Citation Nr: 18146511 Decision Date: 10/31/18 Archive Date: 10/31/18 DOCKET NO. 13-06 251A DATE: October 31, 2018 ORDER Entitlement to service connection for left lower extremity muscle disability (claimed as leg cramps) is denied. Entitlement to service connection for right lower extremity muscle disability (claimed as leg cramps) is denied. Entitlement to service connection for a disability manifested by dizziness is denied. Entitlement to service connection for a respiratory disorder (claimed as non-specific breathing problems) is denied. Entitlement to service connection for hypotension (claimed as low blood pressure) is denied. Entitlement to service connection for left upper extremity neurological disability (claimed as peripheral neuropathy), to include as due to herbicide exposure is denied. Entitlement to service connection for right upper extremity neurological disability (claimed as peripheral neuropathy), to include as due to herbicide exposure is denied. Entitlement to service connection for a disability manifested by memory loss is denied. Entitlement to an increased rating, on an extraschedular basis, for a service-connected tinnitus disability is denied. Entitlement to a disability rating in excess of 30 percent prior to July 22, 2015 for posttraumatic stress disorder is denied. Entitlement to a disability rating in excess of 50 percent from July 22, 2015 for posttraumatic stress disorder is denied. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran does not have a separate and distinct diagnosis of a left lower extremity muscle disability (other than peripheral neuropathy). 2. The Veteran does not have a separate and distinct diagnosis of a right lower extremity muscle disability (other than peripheral neuropathy). 3. The Veteran does not have a current disability manifested by dizziness. 4. The competent and probative evidence is against a finding that a current respiratory disorder (claimed as non-specific breathing problems) had its onset during active service, was caused by active service, or manifested within one year of separation from active service, to include as due to herbicide exposure. 5. The Veteran does not have a diagnosis of a hypotension disability (claimed as low blood pressure). 6. The competent and probative evidence is against a finding that a current left upper extremity neurological disability (claimed as peripheral neuropathy) had its onset during active service, was caused by active service, or manifested within one year of separation from active service, to include as due to herbicide exposure. 7. The competent and probative evidence is against a finding that a current right upper extremity neurological disability (claimed as peripheral neuropathy) had its onset during active service, was caused by active service, or manifested within one year of separation from active service, to include as due to herbicide exposure. 8. The Veteran does not have a diagnosis of a disability manifested by memory loss. 9. The Veteran’s service-connected tinnitus is assigned a 10 percent rating, which is the maximum rating authorized for tinnitus under Diagnostic Code 6260, for either a unilateral or bilateral condition, and does not warrant an increase on an extraschedular basis. 10. The medical evidence of record shows that prior to July 22, 2015, the Veteran's psychiatric disability was predominantly manifested by symptoms of anxiety, mild depression, hypervigilance, sleep impairment, panic attacks less than once weekly, being easily startled, and some crowd avoidance. 11. The medical evidence of record shows that since July 22, 2015, the Veteran's psychiatric disability was predominantly manifested by symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, panic attacks more than once a week, mild memory loss such as forgetting names, directions, or recent events, and difficulty in adapting to stressful circumstances, including work or a work like setting; deficiencies in most areas and total social and occupational impairment was not shown. CONCLUSIONS OF LAW 1. The criteria for service connection for a left lower extremity muscle disability manifested by muscle spasm or pain (other than peripheral neuropathy) have not been met. 38 U.S.C. §§ 1110, 1116, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 2. The criteria for service connection for a right lower extremity muscle disability manifested by muscle spasm or pain (other than peripheral neuropathy) have not been met. 38 U.S.C. §§ 1110, 1116, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 3. The criteria for service connection for a disability manifested by dizziness have not been met. 38 U.S.C. § 1131 (2012); 38 C.F.R. §§ 3.303, 3.310 (2018). 4. The criteria for service connection for a respiratory disability (claimed as non-specific breathing problems) have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2018). 5. The criteria for service connection for hypotension (claimed as low blood pressure) have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018). 6. The criteria for service connection for left upper extremity neurological disability (claimed as peripheral neuropathy), to include as due to herbicide exposure have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. § 3.303 (2018). 7. The criteria for service connection for right upper extremity neurological disability (claimed as peripheral neuropathy), to include as due to herbicide exposure have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. § 3.303 (2018). 8. The criteria for service connection for a disability manifested by memory loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303 (a) (2018). 9. The criteria for an extraschedular rating for service-connected tinnitus have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.321(b) (2018). 10. The criteria for a disability rating in excess of 30 percent prior to July 22, 2015 for posttraumatic stress disorder have not been met. 38 U.S.C. §§ 1110, 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.126, 4.130, Diagnostic Code 9411 (2018). 11. The criteria for a disability rating in excess of 50 percent from July 22,2015 for posttraumatic stress disorder have not been met. 38 U.S.C. §§ 1110, 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.126, 4.130, Diagnostic Code 9411 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1966 to November 1969. In an August 2017 Board decision, the issues of entitlement to service connection for right and left leg cramps and entitlement to service connection for breathing problems were recharacterized as right and left lower extremity muscle disabilities and a respiratory disability respectively. All issues on appeal were remanded for further development. In an August 2018 rating decision, the issues of entitlement to service connection for right lower extremity and left lower extremity peripheral neuropathy were granted and the Veteran did not appeal, therefore those issue are no longer before the Board. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. 1110 (2012); 38 C.F.R. 3.303 (a) (2018). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). 1. Entitlement to service connection for a left lower extremity muscle disability (claimed as leg cramps) After a careful review of the evidence of record, the Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for a left lower extremity muscle disability manifested by muscle spasms or muscle pain, other than peripheral neuropathy. In December 2017, the Veteran underwent a VA muscle injury examination. The examiner noted that the Veteran does not now have a muscle injury, has never been diagnosed with a muscle injury, and denied a history of a muscle injury condition. After interviewing the Veteran, the examiner stated the Veteran erroneously associated his claimed left lower muscle injury condition as intermittent lower leg cramps/ache/pain secondary to his lower extremity neuropathy. The examiner determined that the Veteran’s left lower extremity muscle complaints are a symptom of the idiopathic left lower extremity peripheral neuropathy, and there is no separate muscle injury disability. Without evidence of a current disability due to disease or injury, service connection for a disability is not warranted. Brammer v. Derwinski, 3 Vet. App. 223 (1992); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). Symptoms, such as muscle pain, without an underlying disease or injury, cannot meet the regulatory requirement for the existence of a current disability. See Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Because a medical professional has determined that the Veteran's muscle pain is not indicative of a current disability due to disease or injury, but instead is a symptom of lower extremity idiopathic peripheral neuropathy for which the Veteran is already service connected for, the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply, and the Veteran's claim is denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. at 54-56. 2. Entitlement to service connection for right lower extremity muscle disability (claimed as leg cramps) After a careful review of the evidence of record, the Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for a right lower extremity muscle disability manifested by muscle spasms or muscle pain, other than peripheral neuropathy. In December 2017, the Veteran underwent a VA muscle injury examination. The examiner noted that the Veteran does not now have a muscle injury, has never been diagnosed with a muscle injury, and denied a history of a muscle injury condition. After interviewing the Veteran, the examiner stated the Veteran erroneously associated his claimed right lower muscle injury condition as intermittent lower leg cramps/ache/pain secondary to his lower extremity neuropathy. The examiner determined that the Veteran’s right lower extremity muscle complaints are a symptom of the idiopathic right lower extremity peripheral neuropathy, and there is no separate muscle injury disability. Without evidence of a current disability due to disease or injury, service connection for a disability is not warranted. Brammer v. Derwinski, 3 Vet. App. 223 (1992); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). Symptoms, such as muscle pain, without an underlying disease or injury, cannot meet the regulatory requirement for the existence of a current disability. See Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Because a medical professional has determined that the Veteran's muscle pain is not indicative of a current disability due to disease or injury, but instead is a symptom of lower extremity idiopathic peripheral neuropathy for which the Veteran is already service connected for, the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply, and the Veteran's claim is denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. at 54-56. 3. Entitlement to service connection for a disability manifested by dizziness The Veteran contends that he has a current condition manifested by dizziness that is related to his military service. Service connection may only be granted for a current disability. When a claimed condition is not shown, there may be no grant of service connection. Congress specifically limited entitlement for service-connected disease or injury to cases where the incident resulted in a disability. In the absence of proof of a present disability there can be no valid claim. 38 U.S.C. § 1110 (2012); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). A review of the Veteran’s service treatment records (STRs) shows no evidence of a chronic disability manifested by dizziness beginning on active duty. Post-service treatment records from March 2010 to March 2017 reflect that the Veteran complained of occasional dizziness upon standing. A September 2010 private treatment note shows that the Veteran complained of dizziness while taking the prescription drug Celexa, but after the dosage was adjusted to half the dizziness resolved. The record does not contain evidence that the Veteran has, or had at any point since discharge in 1969, a disability characterized by dizziness. A December 2017 VA medical opinion reflects that there is no current diagnosis of a chronic disability manifested by dizziness. As the examiner determined the Veteran does not have a current disability manifested by dizziness, the examiner opined that it was less likely as not that such disability was related to service, due to conceded exposure to herbicides or service in Vietnam, or was caused or aggravated by his service-connected PTSD and service-connected coronary artery disease. Lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example, a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In the present case, while a lay person may be competent to report symptoms of dizziness, they are not competent to diagnose a chronic condition manifested by dizziness. The diagnosis of a disability manifested by dizziness requires greater medical knowledge and testing to determine a diagnosis, which the Veteran has not shown he possesses. Accordingly, the Veteran is not competent to establish diagnosis for his claimed occasional dizziness. In the absence of proof of a current disability, there is no valid claim of service connection. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement that a current disability be present is satisfied when a claimant has a disability at any time during the pendency of a claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The record does not demonstrate that the Veteran has been diagnosed with a chronic disability manifested by dizziness. The threshold element of a service connection claim (a current disability) has not been met; therefore, service connection for dizziness must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As the preponderance of the evidence is against the claim for service connection for dizziness, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for a respiratory disability (claimed as non-specific breathing problems) The Veteran asserts that he has a respiratory disorder attributable to military service. There is no evidence of a respiratory condition during active duty service. Post-service treatment records show that the Veteran has a diagnosis of COPD. A December 2017 VA examination reflects that the Veteran reported he began smoking at age 20 and smoked a pack to a pack and a half per day until he quit smoking in 2016. He also reported many years of progressive worsening dyspnea, and that he believed his respiratory issues were due to smoking. The examiner stated the Veteran’s respiratory condition has been diagnosed as COPD and is less likely as not incurred in, related to, or caused by any incident in service, including conceded exposure to herbicides, and more likely secondary to many years of smoking. To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). There is no evidence of an in-service incurrence of a disease or injury and there is no competent medical evidence linking the Veteran’s current COPD disability to the Veteran’s military service. Accordingly, the preponderance of the evidence is against the claim for service connection for a respiratory condition. The benefit of the doubt rule does not apply, and the Veteran's claim for service connection for a respiratory condition is denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. at 54-56. 5. Entitlement to service connection for hypotension (claimed as low blood pressure) A review of the Veteran’s STRs does not reveal any treatment for or diagnosis of hypotension. Post-service treatment records reflect that the Veteran does not have a current diagnosis of hypotension. In February 2017, the Veteran underwent a coronary artery bypass graft after which he experienced an episode of post-operative hypotension. As noted by the December 2017 VA examiner, the episode was acute and transient without persistent or recurrent sequelae and there is no evidence of the condition after medication adjustments were made. Service connection may only be granted for a current disability. When a claimed condition is not shown, there may be no grant of service connection. Congress specifically limited entitlement for service-connected disease or injury to cases where the incident resulted in a disability. In the absence of proof of a present disability there can be no valid claim. 38 U.S.C. § 1110 (2012); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example, a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In the present case, while a lay person may be competent to report symptoms, they are not competent to diagnose a chronic hypotension condition. The diagnosis of hypotension requires greater medical knowledge and testing to determine a diagnosis, which the Veteran has not shown he possesses. Accordingly, the Veteran is not competent to establish diagnosis for his claimed hypotension. In the absence of proof of a current disability, there is no valid claim of service connection. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement that a current disability be present is satisfied when a claimant has a disability at any time during the pendency of a claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The record does not contain evidence that the Veteran has, or had at any point since discharge in 1969, a chronic hypotension disability. The threshold element of a service connection claim (a current disability) has not been met; therefore, service connection for hypotension must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As the preponderance of the evidence is against the claim for service connection for hypotension, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 6. Entitlement to service connection for left upper extremity neurological disability (claimed as peripheral neuropathy) The Veteran contends that he has a current left upper extremity neurological disability that is related to service, to include exposure to herbicides. According to the record, the Veteran has submitted personal statements, including buddy statements, attesting to his long history of numbness in his left hand that he asserts began in 1978. He received no further treatment until he was seen in 2013 for an evaluation. In 2014, the Veteran had a nerve conduction velocity test (NVC)/ electromyogram (EMG) which was positive for peripheral neuropathy, carpal tunnel syndrome, and ulnar nerve entrapment. The Veteran received a VA examination for peripheral nerve conditions in December 2017. The examiner opined it was less likely as not the Veteran’s left upper extremity neurological disability was incurred in, related to, or caused by any incident of the Veteran’s service, including conceded exposure to herbicides. The examiner stated the current condition was secondary to the nerves being physically compressed or entrapped at various “tunnel” regions, where they may be predisposed or vulnerable to compression. Although acute and subacute peripheral neuropathy are eligible for presumptive service connection due to herbicide agent exposure, here the presumption is rebutted by the fact that the Veteran did not report any symptoms in service, there is no other evidence to establish peripheral neuropathy within one year following service discharge, and a NVC/EMG conducted 35 years after the exposure showed the Veteran had peripheral neuropathy, carpal tunnel syndrome, and ulnar nerve entrapment. Additionally, the VA examiner opined the Veteran’s left upper extremity neurological disability was caused by the nerves being physically compressed or entrapped at various “tunnel” regions and there is no medical evidence to the contrary. Thus, the Veteran's neurological disability involving his left upper extremity does not meet the criteria for presumed service connection for acute and subacute peripheral neuropathy. The Board has considered the Veteran’s assertions that his current left upper extremity neurological disability is related to service; however, neurological disabilities, such as peripheral neuropathy, require specialized training for determinations as to diagnosis and causation, and is therefore, not susceptible to lay opinions on etiology. The origin or cause of the Veteran's left upper extremity neurological disability is not a simple question that can be determined based on personal observation by a lay person. Therefore, the Veteran's lay assertion is not competent to establish a nexus. Jandreau v. Nicholson, 492 F.3d at 1376-77; see also Davidson v. Shinseki, 581 F.3d at 1316 (Fed. Cir. 2009). In sum, the Board concludes that the preponderance of the evidence of record is against the Veteran's claim for service connection for a left upper extremity neurological disability. The benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107 (b) is not applicable, as there is no approximate balance of evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 7. Entitlement to service connection for right upper extremity neurological disability (claimed as peripheral neuropathy) The Veteran contends that he has a current right upper extremity neurological disability that is related to service, to include exposure to herbicides. According to the record, the Veteran has submitted personal statements, including buddy statements, attesting to his long history of numbness in his right hand that he asserts began in 1978. He received no further treatment until he was seen in 2013 for an evaluation. In 2014, the Veteran had a nerve conduction velocity test (NVC)/ electromyogram (EMG) which was positive for peripheral neuropathy, carpal tunnel syndrome, and ulnar nerve entrapment. The Veteran received a VA examination for peripheral nerve conditions in December 2017. The examiner opined it was less likely as not the Veteran’s right upper extremity neurological disability was incurred in, related to, or caused by any incident of the Veteran’s service, including conceded exposure to herbicides. The examiner stated the current condition was secondary to the nerves being physically compressed or entrapped at various “tunnel” regions, where they may be predisposed or vulnerable to compression. Although acute and subacute peripheral neuropathy are eligible for presumptive service connection due to herbicide agent exposure, here the presumption is rebutted by the fact that the Veteran did not report any symptoms in service, there is no other evidence to establish peripheral neuropathy within one year following service discharge, and a NVC/EMG conducted 35 years after the exposure showed the Veteran had peripheral neuropathy, carpal tunnel syndrome, and ulnar nerve entrapment. Additionally, the VA examiner opined the Veteran’s right upper extremity neurological disability was caused by the nerves being physically compressed or entrapped at various “tunnel” regions and there is no medical evidence to the contrary. Thus, the Veteran's neurological disability involving his right upper extremity does not meet the criteria for presumed service connection for acute and subacute peripheral neuropathy. The Board has considered the Veteran’s assertions that his current right upper extremity neurological disability is related to service; however, neurological disabilities, such as peripheral neuropathy, require specialized training for determinations as to diagnosis and causation, and is therefore, not susceptible to lay opinions on etiology. The origin or cause of the Veteran's right upper extremity neurological disability is not a simple question that can be determined based on personal observation by a lay person. Therefore, the Veteran's lay assertion is not competent to establish a nexus. Jandreau v. Nicholson, 492 F.3d at 1376-77; see also Davidson v. Shinseki, 581 F.3d at 1316 (Fed. Cir. 2009). In sum, the Board concludes that the preponderance of the evidence of record is against the Veteran's claim for service connection for a right upper extremity neurological disability. The benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107 (b) is not applicable, as there is no approximate balance of evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 8. Entitlement to service connection for a disability manifested by memory loss The Veteran is seeking service connection for memory loss as a condition separate and distinct from his already service-connected PTSD disability. The Veteran’s PTSD disability is rated under 38 C.F.R. § 4.130, DC 9411, which contemplates memory loss and impairment. There is no evidence of any condition in service causing memory loss, and there is no evidence of a separate cognitive disorder associated with memory loss currently. The Veteran was afforded VA PTSD examinations in January 2011, July 2015, and December 2017. At the January 2011 VA examination, the Veteran report some short-term memory loss that the examiner determined appeared to be age-related. During the July 2015 examination, the Veteran reported mild memory loss such as forgetting names, directions, or recent events. The December 2017 VA examiner noted the Veteran’s memory appeared grossly intact with no evidence of any significant cognitive dysfunction or severe memory impairment. The examiner stated there is no diagnosis related to any disability manifested by memory loss. The examiner went on to state that memory loss is not a symptom of PTSD and that while PTSD can impact concentration in some individuals as related to the sometimes high-anxiety, this is not at all the same as a separate memory or cognitive disorder. The examiner pointed out that neither the Veteran’s VA or private treatment notes mention cognitive dysfunction or memory impairment complaints. Additionally, the Veteran appeared to believe that his current memory problems were age-related stating that he couldn’t remember things as well as he could when he was younger. The examiner found, and there is no evidence to the contrary, that the Veteran’s mild memory loss is likely age-related. Additionally, the Veteran does not have a diagnosis of a current chronic diagnosed disability affecting memory or indicating a cognitive impairment. Thus, the Board finds that service connection for memory loss is not warranted. As the Veteran's symptoms of memory loss have not been attributed to a separate memory or cognitive dysfunction, no further discussion of service connection for memory loss is warranted. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2018). The Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). The Veteran's entire history is reviewed when making disability ratings. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Staged ratings are also appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). 9. Entitlement to an extraschedular rating for service-connected tinnitus disability The Veteran claims entitlement to a disability evaluation, on an extraschedular basis, in excess of 10 percent for tinnitus. Tinnitus is defined as "a noise in the ears such as ringing, buzzing, roaring, or clicking." Smith v. Principi, 17 Vet. App. 168, 170 (2003) (quoting Dorland's Illustrated Medical Dictionary 1714 (28th ed. 1994)). Tinnitus is a type of disorder capable of lay observation and description. Charles v. Principi, 16 Vet. App. 370, 374 (2002). Tinnitus is evaluated under Diagnostic Code 6260 under which a single 10 percent evaluation is assigned for "recurrent" tinnitus, whether the sound is perceived as being in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note (2) (2017). A 10 percent rating is the maximum schedular rating permitted under Diagnostic Code 6260. In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321 is a three-step, or element, inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. The Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Id. In March 2018 the AOJ, per an August 2017 Board remand, requested an extraschedular memorandum from the Director of Compensation Services for a determination on the Veteran’s claim for an increased rating in excess of 10 percent for tinnitus. In an April 2018 memorandum after review of the entire record, the Director found that the Veteran has a high school education with two years of college and last worked in 2009 as a construction worker. The Veteran reported he had to stop working due to his depression and numbness and cramping in his hands and feet. Based on the evidence in the claims file, the Director determined that there was no sufficient evidence to demonstrate that the Veteran has had an exceptional or unusual disability picture presented with such related factors as marked interference with employment or frequent periods of hospitalization that renders application of regular rating schedular standards impractical due solely to his service-connected tinnitus disability. The Director noted that a September 2012 VA tinnitus examination reflects the Veteran had subjective complaints of constant tinnitus in both ears daily, but there was no evidence of frequent hospitalizations, emergency room visits, or surgical procedures performed due to this condition. Lastly, the Director stated the objective findings for all VA examinations are consistent with the current evaluation. In sum, consideration for an increased rating for service-connected tinnitus on an extraschedular basis was denied. Accordingly, the assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321 (b) is not warranted. 10. Entitlement to a disability rating in excess of 30%, prior to July 22, 2015 for posttraumatic stress disorder PTSD is rated using the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9413 (2018). A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of the inability to perform his or her 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). A 50 percent rating is warranted 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for 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 ideations; 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 the veteran’s personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for 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 the activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411, General Rating Formula for Mental Disorders (2018). Treatment records and psychological assessments prior to July 22, 2015 reflect that to varying degrees, the Veteran exhibited symptoms that more nearly approximate those warranting a 30 percent disability rating. A January 2011 PTSD examination reflects that the Veteran reported difficulty staying asleep, some panic attacks but less than one a week, anxiety, mild depression, hypervigilance, some short-term memory loss that appears to be age-related, and some feeling of detachment from family and friends. The Veteran also reported some obsessive behavior in washing his hands 25-50 times a day but stated it does not interfere with his functional abilities. He stated that he was able to work without difficulty before retirement. The Veteran had no impairment of thought process or communication, delusions or hallucinations, and denied suicidal or homicidal thoughts. The Veteran is also able to maintain activities of daily living and personal hygiene. Socially, the Veteran reported good relationships with his daughter and son as well as his three grandchildren, and has some friends that he goes to car shows with on an irregular basis. After a review of the evidence for this period, including lay testimony, the Board finds that the probative medical and lay evidence of record shows that the frequency, duration, and severity of the Veteran's psychiatric symptoms demonstrate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of the inability to perform his or her occupational tasks. Specifically, focusing on the social and occupational impairment resulting from the Veteran’s PTSD symptoms prior to July 22, 2015, his disability more nearly approximates a 30 percent disability rating. Accordingly, the Board finds that the evidence supports the assignment of a 30 percent rating, but not higher, for the Veteran’s PTSD disability from July 22, 2015. The Board finds that the preponderance of the evidence is against the assignment of a higher rating during this time period. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 11. Entitlement to a disability rating in excess of 50 percent from July 22, 2015 for posttraumatic stress disorder At his July 2015 VA PTSD examination, the Veteran reported that he had symptoms of depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, mild memory loss such as forgetting names, directions or recent events, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a worklike setting. Other symptoms included avoidance of loud noises or crowded places, an occasional sense of a foreshortened future, trouble with concentration, and at times he was quick to anger but without any physical violence or aggression. The Veteran had no impairment of thought process or communication, delusions or hallucinations, and denied suicidal or homicidal thoughts. The Veteran is also able to maintain activities of daily living and personal hygiene. A December 2017 VA PTSD examination notes that the Veteran’s memory appeared grossly intact and there was no evidence of any significant cognitive dysfunction or severe memory impairment. Anxiety was reported as a symptom of his PTSD disability. After a review of the evidence for this period, including lay testimony, the Board finds that the probative medical and lay evidence of record shows that the frequency, duration, and severity of the Veteran's psychiatric symptoms demonstrate occupational and social impairment with reduced reliability and productivity. Specifically, focusing on the social and occupational impairment resulting from the Veteran’s PTSD symptoms from July 22, 2015, his disability more nearly approximates a 50 percent disability rating. Specifically, nearly all of the Veteran’s PTSD symptoms during this time period more nearly approximate those warranting a 50 percent disability rating. The Board acknowledges the Veteran is noted to have difficulty in adapting to stressful circumstances, including work or a worklike setting, a symptom in the 70 percent rating criteria. However, the Veteran has stated that he had no problems with his PTSD disability at work prior to his retirement. Additionally, the evidence does not show that the psychiatric symptomatology resulted in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. Specifically, the Veteran has no evidence of suicidal ideations; 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; spatial disorientation; neglect of the veteran’s personal appearance and hygiene; or an inability to establish and maintain effective relationships. Accordingly, the Board finds that the evidence supports the assignment of a 50 percent rating, but not higher, for the Veteran’s PTSD disability from July 22, 2015. The Board finds that the preponderance of the evidence is against the assignment of a higher rating during this time period. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities is remanded. Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review of the TDIU issue. The Veteran contends that his service-connected disabilities precluded him from obtaining and maintaining substantially gainful employment. While an opinion has been rendered on the Veteran’s claim for entitlement to TDIU for some of the Veteran’s service-connected disabilities, since then the Veteran has been service connected for left lower extremity peripheral neuropathy, right lower peripheral neuropathy, right and left ear hearing loss, and coronary artery disease. According to the evidence of record, a September 2016 addendum TDIU opinion only discusses the functional effects of the Veteran’s PTSD relative to the Veteran’s ability to secure or follow substantially gainful employment. Accordingly, the Board finds a remand is necessary for comment on functional impairment due to all of the Veteran’s service-connected disabilities. The matter is REMANDED for the following action: 1. Obtain and associate any outstanding VA or private treatment records pertinent to the claims on appeal. (Continued on the next page)   2. Thereafter, the AOJ should submit the claims file to an appropriate examiner for the purpose of commenting on the functional effects of all of the Veteran’s service-connected disabilities, relative to the Veteran’s ability to secure or follow substantially gainful employment. The claims folder should be made available for review in connection with this examination. The examiner should provide a complete rationale for all conclusions reached. Nonservice-connected disability and age should be neither considered nor discussed. THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Mitchell, Associate Counsel