Citation Nr: 18140680 Decision Date: 10/05/18 Archive Date: 10/04/18 DOCKET NO. 16-01 853 DATE: October 5, 2018 ORDER New and material evidence has not been received that is sufficient to reopen the claim for service connection for hypertension; the claim is not reopened. Service connection for erectile dysfunction, secondary to service-connected diabetes mellitus, is granted, subject to controlling regulations governing the payment of monetary awards. An effective date earlier than August 14, 2012, for the grant of service connection for PTSD, hearing loss, and tinnitus is denied. An initial compensable rating for bilateral hearing loss is denied. An initial rating higher than 10 percent for tinnitus is denied. A rating higher than 20 percent for diabetes mellitus with cataracts is denied. An initial rating higher than 70 percent for posttraumatic stress disorder (PTSD), is denied. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). FINDINGS OF FACT 1. In a rating decision issued in September 2010, the RO denied a claim for service connection for hypertension based on the determination that the evidence did not show that the Veteran’s hypertension was related to his service-connected diabetes mellitus or any evidence of hypertension during service. 2. The evidence received since the September 2010 RO decision, which denied a claim of entitlement to service connection for hypertension, which was not previously of record, and which is not cumulative of other evidence of record, does not raise a reasonable possibility of substantiating the claim. 3. Giving him the benefit of the doubt, the Veteran has erectile dysfunction that is etiologically related to his service-connected diabetes mellitus. 4. The record contains no informal claim, formal claim, or any written intent to file a claim for entitlement to service connection for PTSD, bilateral hearing loss, and tinnitus prior to August 14, 2012. 5. The Veteran’s bilateral hearing loss disability has been manifested by loss of hearing acuity measured at no worse than Level II in the right ear and Level I in the left ear, or no worse than Level I hearing, bilaterally. 6. The Veteran’s diabetes mellitus requires oral medication and restricted diet for control, is not productive of regulation of activities, and is not manifested by cataracts that have resulted in compensable visual impairment. 7. The most probative evidence of record indicates that the Veteran’s psychiatric disorder has been manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. CONCLUSIONS OF LAW 1. The September 2010 rating decision that denied service connection for hypertension, is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.160 (d), 20.201, 20.302, 20.1103 (2018). 2. The evidence received subsequent to the September 2010 rating decision is not new and material, and the requirements to reopen the claim of entitlement to service connection for hypertension have not been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018). 3. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for erectile dysfunction, secondary to service-connected diabetes mellitus, are met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2018). 4. The criteria for an effective date earlier than August 14, 2012, for the award of service connection for PTSD, bilateral hearing loss, and tinnitus have not been met. 38 U.S.C. §§ 5103 (a), 5103A, 5107(b), 5110 (2012); 38 C.F.R. §§ 3.1 (p), 3.400 (2018). 5. The criteria for an initial compensable rating for bilateral hearing loss have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.86, Diagnostic Code 6100 (2018). 6. The criteria for an initial rating higher than 20 percent for diabetes mellitus with cataracts have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.119, Diagnostic Code (DC)7913 (2018). 7. The criteria for a rating higher than 70 percent for PTSD, are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.130, DC 9411 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1969 to August 1971. These matters are on appeal from a February 2013 rating decision. The Veteran served on active duty from February 1968 to October 1972. These matters are on appeal from a September 2013 rating decision. His decorations for his active duty service include a Combat Infantry Badge. During the pendency of the appeal for a higher initial rating for PTSD, a December 2015 rating decision, granted a 70 percent evaluation, effective August 14, 2012, the date of the service connection claim. As the higher rating does not represent a grant of the maximum benefits allowable under the VA Schedule for Rating Disabilities, the Veteran’s appeal remains for Board consideration. AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a grant of a higher rating during the course of an appeal, but less than the maximum benefits allowable, does not abrogate the appeal). New and material evidence claim A September 2010 rating decision denied service connection for hypertension on the bases that the evidence did not show that the hypertension was related to his service-connected diabetes mellitus or any evidence of hypertension during service. Although the RO declined to reopen the claim in a December 2015 Statement of the Case, the Board has a legal duty under 38 U.S.C.§§ 5108, 7104 to address whether new and material evidence has been received to reopen the claim for service connection. That matter goes to the Board’s jurisdiction to reach the underlying claim and adjudicate the claim on a de novo basis. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). A finally adjudicated claim is an application which has been allowed or disallowed by the agency of original jurisdiction, the action having become final by the expiration of one year after the date of notice of an award or disallowance, or by denial on appellate review, whichever is the earlier. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.160 (d), 20.302, 20.1103 (2018). Since the Veteran did not appeal that decision or submit any additional evidence within one year of the September 2010 rating decision, that decision became final. See 38 U.S.C. § 7105 (c); 38 C.F.R. §§ 3.104 (a), 3.156, 20.302, 20.1103 (2018). VA may reopen a claim that has been previously denied if new and material evidence is submitted by or on behalf of a veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). New and material evidence is defined as 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 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 Shade v. Shinseki, 24 Vet. App. 100 (2010), the United States Court of Appeals for Veterans Claims (Veterans Court) held that 3.159(c)(4) does not require new and material evidence as to each previously unproven element in order for the claim to be reopened and the duty to provide an examination triggered. In a fact pattern where a prior denial was based on lack of current disability and nexus, the Veterans Court found that newly submitted evidence of a current disability was, in concert with evidence already of record establishing an injury in service, new and material and sufficient to reopen the claim and obtain an examination. The standard is low. However, it must be met to reopen the claim. The pertinent evidence of record at the time of the September 2010 rating decision included the Veteran’s DD Form 214, service treatment records (STRs), private treatment records, and a VA examination. It is important for the Veteran to understand that the unestablished fact necessary to substantiate service connection for his hypertension is a nexus between his current disability and service. Evidence received since the September 2010 RO decision includes additional VA and private treatment records and VA examinations. As a result, the Board finds that the newly received evidence does not relate to an unestablished fact necessary to substantiate the claim on appeal, thus is not new and material and this claim is not reopened. 38 C.F.R. § 3.156 (a). In any event, even if the Board did reopen the claim, it is important for the Veteran to understand that a great deal of the evidence he has recently submitted would provide highly probative factual evidence against his claim. As previously stated, newly received does not indicate any etiologically relationship between the current hypertension and his service or any service-connected disability. In this regard, the evidence would only provide highly probative evidence against the claim on the merits. The Board notes that the Veteran has been notified in writing of the reasons for the denial of service connection and for the reasons of the denial of his application to reopen. He has offered no additional information regarding the claim that would provide a reasonable basis for further development. Under these circumstances, the Board must conclude that new and material evidence to reopen the claim of entitlement to service connection for hypertension, has not been received. As such, the September 2010 rating decision remains final, and the appeal must be denied. As the Veteran has not fulfilled the threshold burden of submitting new and material evidence to reopen the finally disallowed claim, the benefit-of-the-doubt doctrine is not applicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). Service connection claim The Veteran is seeking service connection for erectile dysfunction secondary to his service-connected diabetes mellitus. The Veteran’s service treatment records are void of findings, complaints, symptoms, or any diagnosis of erectile dysfunction. The record includes a September 2013 VA medical opinion in which the examiner opined the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness based on the rationale that careful review of the available medical records, including a previous compensation evaluation as well as his private medical records, failed to identify any neuropathic or vasospastic dysfunction. The examiner concluded that in the absence of either of these disorders, erectile dysfunction is less likely as not caused by or a result of the well-controlled diabetes. However, in December 2015, the Veteran submitted private treatment records which include an April 2011 report which indicate a diagnosis of erectile dysfunction and states that diabetic complications include impotence. In light of the Veteran’s currently diagnosed erectile dysfunction and symptomatology, and the private and VA medical opinions of record, the Board gives the Veteran the benefit of the doubt and finds that entitlement to service connection for erectile dysfunction on a secondary basis is warranted. The nature and extent of the erectile dysfunction caused by the service-connected disability is not currently before the Board. Earlier effective date claim The Veteran is seeking an effective date earlier than August 14, 2012, for the grants of service connection for his PTSD, hearing loss, and tinnitus. Generally, the effective date of an award of disability compensation based on an original claim shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.§ 5110 (a) (2012); 38 C.F.R. § 3.400 (2018). If the claim is received within one year after separation from service, the effective date of an award of disability compensation shall be the day following separation from active service. 38 U.S.C. § 5110 (b)(1) (2012); 38 C.F.R. § 3.400 (b)(2)(i) (2018). Unless specifically provided, the effective date will be assigned on the basis of the facts as found. 38 C.F.R. § 3.400 (a) (2018). A review of the record shows that the Veteran’s original claim for service connection for PTSD, bilateral hearing loss, and tinnitus was filed with VA on August 14, 2012. See, VA Form 21-4138, received August 14, 2012. A September 2013 rating decision granted service connection for PTSD, bilateral hearing loss, and tinnitus, effective August 14, 2012. The evidence of record does not contain, and the Veteran does not allege, that there is any communication from him prior to August 14, 2012 that may be construed as an intent to seek or apply for service connection for PTSD, bilateral hearing loss, and tinnitus. Given the foregoing, the earliest possible effective date, under the law, for the grant of service connection for PTSD, bilateral hearing loss, and tinnitus, is August 14, 2012. See 38 C.F.R. § 3.400. The controlling statute and regulation provide that the effective date for a grant of service connection is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (b)(2)(i). Here, there is no dispute. Therefore, the date of claim, August 14, 2012, is the later of the two dates, and is the appropriate effective date. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (b)(2)(i). The Court has held that where the law not the evidence is dispositive, the Board should deny an appeal because of an absence of a legal merit or the lack of entitlement under the law. Sabonis v. Brown, 6 Vet. App. 426 (1994). The Veteran has failed to allege facts which meet the criteria in the law or regulations, and his claim must be denied. Increased rating claims Disability ratings are determined by the application of the VA’s Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities, which are based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2018). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). Reasonable doubt regarding the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2018). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2018). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2018). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 1. Hearing loss Disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are made. Bruce v. West, 11 Vet. App. 405 (1998); Lendenmann v. Principi, 3 Vet. App. 345 (1992). The regulations set forth eleven auditory acuity levels, designated from Roman numerals I to XI, in escalating order of hearing impairment. 38 C.F.R. § 4.85 (2018). The appropriate auditory acuity level is determined based on a combination of the percentage of speech discrimination and the puretone threshold average. Additional considerations apply when exceptional patterns of hearing loss are demonstrated, which are defined as either a) puretone averages of 55 or greater at 1000, 2000, 3000, and 4000 Hertz, or; b) a puretone threshold of 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86 (a) (2018). Once an acuity level is established for each ear, Table VII, Percentage Evaluations for Hearing Impairment, is used to determine the appropriate disability evaluation. The appropriate rating is determined based on a combination of the levels of hearing impairment established for each ear. Hearing loss disabilities are rated by application of a mechanical process that is explained here. Initially, VA must determine the Roman numerical designation for the degree of hearing impairment in each ear based upon a combination of the percent of speech discrimination and the pure tone threshold average. 38 C.F.R. § 4.85. In general, the Roman numerical designation is determined through application of 38 C.F.R. § 4.85 (h), Table VI. Under Table VI, the horizontal rows represent eight separate ranges of pure tone threshold averages, as demonstrated through audiometric testing for the frequencies at 1000, 2000, 3000, and 4000 Hertz. The average pure tone threshold is calculated by determining the sum of the pure tone thresholds demonstrated at the four aforementioned frequencies and dividing that sum by four. The vertical columns under Table VI represent nine separate ranges of speech discrimination percentage, as determined through Maryland CNC testing. The Roman numerical designation of impaired efficiency is determined for each ear by intersecting the horizontal row appropriate for the calculated pure tone threshold average and the vertical column appropriate for the demonstrated percentage of speech discrimination. 38 C.F.R. § 4.85(b) (2018). Table VIA, which assigns a Roman numeral designation based solely on the puretone threshold average, is used when the examiner certifies that use of the speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc. 38 C.F.R. § 4.85 (c). In addition, where audiometric testing reveals an exceptional pattern of hearing impairment, Roman numerical designations may be determined under 38 C.F.R. § 4.85(h), Table VIA (2018). Pursuant to 38 C.F.R. § 4.86, an exceptional pattern of hearing impairment exists where audiometric testing reveals either: (1) pure tone thresholds of 55 decibels or more at each of the frequencies at 1000, 2000, 3000, and 4000 Hertz; or (2) a pure tone threshold at 30 decibels or less at 1000 Hertz and 70 decibels or greater at 2000 Hertz. 38 C.F.R. §§ 4.85 (h); 4.86 (2018). After the Roman numerical designation has been determined for each ear, VA then determines the appropriate disability rating through application of 38 C.F.R. § 4.85 (h), Table VII (2018). Table VII is applied by intersecting the appropriate horizontal row (which represents the Roman numerical designation for the poorer ear) with the appropriate vertical column (which represents the Roman numerical designation for the better ear). 38 C.F.R. § 4.85 (e) (2018). In Martinak v. Nicholson, 21 Vet. App. 447 (2007), the Court held that in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak, 21 Vet. App. at 455. The Court also noted, however, that even if an audiologist’s description of the functional effects of the veteran’s hearing disability was somehow defective, the veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination. Id. The Veteran contends that his service-connected bilateral hearing loss is more severe than his current rating and warrants an initial compensable rating. Turning to the merits of the claim, VA treatment records include an October 2012 VA audiology evaluation which indicates puretone thresholds for the right ear, in decibels, at 1000, 2000, 30000, and 4000 Hz were as follows: 15, 35, 40, and 85, decibels; the average puretone decibel loss was 44 decibels. The pure tone thresholds for the left ear, in decibels, at 1000, 2000, 3000, and 4000 Hz as follows: 25, 20, 25, and 55 decibels; the average puretone decibel loss was 31 decibels. Speech recognition scores were not provided. Applying the puretone threshold averages of 44 decibels for the right ear and 31 decibels for the left ear, to the rating criteria results in a numeric designation of Level II for the right ear and Level I for the left ear. See 38 C.F.R. § 4.85, Table VIA. Application of the levels of hearing impairment in each ear to Table VII at 38 C.F.R. § 4.85 produces a noncompensable rating. There likewise remains no basis for assigning a higher rating under 38 C.F.R. § 4.86 On July 2013 VA hearing loss and tinnitus Disability Benefits Questionnaire (DBQ) examination, puretone thresholds for the right ear, in decibels, at 1000, 2000, 30000, and 4000 Hz were as follows: 25, 30, 45, and 85 decibels; the average puretone decibel loss was 46 decibels. The pure tone thresholds for the left ear, in decibels, at 1000, 2000, 3000, and 4000 Hz as follows: 25, 30, 35, and 70 decibels; the average puretone decibel loss was 40 decibels. The CNC word list speech recognition score was 96 percent, bilaterally. Under Table VI, these audiometric findings correspond to Level I hearing loss, bilaterally. Those Roman numerical designations equate to a noncompensable disability rating under Table VII. The examiner diagnosed sensorineural hearing loss, bilaterally. The examiner opined that the hearing loss did not impact ordinary conditions of daily life, including the ability to work. Based on these findings the Board finds that the preponderance of the evidence is against assignment of a compensable rating for hearing loss during any period at issue in this appeal. The Board has considered the provisions of 38 C.F.R. § 4.86 governing exceptional patterns of hearing impairment, but they do not apply because the Veteran did not demonstrate an exceptional pattern of hearing impairment. The Board is mindful that an audiologist must provide a description of the functional effects caused by a hearing loss disability. Martinak v. Nicholson, 21 Vet. App. 447 (2007). On October 2012 and July 2013 VA examinations, the Veteran complained of difficulty in understanding others. The Board finds these comments are sufficient to comply with the applicable VA policies. Id. 2. Tinnitus The Veteran contends that his service-connected tinnitus is more severe than his initial 10 percent rating would indicate. Under Diagnostic Code 6260, tinnitus which is unilateral or bilateral, is assigned a 10 percent rating. 38 C.F.R. § 4.87. Diagnostic Code 6260 was revised effective June 23, 2003, to clarify existing VA practice that only a single 10 percent evaluation is assigned for tinnitus, whether the sound is perceived as being in one ear, both ears, or in the head. Id. Note (2) (2018), see also Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). Thus, a 10 percent rating is the maximum schedular rating available for service-connected tinnitus. As such, the appeal is denied. Although the Veteran argues that he is entitled to an initial rating higher than 10 percent for his tinnitus and is competent to report the symptoms of his disability, DC 6260 precludes an evaluation higher than a single 10 percent rating for tinnitus. As there is no legal basis upon which to award separate schedular evaluations for tinnitus in each ear or a higher schedular rating for tinnitus, the Veteran’s claim for such a benefit is without legal merit. Sabonis v. Brown, 6 Vet. App. 426 (1994). 3. Diabetes mellitus The Veteran’s diabetes mellitus has been rated 20 percent disabling under Diagnostic Code 7913. Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes mellitus requiring insulin and restricted diet; or oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities (defined within the diagnostic code as avoidance of strenuous occupational and recreational activities). A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, DC 7913 (2018). Complications of diabetes 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. 38 C.F.R. § 4.119, DC 7913, Note (1) (2018). Turning to the merits of the claim, on December 2015 VA diabetes mellitus DBQ examination, treatment of the Veteran’s diabetes mellitus was noted to include management by restricted diet and oral hypoglycemic agent(s). It did not require regulation of activities as part of medical management of diabetes mellitus. He visited his diabetic care provider for episodes of ketoacidosis and hypoglycemia less than two times per month. There were no hospitalizations for treatment of his diabetes mellitus. The examiner indicated that he did not have any recognized complications related to his diabetes mellitus. The examiner opined that the diabetes mellitus had no impact on his ability to work and the Veteran reported no impact on his activities of daily living. On review of the evidence, the Board finds that a rating higher than 20 percent for the Veteran’s service-connected diabetes mellitus is not warranted at any time during the pendency of the appeal. The threshold requirement for a 40 percent rating is regulation of activities. Camacho v. Nicholson, 21 Vet. App. 360 (2007). In order to meet a higher rating of 40 percent, the Veteran must have been told to avoid any strenuous occupational or recreational activities. 38 C.F.R. § 4.119, DC 7913 (2018). While the evidence shows that the Veteran was prescribed insulin and placed on a restricted diet, the evidence does not indicate that the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities, as is required in order to merit a higher rating of 40 percent. In addition, there were no periods of ketoacidosis or hospitalization for treatment of his diabetes mellitus. Therefore, the Board finds that the medical evidence does not support a rating greater than 20 percent for the Veteran’s service-connected diabetes mellitus at any time during the pendency of the appeal, as his overall symptomatology more nearly approximates the criteria for a rating of 20 percent. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial rating higher than 20 percent for his diabetes mellitus. Next, the Board will address whether a separate compensable rating is warranted for cataracts associated with diabetes mellitus. The Board recognizes that under Note (1) to Diagnostic Code 7913, the rater is to evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent rating. The Veteran’s bilateral cataract disability is currently rated as part of his service-connected diabetes mellitus under 38 C.F.R § 4.119, DC 7913, applicable to diabetes mellitus. 38 C.F.R. § 4.79, DC 6027 is applicable to cataracts of any type, and therefore, is the appropriate diagnostic code under which to rate the Veteran’s disability. DC 6027 provides that preoperative cataracts should be evaluated based on visual impairment. For postoperative cataracts, DC 6027 provides that if a replacement lens is present (pseudophakia), evaluated based on visual impairment. If there is no replacement lens, evaluate based on aphakia. As the evidence indicates that throughout the period on appeal the bilateral cataracts were either preoperative or postoperative with a replacement lens, the bilateral cataract disability is rated based on visual impairment. Id.; see also November 2016 VA examination report. Eye disabilities with visual impairment are rated based on impairment in visual acuity with correction. See 38 C.F.R. §§ 4.75, 4.76. Impairment of central visual acuity warrants a zero percent, or noncompensable, rating when the vision in both eyes is 20/40 (6/12) or better. 38 C.F.R. § 4.79, DC 6066. A 10 percent rating is provided for vision in one eye of 20/50 (6/15) and vision in the other of 20/40 (6/12) or 20/50 (6/15) or vision in one eye of 20/70 (6/21) or 20/100 (6/30) with vision in the other of 20/40 (6/12). Id. Turning to the evidence of record, VA treatment records include a February 2013 ophthalmology note shows that the Veteran reported little to no vision OS (left eye). Mature cataract (OS) was diagnosed. On July 2013 VA eye examination, the examiner diagnosed bilateral pseudophakia. The Veteran presented with a history of cataract surgery with IOL implantation in 2010 for the right eye and in June 2013 for the left eye. After the first cataract removal, he underwent a YAG capsulotomy in the right eye. He had no visual symptoms in the right or left eye. There was no diplopia in either eye and funduscopic examination of both eyes was normal. There was no visual field defect or visual acuity worse than 5/200. There was no corneal disorder (including keratoconus) that resulted in severe irregular astigmatism that could be improved more by contact lenses that by eyeglass lenses. There was no difference equal to two or more scheduled steps or lines of visual acuity between near and distance corrected vision for either eye, with the near vision being worse. There were no incapacitating episodes due to eye disease. Uncorrected distance visual acuity was 20/20 in the right eye and 20/60-2 in the left eye. Uncorrected near visual acuity was 20/30 in the right eye and 20/40 in the left eye. Corrected distance visual acuity was 20/20 in the right eye and 20/40-2 in the left eye. Corrected near visual acuity was 20/30 in the right eye and 20/40 in the left eye. Slight lamp findings in the eyes were abnormal. In the right eye and left eye lens, the eye intraocular lens had been replaced (implant). He was a bilateral pseudophake. He was diagnosed with bilateral pseudophakia with no significant effects on employment. Based on a review of the evidence, both lay and medical, the Board finds that a compensable rating for a bilateral cataract disability is not warranted for the entire period on appeal. The July 2013 VA examination reports indicated that the Veteran’s bilateral corrected visual acuity was 20/40-2 or better for both near and distance vision. Therefore, the weight of the evidence supports a finding that a separate compensable rating for a bilateral cataract disability is not warranted for the entire period on appeal. 4. PTSD Evaluations for various psychiatric disabilities are assigned pursuant to 38 C.F.R. § 4.130. Under the general rating formula for mental disorders, a rating of 30 percent is assigned when there is occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, DC 9411. A rating of 50 percent is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A rating of 70 percent is assigned where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; 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 inability to establish and maintain effective relationships. A 100 percent rating contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the “psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.” Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). As will be discussed in further detail below, during the course of the appeal the Veteran in this case was assigned GAF scores from 50 to 60. A GAF score in the range of 41 to 50 represents “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).” Id. A GAF scale score in the range 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).” Id. Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV. The amendments replace those references with references to the recently updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. Id. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014. See 80 Fed. Reg. 53, 14308 (March 19, 2015). The RO certified the Veteran’s appeal to the Board in March 2016 therefore the claim is governed by DSM-V. Nonetheless, the Board notes that the use of GAF scores has been abandoned in the DSM-5 because of, among other reasons, “its conceptual lack of clarity” and “questionable psychometrics in routine practice.” See Diagnostic and Statistical Manual for Mental Disorders, Fifth edition, p. 16 (2013). In this case, however, DSM-IV was in use at the time the medical entries of record were made. Thus, the GAF scores assigned remain relevant for consideration in this appeal. In reviewing the evidence of record, the Board will consider the assigned GAF scores; however, the Board is cognizant that GAF scores are not, in and of themselves, the dispositive element in rating a disability. Rather, GAF scores must be considered in light of the actual symptoms of the Veteran’s disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126 (a) (2018). We also carefully look at the Veteran’s statements. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive. The Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). On the other hand, if the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has embraced the Mauerhan Court’s interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) provided additional guidance in rating psychiatric disability. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Specifically, the Federal Circuit emphasized that the list of symptoms under a given rating is a nonexhaustive list, as indicated by the words “such as” that precede each list of symptoms. Id. at 2. It held that 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. Id. at 4. Other language in the decision indicates that the phrase “others of similar severity, frequency, and duration,” can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 2. When it is not possible to separate the effects of a nonservice-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant’s favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Turning to the merits of the claim, VA treatment records include an August 2012 report which notes that the Veteran was laid off from his job of 30 years installing fiberoptic equipment. On mental status examination, he was alert, oriented, engaged. Mood and affect was somewhat discouraged with insight voiced. Thought process was clear with no evidence of delusions or hallucinations. Speech was spontaneous with good eye contact. He denied suicidal ideations and no homicidal ideations identified. A September 2012 report which shows that on mental status evaluation, the Veteran was pleasant and cooperative. He was dressed and groomed appropriately. Mood was depressed with congruent affect. His responses were brief, but he appeared to gain comfort with the process throughout the session and was forthcoming with information. No perceptual or thought disturbance was observed or reported. He denied suicidal and homicidal ideations. He was assigned a GAF score of 60. Another September 2012 report shows that he presented with complaints of nightmares, intrusive memories, generalized anxiety, irritability, and a depressed mood. He indicated that he was laid off in January 2012 and was advised to pursue a TDIU claim. On mental status examination, he was pleasant and cooperative and was dressed and groomed appropriately. His responses were brief, but he appeared to gain comfort with the process throughout the session and was forthcoming with information. No perceptual or thought disturbance was observed or reported. He denied suicidal and homicidal ideation. He was assigned a GAF score of 60. In October 2012, the Veteran’s mood was depressed with very flat affect. His thought process seemed clear. In March 2013, he was dressed and groomed appropriately. He was depressed with flat affect. He indicated that he worked on occasion, but was also receiving Social Security. He identified boredom as his biggest trigger for a low mood and intrusive thoughts. He spent time watching television and working outdoors when he could. He was close with his wife, stepdaughter, and stepchildren. He reported experiencing nightmares and intrusive thought of Vietnam. He was assigned a GAF score of 60. Another March 2013 record indicates complaints of combat nightmares, intrusive memories, generalized anxiety, irritability, and depressed mood. In April 2013, his mood was depressed with very flat affect. Thought process seemed clear. He denied homicidal and suicidal ideation. In a March 2013 statement, the Veteran’s wife stated that she had been married to the Veteran for almost 19 years. She stated that he had nightmares and fought in his sleep. She had to wake him using a broom, because he swung his fists and kicked her. On April 2013 VA PTSD psychosocial assessment, it was noted that the Veteran was employed as an installer for a communication company. He denied any occupational problems related to his continued heavy use of alcohol; in fact, he reported that he excelled in this work and eventually got to run his own crew of installers. Although he remained employed as a communications equipment installer, he indicated that he had not worked since January 2013 due to reduced demand. He was pleased with this trend as he reportedly felt ready to retire. Socially, he stated that his wife was his main source of social interaction and stated that he saw his stepdaughter and grandchildren frequently. On mental status examination, he arrived on time dressed and groomed appropriately. His mood was consistently depressed with very flat affect. He offered very little spontaneous conversation and although he answered all the questions asked, his responses were consistently brief and lacking in substance. His response style was matter-of-fact and although he was forthcoming with information he did not provide additional details or examples. There was no evidence of hallucinations, delusions, or deficits in cognitive capacities. Overall, he presented in minimal distress. He was assigned a GAF score of 60. The examiner opined that his symptoms were relatively mild and that he developed several positive coping skills. On July 2013 VA initial PTSD DBQ examination, the Veteran presented with a history of had three divorces, a 19-year long marriage with his fourth wife, and good relationships with his wife and his family members, avoided people, and did not have any social relationships. He self-isolated and did not have any leisure or recreational activities. The Veteran’s level of occupational and social impairment was best summarized by 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; criteria which warrant the assignment of a 30% rating. For VA rating purposes, symptoms included anxiety, suspiciousness, panic attacks that occurred weekly or less often, disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; and an inability to establish and maintain effective relationships; symptoms which warrant the assignment of a 70% rating. The examiner diagnosed PTSD and assigned a GAF score of 50. In May 2013, on mental status examination he had depressed mood with flat affect. His thought process seemed clear. He denied suicidal and homicidal ideations. On March 2014 private psychiatric PTSD DBQ examination, the Veteran presented with a history of a 20-year marriage. He lived with his wife and adult step-grandson. He was socially isolated and only left his home to attend appointments or to dine out on occasion. Regarding relevant occupational and educational history, the Veteran’s longest and last job was installing office equipment for telecommunication companies for 30 years until November 2013. Upon mental status examination, the Veteran’s attention was normal and concentration appeared variable. He complained of increased trouble with short and long-term memory. He struggled with remembering basic information. Speech was normal, although he was brief with information offered. Thought content was appropriate for the circumstances. Organization of thought was goal-directed. There was no report of overt hallucinations. Mood was anxious and nervous, affect was restricted. He was anxious and depressed. In fact, on that day he endorsed symptomatology of PTSD, as he was suspicious and seemed rather vigilant when speaking with the examiner. For VA rating purposes, his symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; difficulty in establishing and maintaining effectiveness work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships; symptoms which warrant the assignment of a 70% rating. Regarding other symptoms, he detailed great ongoing difficulty with his symptom pattern. He remarked that he no longer enjoyed the simplest of activities. In an attached statement, it was noted that he had assistance from his wife in performing some of his daily living tasks, but he tried to help with maintaining the household chores. He had no problems maintaining his personal hygiene and showered daily. She assigned a GAF score of 50 since she believed his PTSD and social impairment were emotionally debilitating. The DSM states individuals with this GAF score range typically have few friends and inability to keep a job. She opined that his GAF score of 50 dated back to his original claim in August 2012. She explained that the GAF score was based on his inability to maintain and form positive relationships. He reported chronic sleep impairment, including having frequent nightmares. He reported irritability outbursts of anger and was easily agitated. She opined that he could not sustain stress from a competitive work environment and could be expected to engage in gainful activity due to his PTSD. In fact, he left his last job, because he was unable to maintain the responsibilities required for the job. His inability to maintain effective relationships also indicated he struggled with a severe impairment. In an accompanying opinion regarding his ability to do work-related, the psychologist opined that he would miss one day of work per month due to mental problems. Two days per month he would need to leave work early due to mental problems. More than 3 days per month he would not stay focused for at least 7 hours of an 8-hour workday. If the Veteran were subjected to the normal pressures and constructive criticisms of a job, more than once per month he would respond in an angry manner, but would not actually become violent. After review of the evidence, the Board finds that a higher evaluation of 100 percent for the Veteran’s psychiatric disorder is not warranted. The Veteran’s GAF scores have ranged from 50, indicative of serious symptoms, to 60, indicative of moderate symptoms. Overall, the evidence of record supports the assignment of no higher than a 70% evaluation. In this regard, the VA and private examiners have consistently opined that the Veteran’s psychiatric disorder is manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood; criteria which warrant the assignment of a 70% disability evaluation. In this case, there was no evidence of such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); or disorientation to time or place. The Board fully recognizes that the listed symptoms for a 100 percent schedular rating are not all encompassing and their presence is not necessarily determinative. However, the Veteran’s symptoms must cause the occupational and social impairment in the referenced areas. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). While total occupational impairment due to his psychiatric disorder has been demonstrated, as will be discussed in further detail below, total social impairment, as contemplated by the rating criteria, is simply not shown or even approximated. It is important for the Veteran to understand that a disability evaluation of 70 percent will cause him many problems and that this fact is not in dispute. If there were no problems associated with his disability during this period, there would be no basis for a compensable evaluation (zero), let alone a 70 percent evaluation. The Veteran’s statements made during the VA and private examinations in many respects support a 70% evaluation, not a 100% finding. The critical question in this case, however, is whether the problems the Veteran has believably cited meet an even higher, 100 percent, level under the rating criteria. For reasons cited above, they do not, for any part of the rating period. Additional Considerations With regard to his PTSD, tinnitus, and bilateral hearing loss disability, the Veteran is competent to report complaints such as anxiety and difficulty hearing as these observations come to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board also acknowledges the Veteran’s belief that his symptoms are of such severity as to warrant a higher rating and has taken these contentions seriously. He is not, however, competent to identify a specific level of disability of his PTSD, hearing loss, and tinnitus according to the appropriate diagnostic code. On the other hand, such competent evidence concerning the nature and extent of the Veteran’s PTSD, bilateral hearing loss, and tinnitus has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. Finally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (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). REASONS FOR REMAND The Veteran contends that he is unemployable due to his service-connected PTSD. Private treatment records include an April 2012 report which states that the Veteran had retired, but continued to work intermittently. VA treatment records dated in August 2012 indicate that he was both unemployed due to a lay off and lost his job after failing to properly respond to a co-worker. A March 2013 report shows that he was unemployed since January 2012. On April 2013 VA PTSD psychosocial assessment, it was reported that although he remained employed as a communications equipment installer, he indicated that he had not worked since January 2013 due to reduced demand. He was pleased with this trend as he reportedly was ready to retire. However, in a March 2014 private report the psychologist opined that the Veteran’s service-connected impairments affected his ability to do work-related activities. She indicated that one day per month he would miss work and need to leave work early two days per month, due to his psychiatric disorder. More than three times per month he would be unable to remain focused to continue simple repetitive tasks. More than once per month he would respond in an angry manner, but would not actually become violent. At the time, the Veteran has a combined disability rating of 80 percent. Therefore, the Veteran meets the minimum schedular threshold requirement (of a combined disability rating of 70 percent or more) to be considered for a TDIU, pursuant to 38 C.F.R. § 4.16 (a). Given that the evidence of record demonstrates that the Veteran may be unemployable due to his service-connected PTSD, on remand a VA examination and opinion would be helpful in determining whether his service-connected disabilities render him unemployable. The matters are REMANDED for the following actions: 1. Rate the now service-connected erectile dysfunction (the rating of this disability will not be before the Board unless this issue is appealed). 2. Thereafter, schedule the Veteran for an appropriate VA examination, to be conducted, if possible, by a vocational specialist. The claims folder should be made available to and reviewed by the examiner. All appropriate tests should be conducted. The examiner should opine as to whether, without regard to the Veteran’s age or the impact of any nonservice-connected disabilities, it is at least as likely as not that his service-connected disabilities, to specifically include his psychiatric disability, render him unable to secure or follow a substantially gainful occupation (versus just marginal employment). The examiner should take into consideration the Veteran’s level of education, special training, and previous work experience. The report of examination should include the complete rationale for all opinions expressed. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Adams, Counsel