the February 2015 opinion significant probative weight, as the medical evidence of record simply does not support her conclusion. Ultimately, the Board concludes that the preponderance of the evidence is against a finding that the Veteran's PTSD is manifested by symptoms warranting a 70 percent or higher evaluation prior to January 9, 2017, and the evidence does not show functional impairment comparable to occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. See 38 C.F.R. § 4.130, Diagnostic Code 9411; Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). "[A] veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio, 713 F.3d at 117. Here, the preponderance of the evidence weighs against a finding that the Veteran's disability picture more nearly approximates the symptoms as listed for a 70 percent rating, or other symptoms of a similar severity, frequency, or duration prior to January 9, 2017. Rather, the Veteran's symptoms are all reasonably contemplated by the rating criteria for ratings of 50 percent or lower, prior to January 9, 2017. Additionally, the Board concludes that a staged initial disability rating greater than 70 percent is warranted for the Veteran's PTSD from January 9, 2017, as the evidence does not show that the Veteran's PTSD resulted in total occupational and social impairment since January 9, 2017. From January 9, 2017, the evidence shows that the Veteran's PTSD was manifested by suicidal ideation, depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function, chronic sleep impairment, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control, deficiencies in family relations, persistent irrational fears, intrusive recollections of traumatic experience, unprovoked irritability, inability to establish and maintain effective relationships, and mild memory loss, such as forgetting names, directions, or recent events. The January 2017 VA examiner concluded that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The Board concludes that the preponderance of the evidence is against a finding that the Veteran's PTSD was manifested by symptoms warranting a 100 percent evaluation from January 9, 2017, as the evidence does not show functional impairment comparable to total occupational and social impairment. See 38 C.F.R. § 4.130, Diagnostic Code 9411; Vazquez-Claudio, 713 F.3d at 116-17. Here, the preponderance of the evidence shows that the Veteran does not experience any of the symptoms listed for a 100 percent rating, or other symptoms of a similar severity, frequency, or duration, but rather that his symptoms are all reasonably contemplated by the rating criteria for a 70 percent or lower disability rating from January 9, 2017. Although there is evidence that the Veteran's PTSD symptoms interfered with social and occupational functioning, the evidence does not show total social impairment, as the Veteran reported that he was married for over 45 years. Additionally, the evidence does not reflect total occupational impairment, as the August 2017 PTSD assessment from P.F. concluded that the Veteran was generally able to perform job requirements with some limitations in work environment, such as the ability to remove himself from a situation if triggered. Moreover, the January 2017 VA examiner concluded that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood, suggestive of a 70 percent disability rating. The Veteran's PTSD from January 9, 2017 more closely corresponds to the requirements for a 70 percent evaluation and does not more nearly approximate a 100 percent rating. Accordingly, a staged initial rating greater than 70 percent for PTSD from January 9, 2017 is not warranted. With consideration of the benefit of the doubt, an initial disability rating of 50 percent, but no greater, is warranted for the Veteran's PTSD prior to April 13, 2016. However, the preponderance of the evidence is against a rating in excess of 50 percent prior to January 9, 2017 and a rating greater than 70 percent from January 9, 2017. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). b. Allergic rhinitis The Veteran contends that a compensable initial rating is warranted for allergic rhinitis. Service connection for allergic rhinitis was granted by the RO in a December 2010 rating decision, and a noncompensable rating was assigned, effective February 25, 2010, under 38 C.F.R. § 4.97, Diagnostic Code 6522. Under Diagnostic Code 6522, allergic or vasomotor rhinitis warrants a 10 percent rating where there are no polyps, but with greater than 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. 38 C.F.R. § 4.97, Diagnostic Code 6522. A maximum 30 percent rating is for application when there are polyps. Id. In September 2010, the Veteran underwent a VA Examination. The Veteran reported a history of allergic rhinitis, which had progressively worsened since service. He denied any surgery, oxygen, or respirator use. He noted that he used loratadine with poor response. He complained of interference with breathing through the nose and congestion, as well as purulent discharge. He denied any speech impairment or the ability to speak below a whisper, and denied chronic sinusitis. He noted occasional headaches with allergic rhinitis. He stated that flare-ups occurred almost daily during the fall and spring seasons, but denied any antibiotic use or periods of incapacitation. He indicated that his allergies did not affect his occupation or activities of daily living. There was no neoplasm of the nose, sinus, larynx, or pharynx. Physical examination showed no sinus tenderness with palpation of the maxillary, frontal, or ethmoid sinuses. There were no nasal polyps in the bilateral naris. There was no evidence of permanent hypertrophy of the turbinates or granulomatous disease, including rhinoscleroma. There was no evidence of bacterial rhinitis. There was partial obstruction of both naris at 50 percent, bilaterally, with no septal deviation, tissue loss, scarring, or deformity of the nose. There was no objective evidence of sinusitis, no purulent discharge, and no crusting. There was no nasal regurgitation or speech impairment. There was no laryngectomy and no residuals of injury or disease to the pharynx. A computed tomography (CT) scan of the sinuses showed focal mucosal thickening in the floor of the left maxillary, where a retention cyst or polyp was not excluded. The other visualized paranasal sinuses were clear. There was a right-sided anterior nasal septal deviation. The right frontal sinus was hypoplastic. There were partially pneumatized bilateral middle turbinates. There was asymmetry in the size of the lateral ventricles, which was thought to be a normal variant. The diagnosis was allergic rhinitis with an active sinus infection of the left maxillary region. In September 2012, the Veteran underwent another VA examination. The Veteran reported that he took over-the-counter medication for allergic rhinitis when it flared, which was usually only once or twice a year for two weeks. Otherwise, he denied taking medication. Physical examination did not show greater than 50 percent obstruction of the nasal passages on both sides due to rhinitis; complete obstruction on one side due to rhinitis; permanent hypertrophy of the nasal turbinates; nasal polyps; granulomatous rhinitis; rhinoscleroma; Wegener's granulomatosis; lethal midline granuloma; or other granulomatous infection. There was no evidence of chronic laryngitis and there was no vocal cord paralysis or other pharyngeal or laryngeal condition. There was not at least 50 percent obstruction of the nasal passage on both sides due to traumatic septal deviation, and there was not complete obstruction on one side due to traumatic septal deviation. There were no benign or malignant neoplasms or metastases related to allergic rhinitis, and there were no scars related to allergic rhinitis. There were no other pertinent physical findings. A CT scan of the sinuses showed that the right frontal sinus was absent. There was mild chronic type thickening in the anterior ethmoid sinuses, bilaterally, and there was a deviated bony and membranous nasal septum. There was a small mucus retention cyst or focal mucosal thickening in the lateral wall of the floor of the left maxillary sinus. There was also bilateral concha bullosa. The examiner concluded that the Veteran's allergic rhinitis did not impact his ability to work. A February 2014 VA treatment record notes the Veteran's reports that he had an intermittent bilateral nasal obstruction. The Veteran explained that he thought that his right nostril was more obstructed than his left, and that he had difficulty sleeping through his nose while supine. Physical examination of the nose showed pink and moist nasal mucosa, anteriorly, with no active rhinorrhea. The septum had a caudal deviation into the left nasal cavity with midcartilagenous curvature into the right nasal cavity. The diagnosis was obstructive sleep apnea with slight septal deviation. In January 2017, the Veteran underwent another VA examination. The Veteran reported more problems with a stuffy sinus and head, as well as burning eye, popping ears, and sinus headaches. Physical examination showed that there was not greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis; complete obstruction on either side due to rhinitis; permanent hypertrophy of the nasal turbinates; nasal polyps; or any granulomatous conditions. There were no other pertinent physical findings related to allergic rhinitis, and there were no related scars. The diagnosis was allergic rhinitis. The examiner noted that the Veteran's allergic rhinitis was active, but did not pose any functional limitations and did not impact his ability to work. Based upon review of the evidence of record, the Board finds that the Veteran is not entitled to a compensable rating for his service-connected allergic rhinitis. The evidence of record fails to demonstrate allergic rhinitis with either greater than 50 percent obstruction of the nasal passage on both sides or with complete obstruction on one side. Although the Veteran reported his belief that he had nasal obstruction during in February 2014, the VA physician's nose examination did not document a 50 percent obstruction of the nasal passage on both sides or a complete obstruction on one side. Despite the Veteran's complaints, the treatment records and VA examinations of record do not reflect symptomatology meeting the rating criteria for a 10 percent rating pursuant to Diagnostic Code 6522. As such, a compensable rating for allergic rhinitis must be denied. c. Other considerations The Board has considered whether the Veteran's claims should be referred for an extraschedular rating. See 38 C.F.R. § 3.321(b) (2017); Thun v. Peake, 22 Vet. App. 111, 114 (2008). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun, 22 Vet. App. at 114. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). In this case, the Board finds that referral for extraschedular consideration is not warranted. As shown in the above discussion, the symptoms of the Veteran's PTSD and allergic rhinitis are contemplated by the rating criteria. See Thun, 22 Vet. App. at 115. A comparison of the Veteran's symptoms and functional impairment with the schedular criteria does not show that the Veteran's PTSD or allergic rhinitis present "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Consequently, the Board finds that the schedular evaluations are adequate to rate these disabilities. In the absence of this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). Therefore, referral for extraschedular consideration is not warranted. Last, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for entitlement to a total disability rating based on individual unemployability is part of an increased rating claim when such claim is raised by the record. In this case, the Veteran has appealed the denial of his claim for entitlement to a TDIU prior to April 13, 2016. This claim is addressed in the Remand section of this decision, below. ORDER New and material evidence not having been received, the claim for entitlement to service connection for hypertension is not reopened. New and material evidence not having been received, the claim for entitlement to service connection for hyperlipidemia is not reopened. Entitlement to service connection for gout is denied. Entitlement to an initial disability rating of 50 percent, but no greater, is warranted for PTSD prior to April 13, 2016, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an initial disability rating greater than 50 percent for PTSD prior to January 9, 2017 is denied. Entitlement to a staged initial disability rating greater than 70 percent for PTSD from January 9, 2017 is denied. Entitlement to a compensable initial disability rating for allergic rhinitis is denied. REMAND I. Back Disability The Veteran underwent a VA spine examination in January 2017; however, review of the examination report reflects that it is inadequate for the reasons described below. The January 2017 VA spine examination reported that there was evidence of pain with low back flexion, right and left flexion, and right and left rotation; however, the examiner did not state at what point pain began. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45 (2017), pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare ups. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner must also determine the point, if any, at which such factors cause functional impairment. Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.59 (2017). In the instant case, although the VA examiner noted objective evidence of pain with lumbar spine range of motion, the examiner made no specific finding as to the degree of range of motion loss due to pain on use. In Mitchell, the Court found similar examination findings to be inadequate because the examiner did not explicitly report "whether and at what point during the range of motion the appellant experienced any limitation of motion that was specifically attributable to pain." Mitchell, 25 Vet. App. at 44. The Court stressed that such a finding is important in providing a "clear picture of the nature of the veteran's disability and the extent to which pain is disabling," so as to "allow the Board to ensure that the disabling effects of pain are properly considered when evaluating any functional loss due to pain that is attributable to the veteran's disability." Id. Where this information is not provided in the examination report, or the report does not include an explanation for why this information could not feasibly be provided, the examination report is inadequate for rating purposes. Id. at 44. Additionally, in a recent case, the United States Court of Appeals for Veterans Claims (Court) held that "to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of" 38 C.F.R. § 4.59. See Correia v. McDonald, 28 Vet. App. 158 (2016). 38 C.F.R. § 4.59 (2017) states that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." As such, pursuant to Correia, an adequate VA spine examination must, wherever possible, include range of motion testing on active and passive motion and in weight-bearing and nonweight-bearing conditions. Although the January 2017 VA examiner reported that there was objective evidence of pain on passive range of motion testing of the back and that there was objective evidence of pain on non-weight bearing testing of the back, the VA examiner did not provide range of motion testing results on both active and passive motion and in both weight-bearing and nonweight-bearing conditions. For the foregoing reasons, a new VA examination addressing the severity of the Veteran's lumbar spine disability is required. II. Diabetes Mellitus, Type II The Veteran was afforded a VA examination in January 2017 in connection with his increased claim for type II diabetes mellitus. The Board finds that the examination is inadequate. See Barr v. Nicholson, 21, Vet. App. 303, 312 (2007). Notably, the examiner indicated that he had not reviewed the Veteran's claims folder, or any records such as VA treatment reports, in conjunction with the examination. Furthermore, he determined that the Veteran was required to regulate his activities as part of his medical management of diabetes based on the Veteran's reports that he could not do excessive repetitive labor in heat or cold weather anymore or anything recreational that is repetitive. However, the Board did not locate any references to the Veteran's regulation of activities in the available VA treatment reports of record. In this respect, in order to demonstrate a regulation of activities, "medical evidence" is required to show that both occupational and recreational activities have been restricted. See Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007). The phrase "regulation of activities" means "avoidance of strenuous occupational and recreational activities." Camacho, 21 Vet. App. at 362. Pursuant to Camacho, it is insufficient for the Veteran to make the determination that his activities are restricted due to diabetes. Rather, the VA examiner should have reviewed the referenced medical evidence and subsequently supported his determination with examples. However, as previously stated, the VA examiner did not review any records associated with the Veteran's claims file, to include VA treatment records, and did not provide any explanation for the conclusion that the Veteran's type II diabetes requires regulation of activities aside from referencing the Veteran's reports of activity restrictions. Therefore, the Board finds that remand is necessary to obtain an additional VA examination to determine the severity and manifestations of the Veteran's type II diabetes mellitus. III. Manlicon Issues The claims for entitlement to initial disability ratings greater than 20 percent for right upper extremity diabetic peripheral neuropathy of the radial nerve, median nerve, and ulnar nerve; entitlement to an effective date earlier than January 10, 2017 for the grant of service connection for right upper extremity peripheral neuropathy; entitlement to an effective date earlier than April 13, 2016 for the grant of Dependents' Educational Assistance; and entitlement to an effective date earlier than January 9, 2017 for the grant of special monthly compensation based on housebound status are remanded to the RO for the issuance of a statement of the case. When a notice of disagreement has been filed, the RO must issue a statement of the case. Manlicon v. West, 12 Vet. App. 238, 240-41 (1999); see also Godfrey v. Brown, 7 Vet. App. 398, 408-10 (1995) (noting that the filing of a notice of disagreement initiates the appeal process and requires VA to issue a statement of the case). In a May 2017 rating decision, the RO granted basic eligibility to Dependents' Educational Assistance, effective April 13, 2016; granted entitlement to special monthly compensation based on housebound status, effective January 9, 2017; and granted entitlement to service connection for diabetic peripheral neuropathy of the right upper extremity (radial nerve, median nerve, and ulnar nerve), awarding a 20 percent disability rating, effective January 10, 2017. In July 2017, the Veteran filed a notice of disagreement contesting the rating assigned for right upper extremity diabetic neuropathy as well as the effective dates for the awards of service connection for right upper extremity diabetic neuropathy, Dependents' Educational Assistance, and special monthly compensation based on housebound status. As the RO has not yet issued a statement of the case with regard to these issues, remand is necessary. IV. TDIU prior to April 13, 2016 Last, the issue of entitlement to a TDIU prior to April 13, 2016 is intertwined with the claims remanded herein; accordingly, it must also be remanded. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with a new VA examination to determine the current severity of his service-connected lumbar spine disability. The Veteran's claims file and a copy of this Remand must be reviewed by the examiner. All pertinent symptomatology and findings must be reported in detail. Any diagnostic tests deemed necessary for an accurate assessment must be conducted. The examiner must record all pertinent medical complaints, symptoms, and clinical findings, in detail. The examiner must determine the range of motion of the Veteran's lumbar spine, in degrees, noting by comparison the normal range of motion of the lumbar spine. The VA examiner must specifically state whether there is any favorable or unfavorable ankylosis in the lumbar spine. The examiner must also state whether there is weakened movement, excess fatigability, incoordination, or other functional impairment attributable to the service-connected lumbar spine disorder. The examiner must report the additional functional limitation in degrees of additional limitation due to weakened movement, excess fatigability, incoordination, flare-ups, or pain. Finally, an opinion must be stated as to whether any pain found in the lumbar spine could significantly limit functional ability during flare-ups or during periods of repeated use, noting the degree of additional range of motion loss or favorable or unfavorable ankylosis due to pain on use or during flare-ups. This determination should be portrayed in terms of the degree of additional range of motion loss. The examiner must also state whether the Veteran has intervertebral disc syndrome; if so, the examiner must state whether the Veteran experiences incapacitating episodes requiring bedrest prescribed by a physician and treatment by a physician, and note the frequency and total duration of such episodes over the course of the past 12 months. With respect to range of motion testing, this must be conducted and reported on active and passive motion and in weight-bearing and nonweight-bearing conditions (pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016)). If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. 2. The Veteran should be afforded a VA examination with the appropriate specialist to ascertain the current severity and manifestations of his service-connected type II diabetes mellitus. The examiner is requested to review all pertinent records associated with the claims file, including the January 2017 VA examination report, and lay assertions. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran's disability under the rating criteria, utilizing the appropriate Disability Benefits Questionnaire. In particular, the examiner should indicate whether the Veteran's diabetes mellitus requires insulin, restricted diet, and regulation of activities. In discussing the regulation of activities, the examiner should state whether the Veteran's occupational and recreational activities must be restricted due to his type II diabetes mellitus and provide examples. The examiner should also indicate whether there have been any episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider. In addition, the examiner should identify and describe all complications of the Veteran's type II diabetes mellitus that may be present. It should be noted that the Veteran is separately service-connected for peripheral neuropathy of the bilateral upper and lower extremities associated with the diabetes mellitus. A clear rationale for any opinions stated should be provided. 3. Notify the Veteran that it is his responsibility to report for the examinations and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2017). 4. Issue a statement of the case and notification of the Veteran's appellate rights for the issues of entitlement to initial disability ratings greater than 20 percent for right upper extremity diabetic peripheral neuropathy of the radial nerve, median nerve, and ulnar nerve; entitlement to an effective date earlier than January 10, 2017 for the grant of service connection for right upper extremity peripheral neuropathy; entitlement to an effective date earlier than April 13, 2016 for the grant of Dependents' Educational Assistance; and entitlement to an effective date earlier than January 9, 2017 for the grant of special monthly compensation based on housebound status. 38 C.F.R. § 19.26 (2017). The Veteran and his representative are reminded that, to vest the Board with jurisdiction over these issues, a timely substantive appeal must be filed. If the Veteran perfects an appeal, the same should be returned to the Board for appellate review. 5. When the above development has been completed, readjudicate the issues on appeal. If any benefit sought on appeal remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and afford the Veteran and his representative an adequate opportunity to respond, prior to returning the issue to the Board for appellate review. 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 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. §§ 5109B, 7112 (2012). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs