Citation Nr: 18140140 Decision Date: 10/02/18 Archive Date: 10/02/18 DOCKET NO. 09-42 459 DATE: October 2, 2018 ORDER Service connection for peripheral vascular disease (PVD) of the bilateral lower extremities is granted. An initial compensable rating for balance impairment due to Parkinson’s disease is denied. An initial compensable rating for loss of smell due to Parkinson’s disease is denied. An initial rating in excess of 30 percent for difficulty chewing and swallowing due to Parkinson’s disease is denied. A rating in excess of 40 percent for Parkinson’s disease with tremors of the right upper extremity is denied. A rating in excess of 20 percent for left upper extremity peripheral neuropathy, median nerve paralysis, due to Parkinson’s disease and diabetes mellitus, type II, is denied. For the entire appeal period prior to January 20, 2017, a rating of 50 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted, subject to the laws and regulations governing the payment of monetary awards. REMANDED Entitlement to an initial rating in excess of 20 percent for muscle rigidity of the right upper extremity due to Parkinson’s disease is remanded. FINDINGS OF FACT 1. Resolving all doubt in the Veteran’s favor, his currently diagnosed PVD of the bilateral lower extremities is aggravated by his service-connected diabetes mellitus, type II. 2. For the entire appeal period, the Veteran’s Parkinson’s disease has not resulted in a diagnosis of vestibular disequilibrium supported by objective findings. 3. For the entire appeal period, the Veteran’s Parkinson’s disease has not resulted in complete loss of smell. 4. For the entire appeal period, the Veteran’s Parkinson’s disease resulted in no more than a moderate stricture of the esophagus. 5. The Veteran is right hand dominant. 6. For the entire appeal period, the Veteran’s Parkinson’s disease resulted in no more than moderate incomplete paralysis of all right upper extremity radicular groups. 7. For the entire appeal period, the Veteran’s Parkinson’s disease resulted in no more than moderate incomplete paralysis of the left upper extremity median nerve. 8. For the entire appeal period stemming from the Veteran’s May 16, 2006, claim to January 20, 2017, his PTSD was manifested by occupational and social impairment with reduced reliability due to his psychiatric symptomatology, without more severe manifestations that more nearly approximated occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for PVD of the bilateral lower extremities have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310 (2006), (2017). 2. The criteria for an initial compensable rating for balance impairment due to Parkinson’s disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.87, Diagnostic Code 6204. 3. The criteria for an initial compensable rating for loss of smell due to Parkinson’s disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.87a, Diagnostic Code 6275. 4. The criteria for an initial rating in excess of 30 percent for difficulty chewing and swallowing due to Parkinson’s disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.114, Diagnostic Code 7203. 5. The criteria for a rating in excess of 40 percent for Parkinson’s disease with tremors of the right upper extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.120, 4.124a, Diagnostic Code 8513. 6. The criteria for a rating in excess of 20 percent for left upper extremity peripheral neuropathy, median nerve paralysis, due to Parkinson’s disease and diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.120, 4.124a, Diagnostic Code 8515. 7. For the entire appeal period stemming from the Veteran’s May 16, 2006, claim to January 20, 2017, the criteria for a rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1965 to September 1969. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in September 2007 and October 2017 by a Department of Veterans Affairs (VA) Regional Office. In November 2015, the Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge in regard to the issues pertaining to entitlement to separate rating for peripheral vascular disease as complication of service-connected diabetes mellitus, type II, and an increased rating for PTSD. A transcript of the hearing is of record. The Veteran has not requested a Board hearing in connection with the remainder of the issues on appeal. In January 2016, the Board, as relevant, denied entitlement to a rating in excess of 30 percent for PTSD. The Veteran appealed the denial of that claim to the United States Court of Appeals for Veterans Claims (Court). In August 2016, the Court granted a Joint Motion for Partial Remand (JMR) that vacated and remanded the claim. Thereafter, in June 2017, the Board remanded such claim, as well as the claims for service connection for peripheral vascular disease and a total disability rating based on individual unemployability (TDIU), for additional development. While on remand, in an October 2017 rating decision, the Agency of Original Jurisdiction (AOJ) granted special monthly compensation (SMC) at the housebound rate as of May 8, 2017, in light of the fact that the Veteran had a single disability (kidney cancer) rated at 100 percent and additional service-connected disabilities independently rated at 60 percent. Thereafter, in a February 2018 rating decision, the AOJ granted an increased rating of 70 percent for PTSD, effective January 20, 2017. The Veteran’s representative subsequently indicated that he only disagreed with denial of an increased rating for PTSD prior to such date. AB v. Brown, 6 Vet. App. 35, 38 (1993). Therefore, the Board has recharacterized such claim as shown on the title page of this decision. The February 2018 rating decision also granted a TDIU, effective December 26, 2006, and advised the Veteran that such decision was a full grant of the benefit he had sought on appeal as to such issue. In this regard, he was notified that his appeal was considered fully resolved and, as such, was now terminated as allowed in the field and no further appellate action is required. He was further informed that, if he disagreed with such decision in any respect, he must file a new notice of disagreement in order to begin a new appeal. Such decision also awarded eligibility to Dependents’ Educational Assistance (DEA) under 38 U.S.C. Chapter 35, effective December 26, 2006, and an earlier effective date of January 20, 2017, for the assignment of SMC at the housebound rate. In June 2018, the Veteran, through his representative, entered a notice of disagreement as to the propriety of the assigned effective date for the award of a TDIU and eligibility to DEA benefits, and rate of SMC assigned. In this regard, he argued for the assignment of earlier effective dates for a TDIU and eligibility to DEA benefits, and the highest rate of SMC possible. Although a statement of the case has not yet been issued, according to the Veterans Appeals Control and Locator System, the claims are still being developed by the AOJ. As a result, the Board declines jurisdiction over them until such time as an appeal to the Board is perfected. Following the issuance of the February 2018 supplemental statement of the case and March 2018 statement of the case, the Veteran, via his representative submitted additional evidence with a waiver of AOJ consideration. 38 C.F.R. § 20.1304(c). Therefore, the Board may properly consider such newly received evidence. The Board further observes that additional VA treatment records have likewise been associated with the record since the AOJ’s most recent adjudications of the Veteran’s claims. However, as such include information that is duplicative to that previously considered by the AOJ, the Board finds such to be irrelevant to the instant claims and there is no prejudice to the Veteran in the Board proceeding with an adjudication of his claims at this time. Id. In a June 2018 statement, the Veteran’s attorney argued that a May 1991 rating decision that denied service connection for PTSD should be reversed or revised on the basis of clear and unmistakable error (CUE). However, inasmuch as such claim has not been adjudicated by the AOJ in the first instance, the Board does not have jurisdiction over it. In this regard, the Board notes that, effective March 24, 2015, a claim for benefits must be submitted on an application form prescribed by the Secretary. See Standard Claims and Appeals Forms, 79 Fed. Reg. 57,660 (Sept. 25, 2014) (Dates). Therefore, if the Veteran, or his attorney, wishes for a claim of CUE in the May 1991 rating decision to be considered, he and/or his attorney must file the appropriate application(s) with the AOJ. 38 C.F.R. §§ 3.1(p), 3.155, 3.160. Separate Rating/Service Connection Claim 1. Entitlement to a separate rating or service connection for PVD of the bilateral lower extremities as secondary to service-connected diabetes mellitus, type II. The Veteran contends that he has PVD of the bilateral lower extremities as a complication of his service-connected diabetes mellitus, type II, or, in the alternative, as secondary to such disease. Diagnostic Code 7913 pertinent to the evaluation of diabetes mellitus includes a Note that provides that complications of diabetes mellitus are evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are deemed part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119. Additionally, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that the provisions of 38 C.F.R. § 3.310 were amended during the pendency of the Veteran’s claim, effective October 10, 2006; however, the new provisions state that service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). Although the stated intent of the change was merely to implement the requirements of Allen, supra, the Board finds that the new provisions amount to a substantive change to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the Veteran as it does not require the establishment of a baseline level of disability before an award of service connection may granted. See generally, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.R.F. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran underwent VA examination for his diabetes mellitus, type II, in August 2002. At such time, the examiner diagnosed vascular insufficiency of the lower extremities with resulting amputations of the right metatarsals in 1991 and amputation of the left great toe in 1995, but found the Veteran did not have any vascular symptoms associated with diabetes mellitus, type II. The record also reflects a hand-written notation that the diagnosed condition was “not related to [diabetes mellitus]”. In May 2006, the Veteran underwent additional VA examination specifically for his PVD. The VA physician provided a positive aggravation opinion relating PVD to diabetes mellitus, type II; however, in June 2017, the Board found the examination inadequate and remanded the claim for an addendum opinion. In October 2017, the same VA physician reviewed the record and indicated that her original opinion stood. Specifically, she indicated that, while the onset of diabetes was five to seven years after PVD, it was at least as likely as not that the complications of vascular disease since that time were attributable to the original disease as well as the vascular damage done by diabetes. As a result, it was more likely than not that diabetes aggravated the original vascular disease as it was known to be a significant contributor to vascular disease. The physician found the relative proportion contributed by the diabetes to the overall vascular disease could not be estimated because it could not be measured and was not known. The physician reported that we only know that diabetes, once it exists, is a major cardiovascular risk factor and contributes substantially to PVD. Upon review, the Board affords the October 2017 VA examiner’s opinion significant probative value as it reflects consideration of all relevant facts and provides a detailed rationale for the conclusion reached. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion...must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Conversely, the August 2002 VA physician did not provide a rationale for the negative opinion, and as such, is entitled to no probative weight. The AOJ initially denied the claim because a baseline of the severity of PVD could not be determined before the onset of the diabetes. However, as noted above, such provision of 38 C.F.R. § 3.310 was amended during the pendency of the Veteran’s claim, which stems from his May 2006 claim for an increased rating for diabetes mellitus, type II, and the earlier version of such regulation, which does not have such requirement, applies in the instant case. Therefore, the Board finds that the Veteran’s currently diagnosed PVD of the bilateral lower extremities was aggravated by his service-connected diabetes mellitus, type II. Consequently, service connection is warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Increased Rating Claims Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The words “mild,” “moderate,” and “severe” as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “severe” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The initial and increased rating claims pertinent to the Veteran’s manifestations of his Parkinson’s disease stem from a May 8, 2017, claim while his claim for an increased rating for his PTSD stem from a May 16, 2006, claim. 2. Entitlement to an initial compensable rating for balance impairment due to Parkinson’s disease. The Veteran is in receipt of a separate noncompensable rating for balance impairment associated with his service-connected Parkinson’s disease, which is rated under 38 C.F.R. § 4.87, Diagnostic Code 6204 pertinent to peripheral vestibular disorders. The Note under Diagnostic Code 6204 states that objective findings supporting the diagnosis of vestibular disequilibrium are required before a compensable evaluation can be assigned under this code. Here, the medical evidence does not reflect a diagnosis of, or objective findings in support of, vestibular disequilibrium. The Board recognizes the medical treatment records and the Veteran’s lay statements that he had decreased balance and could lose his balance easily, which resulted in a mild balance impairment; however, the rating criteria specifically requires a medical diagnosis of vestibular disequilibrium for the assignment of a compensable rating. Therefore, the Board finds the criteria for a compensable rating for such disability is not warranted. 3. Entitlement to an initial compensable rating for loss of smell due to Parkinson’s disease The Veteran is service-connected for loss of smell associated with his service-connected Parkinson’s disease, which is rated as noncompensable under 38 C.F.R. § 4.87a, Diagnostic Code 6275. Diagnostic Code provides a maximum 10 percent rating for complete loss of smell. A May 2017 VA treatment record indicates the Veteran had a decreased sense of smell, and a July 2017 VA examination report shows the Veteran had only partial loss of smell. As the medical evidence does not reflect the complete loss of smell, a compensable rating is not warranted under Diagnostic Code 6275. 38 C.F.R. § 4.87a. 4. Entitlement to an initial rating in excess of 30 percent for difficulty chewing and swallowing due to Parkinson’s disease The AOJ has assigned a separate rating of 30 percent for symptoms of difficulty chewing and swallowing associated with the Veteran’s service-connected Parkinson’s disease. These symptoms are rated under 38 C.F.R. § 4.114, Diagnostic Code 7203 for stricture of esophagus, which provides a 30 percent rating for moderate stricture of esophagus, a 50 percent rating for severe stricture of esophagus, permitting liquids only, and an 80 percent rating for stricture of esophagus permitting passage of liquids only with marked impairment of general health. VA examination in July 2017 revealed the Veteran had moderate difficulty chewing and swallowing associated with his Parkinson’s disease. A November 2017 VA treatment record indicates the Veteran had difficulty chewing due to ill-fitting dentures, as well as swallowing problems. Here, the medical evidence does not reflect severe stricture of esophagus or stricture of esophagus permitting passage of liquids only. As such, the Board finds that a rating in excess of 30 percent for such disability is not warranted under Diagnostic Code 7203. 38 C.F.R. § 4.114. 5. Entitlement to a rating in excess of 40 percent for tremors of the right upper extremity due to Parkinson’s disease The Veteran’s service-connected right upper extremity disability was previously characterized as “right upper extremity peripheral neuropathy, median nerve paralysis” and rated as 10 percent disabling from December 26, 2006, to May 2, 2016, and 30 percent disabling thereafter under Diagnostic Code 8515. Following the submission of the Veteran’s increased rating claim in May 2017, the AOJ granted two separate ratings for the right upper extremity: a 20 percent rating for muscle rigidity of the right upper extremity under Diagnostic Code 5201, and a 40 percent rating for Parkinson’s disease with tremors, right upper extremity under Diagnostic Code 8513, both effective May 8, 2017. The Veteran has perfected an appeal of both issues; however, the Board remands the claim for an increased rating under Diagnostic Code 5201 herein but finds no prejudice in adjudicating the claim for an increased rating under Diagnostic Code 8513 as the evidence is adequate to properly rate such disability under the specific rating criteria. Diagnostic Code 8513 provides the rating criteria for paralysis of all radicular groups and, as the Veteran is right hand dominant, the ratings pertinent to the major side are applicable. Incomplete paralysis of all radicular groups warrants a 20 percent rating when mild, a 40 percent rating when moderate, and a 70 percent rating when severe. Complete paralysis warrants a 90 percent rating. On VA examination in May 2016, the Veteran had mild incomplete paralysis of the median nerve of the right upper extremity with moderate paresthesias and numbness. A May 2017 VA treatment record shows the Veteran had a one to two-year history of tremors and felt most of the symptoms in his right hand. On VA examination in July 2017, the VA examiner reported that a moderate tremor affected the Veteran’s right upper extremity. Here, the medical evidence does not demonstrate a severe incomplete paralysis or complete paralysis at any time during the appeal period. Therefore, a rating in excess of 40 percent for tremors of the right upper extremity under Diagnostic Code 8513. 38 C.F.R. § 4.124a. 6. Entitlement to a rating in excess of 20 percent for peripheral neuropathy of the left upper extremity due to Parkinson’s disease and diabetes mellitus, type II As noted above, the Veteran submitted an intent to file an increased rating claim in May 2017, and therefore, the Board will consider the evidence dated during the one year prior to the submission of the claim. The Veteran’s peripheral neuropathy of the left upper extremity is rated under Diagnostic Code 8515, which provides the rating criteria for paralysis of the median nerve. For the Veteran’s minor left side, incomplete paralysis warrants a 10 percent rating when mild, a 20 percent rating when moderate, and a 40 percent rating when severe. Complete paralysis of the median nerve warrants a 60 percent rating. VA examination in May 2016 revealed mild, incomplete paralysis of the median nerve of the left upper extremity and moderate paresthesias and numbness. A May 2017 VA neurology consultation shows the Veteran reported a one to two-year history of tremors in his hands and that he noticed the symptoms the most in his right hand. On VA examination in July 2017, a mild tremor affected the Veteran’s left upper extremity. Here, the medical evidence reflects, at most, moderate severity of paresthesias of the left upper extremity, and as such, a rating in excess of 20 percent is not warranted for peripheral neuropathy of the left upper extremity. 38 C.F.R. § 4.124a. 7. Entitlement to a rating in excess of 30 percent for PTSD prior to January 20, 2017. The Veteran’s service-connected PTSD is evaluated under the criteria of DC 9411, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. 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; and mild memory loss (such as forgetting names, directions, recent events). 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 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. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work-like setting); and inability to establish and maintain effective relationships. 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. The United States Court of Appeals for the Federal Circuit has held that the evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation...requires an ultimate factual conclusion as to the Veteran’s level of impairment in most areas.” Vazquez-Claudio, 713 F.3d at 117-118; 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, when evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission,” and must also “assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination.” 38 C.F.R. § 4.126(a). The Board notes that the revised DSM-5, which, among other things, eliminates Global Assessment of Functioning (GAF) scores, applies to appeals certified to the Board after August 4, 2014, as is the case here. See 79 Fed. Reg. 45, 093 (Aug, 4, 2014). Consequently, the Board will not consider the previously assigned GAF scores in determining the outcome of this case. See Golden v. Shulkin, No. 16-1208 (February 23, 2018). In the September 2007 rating decision on appeal, the AOJ granted an increased rating of 30 percent for PTSD, effective May 16, 2006, and in February 2018, the AOJ granted an increased rating of 70 percent, effective January 20, 2017. As explained above, the Board has limited the analysis herein to the period from May 16, 2006, to include the one year look back period, to January 20, 2017, pursuant to the representative’s statement that the Veteran was only seeking a rating in excess of 30 percent prior to January 20, 2017. See AB, supra. In September 2005, the Veteran underwent VA examination. At such time, he reported experiencing daily intrusive recollections of Vietnam and nightmares once per week, had no difficulty discussing it with a friend. There were some things he avoided, but maintained some interest in recreational and entertainment activities. He socialized with people and had a full range of emotions. He did have a restricted view of the future, although the physician found it appeared to be more related to the Veteran’s lifestyle than any trauma. He also experienced irritability, but his concentration was adequate, and he did not have exaggerated startle response. The VA physician noted that the Veteran had an overall moderate number, frequency, and intensity of symptoms associated with minimal reduction of social, vocational, and mental functioning, including reduced social functioning. Concerning social impairment, the Veteran reported that he lived with his wife of 24 years and his two sons in a home he owned. He could manage all his own self-care and helped with cooking, household chores, laundry, and some yard work. He was active with a motorcycle club and had a close friend with whom he spoke frequently. He also talked to his sister-in-law every day. He did find some difficulty with his family relations due to irritability but mainly tried to avoid confrontations. The Veteran was neatly dressed, alert, cooperative, and oriented, with good eye contact. His speech was clear and of normal value, with a varied affect and congruent mood. He had no signs of delusion or frankly paranoid belief systems. The VA physician found the Veteran’s PTSD-related fatigue, concentration problems, and inner turmoil would likely cause mild work inefficiency and lack of productivity. His avoidance of social contact and confrontation would likely interfere mildly with his ability to interact effectively, and he had some mild reduction in his ability to adapt to stressful circumstances. He did not suffer from gross impairment in thought processes, delusions, or hallucinations. Upon review, the Board finds the September 2005 examination results, with consideration of the Veteran’s reported symptoms of avoidance, irritability, and nightmares, reflect a mild severity of occupational and social functioning. The evidence shows the Veteran managed his daily activities of living and took care of his household. Further, the VA examiner provided a clear opinion finding only a mild impairment in functioning based on the Veteran’s own lay statements concerning his relationships with his family and friends and his involvement in social activities. In May 2006, the Veteran’s treating psychiatrist opined the Veteran was not employable due to his ongoing psychiatric condition. VA requested a special psychological evaluation in August 2007. At such time, the Veteran’s appearance was somewhat unkempt, but he was fully oriented and maintained appropriate eye contact. He had full range of affection, and his speech was logical and coherent, without evidence of thought disorder. He did not express delusional content but reported a usual level of depression as seven or eight. He denied current and historical suicidal ideations and stated that his anger issues were “pretty good now, not like it used to be”. The Veteran endorsed intrusive thoughts and memories, with specific triggers and recurrent nightmares. He did enjoy talking to his Vietnam veteran buddies, but was uncomfortable in crowds. The VA physician noted the records showed persistent irritability and anger outbursts with some improvement. Occupationally, the Veteran had been on medical disability since 1998 related to leg conditions. At that time, he helped a buddy deliver newspapers, helped his wife get ready in the morning, and did errands and household chores while talking with his mother and visiting friends or family. The Veteran reportedly independently doing the laundry, shopping, cooking, cleaning, and other chores. The Veteran reported a very bad relationship with his sons and was historically “very nasty” to his wife, for which he wanted to atone. He was reportedly president of his motorcycle club and was active in multiple clubs with veterans, although he attended infrequently. Psychometric testing suggested overall endorsement of severe depressive symptoms, loss of pleasure, punishment feelings, agitation, and loss of energy. The VA examiner found the Veteran had significant depressive symptoms, which were consistent with PTSD and the severe psychosocial stressors currently faced. The VA physician found a moderate frequency and intensity of PTSD and depressive symptoms. The VA physician also noted the treating psychologist’s statement that the Veteran was not employable due to his ongoing psychiatric condition since May 2006. The physician agreed it would be infeasible for the Veteran to engage in sufficient retraining for gainful employment of a sedentary nature; however, the Board finds it significant that the VA physician based the opinion on the Veteran’s medical and psychiatric evaluations of vocational disability as well as the additional daily responsibilities in the provision of care of his wife and concomitant household responsibilities. Notably, the VA physician found the Veteran’s PTSD had minimal impact on social functioning. Based on the physician’s findings that the Veteran’s reported symptoms were severe with moderate frequency and intensity, the Board finds these examination results demonstrate, at most, occupational and social impairment with reduced reliability and productivity. VA treatment records dated during the appeal period reflect similar symptoms and objective findings. However, at an unrelated June 2009 VA examination, the Veteran reported panic attacks and, at such time and in October 2010, stated that he thought about suicide, but subsequent records reflect that he reported improvement in his PTSD symptoms, to include denying suicidal ideation, and their impact on his ability to function. The Board also notes that VA treatment records dated in 2014 and 2015 reflect symptoms of anxiety and nervousness as well as “chronic psychiatric symptoms, without remission”. However, the Veteran had supportive family and friends, could care for others, and was able to maintain activities of daily living. In addition, multiple VA treatment records during this period indicate the Veteran had little to no symptoms associated with his PTSD. At a May 2015 VA examination, a VA physician found the Veteran’s PTSD resulted in occupational and social impairment due to mild or transient symptoms which decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran reported depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, and chronic sleep impairment. He discussed his future plans, to include going to casinos, traveling to Paris, and visiting out west. Upon review, the Board finds the examination results indicate the Veteran’s PTSD symptoms resulted in mild occupational and social impairment at that time, which is consistent with only a 10 percent rating under the applicable rating criteria. VA treatment records dated in 2016 show the Veteran was casually dressed, his speech was within normal limits, his affect was appropriate, and he denied suicidal and homicidal ideations. He was oriented, but his thought processes were tangential, and his insight and judgment were fair. In January 2017, a private physician, Dr. M., opined the Veteran’s PTSD caused severe occupational and social impairment in most areas. The physician cited “near-continuous irritability affecting his ability to interact with others; impaired impulse control with unprovoked argumentation and assaultive behavior; inability to adapt to stressful circumstances; inability to establish and maintain effective relationships; gross impairment in communication; persistent danger of hurting self or others; inability to manage personal or household activities of daily living; disorientation to date; and short and long-term memory loss”. Although dated subsequent to the period on appeal, the Board also has considered an October 2017 VA physician’s opinion that the Veteran’s PTSD had worsened in severity since 2007, which was based on the increased number of symptoms and their increased severity. In accordance with the Court’s instructions, the Board also has paid particular attention to the Veteran’s reported symptomatology throughout the pendency of the appeal, in addition to the medical findings and opinions. As a general overview, the record reflects symptoms of depression, suspiciousness, panic attacks, anxiety, chronic sleep impairment, nightmares, hypervigilance, problems with concentration, irritability, angry outbursts, loss of pleasure, punishment feelings, agitation, and loss of energy. Further, while the Veteran reported thoughts of suicide on two occasions in 2009 and 2010, in Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the Court held that the language of the general rating formula “indicates that the presence of suicidal ideation alone...may cause occupational and social impairment with deficiencies in most areas.” However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran’s service-connected psychiatric disability, and their resulting social and occupational impairment. In this regard, the Veteran has predominantly denied suicidal and homicidal ideations. For example, with regard to the June 2009 notation of suicidal thoughts, treatment records immediately preceding and following that notation refect the Veteran’s denial of suicidal ideation. Furthermore, with regard to the October 2010 notation, the Veteran stated that, although he thought about suicide, he never considered actually doing it and that he did not have a plan. Furthermore, subsequent VA treatment record consistently reflect the Veteran denial of suicidal ideation. With respect to the medical opinions of record, the September 2005 VA physician found the Veteran’s PTSD-related fatigue, concentration problems, and inner turmoil would likely cause mild work inefficiency and lack of productivity. His avoidance of social contact and confrontation would likely interfere mildly with his ability to interact effective, and he had some mild reduction in his ability to adapt to stressful circumstances. The August 2007 VA physician found the Veteran’s PTSD and depressive symptoms were of moderate frequency and intensity and contributed to his unemployability. In May 2015, a VA physician found the Veteran’s PTSD resulted in occupational and social impairment due to mild or transient symptoms which decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress. In January 2017, a private physician opined the Veteran’s PTSD caused severe occupational and social impairment in most areas. Based on these findings, and with consideration of the benefit-of-the doubt rule, the Board finds the above evidence reflects a severity of symptomatology, at most, resulting in occupational and social impairment with reduced reliability and productivity. Therefore, a 50 percent rating for the entire appeal period is warranted. The Board notes Dr. M’s conclusion that the Veteran’s PTSD had resulted in occupational and social impairment in most areas since 2006, which would meet the criteria for a 70 percent rating. However, the Board finds it pertinent that the medical records do not demonstrate many of the cited symptoms upon which the opinion was based. Specifically, the medical evidence does not demonstrate concrete indicators of “near-continuous irritability affecting his ability to interact with others and inability to establish and maintain effective relationships; gross impairment in communication; persistent danger of hurting self or others; inability to manage personal or household activities of daily living; disorientation to date; or short and long-term memory loss”. Rather, the medical records throughout the appeal period show the Veteran maintained relationships with his wife, sons, and fellow Vietnam veterans. He also was active in various clubs, enjoyed speaking with his friends and family, and managed the household chores and his activities of daily living. He denied homicidal ideations and did not report disorientation or memory loss. The Board is not commenting upon the validity of Dr. M’s opinion with respect to the Veteran’s symptomatology at the time of the examination in January 2017. However, the symptomatology reported is not reflected in the medical records dated during the appeal period. In conclusion, the Board attributes significant probative value to the symptomatology and the medical opinions dated during the appeal period and will resolve the benefit of the date in the Veteran’s favor. Upon review of this evidence, the Board finds a 50 percent rating, but no higher, for the Veteran’s PTSD is warranted. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Other Rating Considerations In making its determinations in this case, the Board has carefully considered the Veteran’s contentions with respect to the nature of his service-connected disabilities at issue and notes that his lay testimony is competent to describe certain symptoms associated with these disabilities. The Veteran’s history and symptom reports have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability ratings that have been assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence when evaluating the pertinent symptoms of the service-connected disabilities at issue. As such, while the Board accepts the Veteran’s testimony concerning the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluations of functional impairment, symptom severity, and details of clinical features of the service-connected conditions at issue. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to his initial and increased rating claims adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. Here, the preponderance of the evidence is against the Veteran’s claims of entitlement to increased ratings for balance impairment, loss of smell, difficulty to chewing and swallowing, tremors of the right upper extremity, and peripheral neuropathy of the left upper extremity due to Parkinson’s disease and diabetes mellitus, type II. However, the Board finds the rating criteria for an increased rating of 50 percent, but no higher, for PTSD is warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 8. Entitlement to an initial rating in excess of 20 percent for muscle rigidity of the right upper extremity due to Parkinson’s disease. Currently, the Veteran’s service-connected muscle rigidity of the right upper extremity due to Parkinson’s disease is rated as 20 percent disabling under 38 C.F.R. 4.71a, Diagnostic Code 5201, which provides for limitation of motion of the arm. The Veteran last underwent VA examination to determine the nature and severity of his Parkinson’s disease, to include such muscle rigidity, in July 2017. Although the VA examiner reported the Veteran had mild muscle rigidity and stiffness of the right upper extremity, the examination report does not provide specific measurements for the limitation of motion of the Veteran’s arm due to this service-connected disability. Therefore, remand is warranted for additional examination to properly rate the severity of such under Diagnostic Code 5201. The matter is REMANDED for the following action: Afford the Veteran an appropriate VA examination to determine the current nature and severity of his service-connected muscle rigidity of the right upper extremity due to Parkinson’s disease. The record, to include a complete copy of this Remand, must be made available to the examiner, and the examination report should include discussion of the Veteran’s documented medical history and lay assertions. All indicated tests and studies should be accomplished (with all findings made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. (A) The examiner should identify the current nature and severity of all manifestations of the Veteran’s muscle rigidity of the right upper extremity. (B) The examiner should record the range of motion of the right shoulder in all planes observed on clinical evaluation in terms of degrees. If there is evidence of pain on motion, the examiner should indicate the degree of range of motion at which such pain begins, and whether such pain on movement, as well as weakness, excess fatigability, or incoordination, results in any loss of range of motion. The examiner should record the results of range of motion testing for pain on both active and passive motion, on weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 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. (C) It is also imperative that the examiner comment on the functional limitations caused by flare-ups and repetitive use. In this regard, the examiner should indicate whether, and to what extent, the Veteran’s range of motion is additionally limited during flare-ups or on repetitive use, expressed, if possible, in terms of degrees, or explain why such details cannot be feasibly provided. (D) If the Veteran endorses experiencing flare-ups of his right upper extremity, the examiner must obtain information regarding the frequency, duration, characteristics, severity, and/or functional loss related to such flare-ups. Then, if the examination is not being conducted during a flare-up, the examiner should provide an opinion based on estimates derived from the information above as to the additional loss of range of motion that may be present during a flare-up. If the examiner cannot provide an opinion as to additional loss of motion during a flare-up without resorting to mere speculation, the examiner must make clear that s/he has considered all procurable data (i.e., the information regarding frequency, duration, characteristics, severity, and/or functional loss related to such flare-ups elicited from the Veteran), but any member of the medical community at large could not provide such an opinion without resorting to speculation. (E) The examiner should also comment upon the functional impairment resulting from the Veteran’s muscle rigidity of the right upper extremity. A rationale for all opinions offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. M. Celli, Counsel