Citation Nr: 18144986 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 15-45 404 DATE: October 25, 2018 ORDER Entitlement to an increased rating greater than 70 percent from December 27, 2012, to August 1, 2018 for service-connected posttraumatic stress disorder (PTSD) is denied. Entitlement to a compensable evaluation for bilateral hearing loss is denied. REMANDED Entitlement to an increased rating greater than 50 percent from August 1, 2018, for service-connected PTSD is remanded. Entitlement to service connection for a gastrointestinal disability is remanded. Entitlement to a total disability rating for individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. From December 27, 2012 to August 1, 2018, the Veteran’s service-connected PTSD has been manifested by symptoms causing no more than deficiencies in most areas and is not shown to have been manifested by symptoms causing total social and occupational impairment. 2. During the appellate period, the Veteran’s bilateral hearing loss has been manifested by auditory acuity no worse than Level I in the right ear and Level VI in the left ear; there is no indication of an exceptional pattern of hearing impairment or suggestion that the regular schedular rating criteria do not contemplate his level of functional impairment. CONCLUSIONS OF LAW 1. A rating in excess of 70 percent for PTSD, from December 27, 2012, to August 1, 2018, is not warranted. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2017). 2. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.321(b), 4.85, 4.86, Diagnostic Code 6100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran honorably served on active duty from June 1969 to March 1971, with service in the Republic of Vietnam. This matter is before the Board of Veterans’ Appeals (Board) on appeal from June 2013, September 2013, and April 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. With his appeal of the issue of an increased rating for bilateral hearing loss, the Veteran also appealed the issues of effective dates of the awards of service connection for his bilateral hearing loss and tinnitus. See June 2013 Veteran’s Notice of Disagreement (VA Form 21-0958). These issues were adjudicated and granted back to the desired effective date in a September 2014 rating decision, for which no appeal was subsequently received. Therefore, these issues are not before the Board. In the Representative’s appellate brief, the arguments submitted can be read to as an argument against the appropriateness of the rating reduction proposed in an October 2015 rating decision and enacted in a May 2018 rating decision. To the extent that this is an expression of disagreement with the rating reduction, either procedurally or substantively, this issue is not currently on appeal before the Board. At issue before the Board is whether the Veteran is entitled to an increased rating for his service-connected PTSD greater than 70 percent from December 27, 2012 to August 1, 2018, and greater than 50 percent from August 1, 2018. VA amended its regulations to require all appeals be filed on standard forms prescribed by the Secretary, effective March 24, 2015. See 79 Fed. Reg. 57660 (Sept. 25, 2014). This potential appeal is not currently being considered by VA because it was not submitted on the standard form. If the Veteran wishes to have this potential appeal adjudicated, he MUST submit the claims on the required standard form, VA Form 21-0958 (if he has not already done so). Increased Ratings Disability ratings are based on average impairment in earning capacity resulting from a particular disability, and are determined by comparing symptoms shown with criteria in VA’s Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In any claim for an increased rating, “staged” ratings may be warranted where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App, 119 (1999). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is evenly balanced for and against the claim (in “relative equipoise”), with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board has reviewed all evidence in the claims file, with an emphasis on the evidence relevant to these appeals. Although the Board must provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board will summarize the relevant evidence as appropriate and the analysis will focus on what the evidence shows, or fails to show, as to the claims. 1. Entitlement to an increased rating greater than 70 percent from December 27, 2012, to August 1, 2018, for service-connected PTSD is denied. I. Legal Criteria The Veteran’s psychological disorders are rated as 70 percent disabling for the period at issue under the General Rating Formula for Mental Disorders (General Formula). 38 C.F.R. § 4.130, Code 9411. A 70 percent evaluation is warranted where there is occupational and social impairment, with deficiencies in most areas (such as work, school, family relations, judgment, thinking, or mood). This may be due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for total occupational and social impairment. This may be 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. Id. The list of symptoms in the General Formula is not intended to constitute an exhaustive list, but provides examples of the type and degree of symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, a Veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Furthermore, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. As relevant to this case, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), states that it was recommended that the use of Global Assessment of Functioning (GAF) scores be dropped for several reasons, including their conceptual lack of clarity and questionable psychometrics in routine practice. The Board recognizes the Court’s holding in Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) regarding the importance of GAF scores, however, because the medical community has determined that GAF scores are an unreliable measure of a psychiatric disability, the Board assigns the GAF scores mentioned in the record no probative value, and will not discuss them specifically. See also Golden v. Shulkin, 29 Vet, App. 221 (2018). II. Factual Background On mental health follow-up examinations from October 2011 to October 2012, the Veteran reported that he continued to work, had variable mood and anxiety symptoms, fair sleep that was periodically disrupted by nightmares, no suicidal or homicidal ideation, and adequate control with his medications. He reported that April was the time of year things got busy on his farm, staying busy between his regular job and the farm, with his son’s help. On MSE he showed positive signs of variable mood, anxious affect, fair attention and concentration, but was well-kempt, fully oriented, cooperative, and calm. He had linear thought processes, appropriate thought content, and normal judgment. See October 2011 Mental Health Note by R.W., M.D; January 2012 Mental Health Note by R.W., M.D.; April 2012 Mental Health Note by R.W., M.D.; October 2012 Mental Health Note by R.W., M.D. At his February 2013 VA examination, the Veteran reported that he had a good relationship with his spouse of 41 years and a pretty good relationship with his children and grandchildren, but that he retired after 31 years of employment because he was aggravated with his co-workers and felt harassed. See February 2012 PTSD VA Examination by G.D., Ph.D. He also reported that he was successful at work and had never got into problems. Id. The Veteran had symptoms of anxiety, flattened affect, weekly sleep disturbances, minimal contact outside of his family, and irritability, the latter of which he noted that he would accommodate by remaining quiet out of fear of saying or doing too much. Id. In an April 2013 mental health treatment examination, the Veteran reported that his mood, anxiety, and sleep were all stable, but that he continued to have nightmares. He felt that his medications were adequate and that retirement from his non-farming or livestock occupation reduced his stress levels. On MSE he had variable mood, anxious affect, fair attention and concentration, but was well-kempt, fully oriented, cooperative, and calm. He had linear thought processes, appropriate thought content, and normal judgment. See April 2013 Mental Health Note by R.W., M.D. In his July 2013 follow up examination, the Veteran reported feeling about the same as his previous examination and that, while his stress was manageable, it was a daily struggle. On MSE he showed compromised attention span due to his easy distractibility, anxious affect, and variable mood. See July 2013 Mental Health Note by R.W., M.D. In October 2013, the Veteran reported to his treating psychiatrist that his mood and anxiety symptoms varied depending on his exposures or intrusive thoughts; his sleep was fair, but periodically disrupted by nightmares that had become more frequent and intense; his medications were adequate, but that he wanted to resume group therapy activities. See October 2013 Mental Health Note by R.W., M.D. At his group therapy intake assessment, the Veteran was on time, casually dressed and appropriately groomed, mildly anxious in affect, appropriately behaved, and had linear and logical thought processes. See October 2013 Psychology Outpatient Note by V.B. and K.B., Ph.D. At his April 2014 psychiatric follow up, the Veteran reported his mood and sleep were stable, with his sleep improved on current medications. He also reported that his anxiety varied related to exposure to reminders of Vietnam and that if he missed a dose of Celexa, he noticed a worsening of both of his mood and anxiety symptoms. On MSE he was restless and hypervigilant with a labile affect, which was congruent to his euthymic mood. See April 2014 Mental Health Note by R.W., M.D. At a July 2014 follow up treatment, the Veteran reported anxiety and a more depressed mood related to the stress of his chronic health problems, but no suicidal or homicidal ideation. On MSE he was fully oriented, cooperative, calm, euthymic, with a stable affect, normal memory, and normal judgement. His thought processes were linear and his thought content was appropriate. However, he had only fair attention and concentration. See July 2014 Mental Health Note by R.W., M.D. At a September 2014 VA Examination, the Veteran reported that he spends his days working on his farm, tending to the cattle, that he had pretty good relationships with the members of his family, went to church, and maintained contact with his friends. See September 2014 VA Examination by S.H., Ph.D. The Veteran’s symptoms included anxiety, chronic sleep impairment, and disturbances of motivation and mood. Id. During his October and December 2014 follow-up appointments, the Veteran returned to his psychiatric provider and reported that his anxiety, mood, and sleep were stable, although he continued to have nightmares, and felt that his medications were adequate. On MSE he was restless and hypervigilant with a labile affect. He had normal memory, speech, and judgment. See October 2014 Mental Health Note by R.W., M.D.; December 2014 Mental Health Note by R.W., M.D. In his March 2015 psychiatric follow up appointment, the Veteran reported mood and sleep stability, improved on his current medications, but varying anxiety symptoms. On MSE he was fully oriented and cooperative with linear and appropriate thought content and processes, normal memory, and normal judgment; however, he was suspicious, restless, hypervigilant, dysthymic and had a labile affect. See March 2015 Mental Health Note by R.W., M.D In June 2015, the Veteran reported worsening depression and variable anxiety. From his MSE, he was recorded as being cooperative, fully oriented, and euthymic with linear and appropriate thought content and processes, normal memory, and normal judgment, but only fair attention and concentration. See June 2015 Mental Health Note by R.W., M.D. At his September 2015 psychiatric follow-up appointments, the Veteran reported variable mood and anxiety symptoms, disrupted sleep, and no suicidal or homicidal ideation. He felt that his medications were adequate and on MSE he was fully oriented, cooperative, and euthymic with a congruent, but labile, affect. His thought processes were linear and thought content was appropriate, his judgment was normal, and his memory was normal. See September 2015 Mental Health Note by R.W., M.D. During his December 2015 and March 2016 appointments, the Veteran reported, mood, anxiety, and sleep stability and was restless, hypervigilant, dysthymic, and labile. However, his speech, judgment, and memory were recorded as normal and he had linear thought processes with appropriate thought content. See December 2015 Mental Health Note by R.W., M.D.; March 2016 Mental Health Note by R.W., M.D. During this time, the Veteran reported that he lives with and helps care for his mother-in-law and that he helps care for his 4 grandchildren. See February 2016 Occupational Therapy Discharge Note. In June and August 2016, the Veteran reported increased depression due to the stress of his chronic health problems, but did not have any suicidal or homicidal ideation. On MSE he was fully oriented, cooperative, calm, and euthymic with a stable affect. His thought processes were linear and his thought content was appropriate. The Veteran had normal memory, judgment, and speech, but only fair attention and concentration. See June 2016 Mental Health Note by R.W., M.D.; August 2016 Mental Health Note by R.W., M.D. The Veteran reported to a chaplain after a recent surgery that he felt confident in the outcome of the surgery and that he was motivated to get back to tending his cattle. See June 2016 Chaplain Note. At his November 2016 and February 2017 psychiatric follow-up examinations, the Veteran reported stable mood, sleep, and anxiety, but continuing nightmares. On examination, he was recorded as being restless and hypervigilant, with a labile, but stable, affect congruent to his euthymic mood. He was fully oriented and cooperative, with normal memory and judgment, and linear thought processes. See November 2016 Mental Health Note by R.W., M.D.; February 2017 Mental Health Note by R.W., M.D. Around this time, the record reflects that the Veteran was working with his cattle and potentially physically injured himself in the process. See March 2017 Primary Care General Inquiry Note. In May 2017, the Veteran reported increased depression due to the stress of his health problems, but did not have any suicidal or homicidal ideation. On MSE he was fully oriented, cooperative, and euthymic with a labile affect. His thought processes were linear and organized and his thought content was appropriate. The Veteran had normal memory, judgment, and speech. However, he was noted to be restless and hypervigilant. See May 2017 Mental Health Note by R.W., M.D. During his August 2017 psychiatric follow-up appointment, the Veteran reported continuing increased depression due to his health problems and reported that he had variable anxiety. On MSE he was fully oriented, cooperative, calm, and euthymic with stable affect. His speech, judgment, and memory were normal and his thought processes were linear and his thought content was appropriate. However, he was recorded as having only fair attention and concentration. See August 2017 Mental Health Note by R.W., M.D. In his October 2017 and January 2018 appointments, the Veteran reported mood, anxiety, and sleep stability, although he continued with insomnia and nightmares. He believed his medications were adequate and he was not suicidal. On MSE he was distressed, restless, hypervigilant, and dysthymic with a labile affect, but his speech, memory, and judgment were normal. His thought processes were linear and organized and the content was appropriate. See October 2017 Mental Health Note by R.W., M.D.; January 2018 Mental Health Note by R.W., M.D. During this time the Veteran was continuing to do farm work. See November 2017 Otolaryngology Telephone Encounter Note. In April 2018, the Veteran reported mood and sleep stability, no suicidal ideation, and improved sleep. His anxiety symptoms varied with the extent of his exposure to reminders of Vietnam. On examination, he was restless, hypervigilant, and euthymic with a labile affect. His speech, memory, and judgment were normal and his thought processes were linear and the content appropriate. See April 2018 Mental Health Note by R.W., M.D. III. Legal Analysis A rating of 100 percent, the next level at which the Veteran could receive benefits, requires a showing of total occupational and social impairment. After thoroughly reviewing the evidence, as summarized above, the Board finds that a 100 percent rating for PTSD is not warranted because the evidence simply does not suggest that the Veteran was totally occupationally and socially impaired due to his PTSD prior to August 1, 2018. Rather, the evidence indicates that he consistently denied symptoms of a severity comparable to those listed as representing examples of the 100 percent disability rating. The record reflects that the Veteran was capable of some occupational functioning, as evidenced by his ability to participate in the working of a farm with cattle, help in the care of his mother-in-law, and assist in the care of his grandchildren. Although the Veteran socialized minimally and had some difficulty with his work and family relationships, the Veteran also reported that he had pretty good or good relationships with his family and that he maintained contact with his friends. The evidence indicates that the Veteran was irritable, but that he managed the symptoms by keeping that to himself, which is not grossly inappropriate behavior. His communication and his thought content and processes were not grossly impaired as evidenced by the consistently recorded normal speech, linear thought processes, and appropriate thought content. His memory was consistently reported as normal and he was not disoriented to time or place due to his PTSD. When recorded, the Veteran was well-kempt and there is no indication that his PTSD kept him from performing his activities of daily living. In summary, the Board finds that the Veteran’s social and occupational impairment affected his ability to function appropriately and effectively, and thus, at most meets the criteria for a 70 percent rating. Regarding entitlement to a rating in excess of 70 percent (a 100 percent rating), there is no lay or medical evidence suggesting total social and occupational impairment prior to August 1, 2018. Thus, while he was significantly and seriously impaired by his psychiatric symptoms, the preponderance of the evidence is against finding that his impairment was the kind of gross impairment contemplated by a 100 percent rating. Consequently, an increased rating higher than 70 percent is not warranted prior to August 1, 2018. The Board acknowledges the Veteran’s competent and credible reports of relevant symptoms and appreciates his diligent efforts to describe these symptoms while living with significant disability. However, these symptoms are most consistent with a 70 percent rating. Although the Veteran believes that a higher rating is warranted, this belief is outweighed by the more probative medical evidence of record and the findings of the VA examiners. Based on the examiners’ reports and in consideration of the Veteran’s reported symptoms and mental signs in treatment examinations, a rating higher than 70 percent for PTSD is not warranted. 2. Entitlement to a compensable rating for bilateral hearing loss. I. Legal Criteria Ratings for hearing loss disability are derived from Table VII of 38 C.F.R. § 4.85 by a mechanical application of the rating schedule to numeric designations for hearing acuity assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The numeric designations correspond to eleven auditory acuity levels, indicated by Roman numerals, where Level I denotes essentially normal acuity and Level XI denotes profound deafness. The assignment of the appropriate numeric level is based on the results of controlled speech discrimination tests in combination with the Veteran’s average hearing threshold. The average pure tone threshold is derived from pure tone audiometric testing in the frequencies of 1000, 2000, 3000, and 4000 Hertz. 38 C.F.R. § 4.85. Rating specialists use either Table VI or VIA of 38 C.F.R. § 4.85 to determine the hearing acuity level. Table VIA is used when speech discrimination tests are not appropriate due to language difficulties, inconsistent speech discrimination scores, etc., or where there is an exceptional pattern of hearing loss (defined in 38 C.F.R. § 4.86). One such pattern occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). Another occurs when the pure tone threshold at 1000 Hertz is 30 decibels or less and the pure tone threshold at 2000 Hertz is 70 decibels or more. 38 C.F.R. § 4.86(b). II. Factual Background and Legal Analysis After carefully reviewing the evidence, the Board finds that no audiometry during the period under consideration shows a hearing loss disability warranting a rating higher than zero percent under the schedular criteria for rating hearing loss. The Board further finds that the record does not demonstrate an exceptional pattern of hearing impairment in either ear of the type contemplated by 38 C.F.R. § 4.86 and there are no hearing loss-related symptoms that would warrant submittal for extraschedular consideration. Accordingly, the Board must deny the Veteran’s claim for a compensable disability rating for bilateral hearing loss. During an August 2003 examination, the Veteran stated that his symptoms include difficulty hearing in any sort of background noise. See August 2003 VA Audiological Examination by A.R. The Veteran stated at his January 2004 examination that his primary audiological symptoms related to tinnitus. See January 2004 VA Audiological Examination by A.R. At a June 2011 examination, the Veteran reported that his symptoms include difficulty understanding speech and difficulty with hearing. See June 2011VA Audiological Examination by C.S. At his most recent VA examination, the Veteran reported that his functional effects include difficulty understanding speech, especially in noise. See September 2014 VA Audiological Examination by C.S. The Veteran’s representative submitted argument that the Veteran’s hearing loss should be assigned a compensable rating because the Veteran is unable to hear conversations in crowds and must increase the volume on his television to hear the programs. See July 2018 Appellate Brief by L.G. During the August 2003 VA audiological examination, audiometry showed pure tone thresholds in decibels were: HERTZ 1000 2000 3000 4000 Avg. RIGHT 15 15 35 45 27.5 LEFT 20 20 40 75 38.75 Speech audiometry revealed speech recognition ability of 95 percent in the right ear and of 92 percent in the left ear. See August 2003 VA Audiological Examination by A.R. This means that the Veteran had a numeric designation of “I” in the right ear and “I” in the left ear, which directs a zero percent rating. See 38 C.F.R. § 4.85, Tables VI and VII. During the January 2004 VA audiological examination, audiometry showed pure tone thresholds in decibels were: HERTZ 1000 2000 3000 4000 Avg. RIGHT 15 15 35 45 27.5 LEFT 20 20 45 70 38.75 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 96 percent in the left ear. See January 2004 VA Audiological Examination by A.R. This means that the Veteran had a numeric designation of “I” in the right ear and “I” in the left ear which, by law, directs the Board to assign a zero percent rating. See 38 C.F.R. § 4.85, Tables VI and VII. During a June 2010 VA treatment audiological examination, audiometry showed pure tone thresholds in decibels were: HERTZ 1000 2000 3000 4000 Avg. RIGHT 25 15 35 25 25 LEFT 45 60 65 70 60 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 56 percent in the left ear. See June 2010 VA Treatment Audiological Examination by C.C. The Board notes that at this VA treatment examination the audiologist did not use the Maryland CNC, id., which is a requirement for any examination on which VA is basing its rating assignment. However, even if the Board were to apply the results of this examination to assign a rating, the Veteran would have a numeric designation of “I” in the right ear and “VII” in the left ear, which would direct a 0 percent rating. See 38 C.F.R. § 4.85, Tables VI and VII. [CONTINUED ON NEXT PAGE] During a June 2011 VA audiological examination, audiometry showed pure tone thresholds in decibels were: HERTZ 1000 2000 3000 4000 Avg. RIGHT 10 25 45 30 27.5 LEFT 45 60 75 70 62.5 Speech audiometry revealed speech recognition ability of 92 percent in the right ear and of 60 percent in the left ear. See June 2011 VA Audiological Examination by C.S. This means that the Veteran had a numeric designation of “I” in the right ear and “VI” in the left ear, which directs a zero percent rating. See 38 C.F.R. § 4.85, Tables VI and VII. During a September 2011 VA audiological examination, audiometry showed pure tone thresholds in decibels were: HERTZ 1000 2000 3000 4000 Avg. RIGHT 20 20 40 30 27.5 LEFT 45 60 70 75 62.5 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 60 percent in the left ear. See September 2014 VA Audiological Examination by C.S. This means that the Veteran had a numeric designation of “I” in the right ear and “VI” in the left ear, which directs a zero percent rating. See 38 C.F.R. § 4.85, Tables VI and VII. Regarding the Veteran’s statements that his hearing impairment is greater than reflected by the zero percent rating assigned, the Veteran is qualified (“competent”) to report the symptoms he experiences and, indeed, the audiometry indicates that his hearing has worsened over time. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007). As noted above, however, disability evaluations for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned from audiometric evaluations. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). Accordingly, the Board is unable to grant the appeal because the specific legal criteria for a compensable rating for bilateral hearing loss have not been met. In light of the representative’s argument that the Veteran should be awarded a compensable rating because the Veteran experiences difficulty hearing speech and difficulty listening to television, see July 2018 Appellate Brief by L.G., the Board has also considered whether this matter should be referred for consideration of an extraschedular rating under 38 C.F.R. § 3.321(b). In this case, however, referral for extraschedular consideration is not necessary because the schedular criteria for the Veteran’s hearing loss contemplate the functional effects of difficulty hearing and understanding speech in various contexts. Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (“[The] rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday work environment, as these are precisely the effects that VA’s audiometric tests are designed to measure”). Accordingly, the Veteran’s difficulty hearing and understanding speech in various contexts, including in the presence of background noise or crowds, is adequately contemplated by the schedular criteria. To the extent that the representative is arguing that the examinations themselves are inadequate because they did not adequately consider the functional effects of the Veteran’s symptoms, the Board notes that each examiner included in their reports the Veteran’s functional symptoms. See Martinak v. Nicholson, 21 Vet. App. 447 (2007) (holding that VA audiological examinations must include a report of the effect of hearing loss on activities of daily living and occupational functioning); see also August 2003 VA Audiological Examination by A.R. (noting symptoms of difficulty understanding speech in background noise); January 2004 VA Audiological Examination by A.R. (noting primary audiological symptoms were from tinnitus); June 2011VA Audiological Examination by C.S. (noting functional effects of difficulty understanding speech and difficulty with hearing); September 2014 VA Audiological Examination by C.S. (noting functional effects of difficulty understanding speech, especially in noise). Accordingly, the Board finds that the preponderance of the evidence is against finding that the Veteran’s bilateral hearing loss is entitled to be rated at a compensable amount. See 38 U.S.C. § 1155; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 C.F.R. § 4.85. REASONS FOR REMAND 1. Entitlement to an increased rating greater than 50 percent from August 1, 2018, for service-connected PTSD is remanded. The Board finds that further development of the record is necessary to meet VA’s duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully-informed decision on the claim at this time because the record does not include any evidence addressing the Veteran’s psychological or mental health functioning as of August 1, 2018 or later. The record reflects that the Veteran engaged in regular treatment at the Lexington VAMC. Accordingly, a remand is required to obtain additional evidence and to attempt to obtain a VA examination. 2. Entitlement to service connection for a gastrointestinal disability is remanded. With the Veteran’s claim and appeal, he indicated that he believed that he had a gastrointestinal disability due to exposure to herbicide agents in Vietnam; specifically, that it was contained within the milk that they were provided because the water used to mix with the powdered milk was contaminated. See March 2016 Veteran’s Statement in Support of Claim (VA Form 21-4138); Veteran’s Supplied Printout received April 2016; May 2016 Veteran’s Notice of Disagreement (VA Form 21-0958). VA is required to provide examination when there is insufficient medical evidence to decide the claim, but the record otherwise contains competent evidence of a current disability or recurrent symptoms, evidence of an in-service event, and evidence of an indication of a nexus. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 3. Entitlement to a total disability rating for individual unemployability (TDIU) is remanded. This issue was denied in a September 2013 rating decision and appealed in a September 2013 notice of disagreement. The Board recognizes that the RO interpreted this notice of disagreement as only applying to the Veteran’s claim of an increased rating for service-connected PTSD. However, the notice includes references to a request for 100% disability because he was unable to find employment. See September 2013 Veteran’s Notice of Disagreement. This reflects a reasonable expression of disagreement and a desire to appeal the determination and, therefore, this should have been considered an appeal of the denial of TDIU. See 38 C.F.R. § 20.201 (2013). A statement of the case (SOC) has not yet been issued. Thus, remand pursuant to Manlincon v. West, 12 Vet. App. 238, 240-41 (1999), is necessary. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from April 2018 to the present. 2. After completion of directive one, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his service-connected PTSD. 3. After completion of directive one, schedule the Veteran for an examination by an appropriate clinician to determine the nature and cause of the Veteran’s gastrointestinal condition(s), including Veteran’s diagnosed hernia. Based on the factual evidence of record and the examination, the examiner must provide an opinion that responds to the following: (a.) Please identify the gastrointestinal condition(s) by diagnosis(es). (b.) For EACH of the diagnosed gastrointestinal condition(s), is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current gastrointestinal condition(s) was incurred in active military service, to include herbicide agent exposure*? *By virtue of the Veteran’s service in the Republic of Vietnam, it MUST be presumed that the Veteran was exposed to herbicide agents. In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). [CONTINUED ON THE NEXT PAGE]   If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. SARAH LAMBERT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Lambert, Associate Counsel