Citation Nr: 18151037 Decision Date: 11/19/18 Archive Date: 11/16/18 DOCKET NO. 11-01 722 DATE: November 19, 2018 ORDER Prior to August 31, 2012, a rating in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD) is denied. From August 31, 2012 to March 19, 2015, a rating in excess of 70 percent for service-connected PTSD is denied. New and material evidence has not been presented to reopen the previously denied claim of entitlement to service connection for bilateral hearing loss; therefore, the appeal is denied. New and material evidence has not been presented to reopen the previously denied claim of entitlement to service connection for chronic fatigue; therefore, the appeal is denied. New and material evidence has not been presented to reopen the previously denied claim of entitlement to service connection for chest pain; therefore, the appeal is denied. New and material evidence has not been presented to reopen the claim of entitlement to service connection for right middle finger joint pain; therefore, the appeal is denied. New and material evidence has not been presented to reopen the claim of entitlement to service connection for shortness of breath; therefore, the appeal is denied. New and material evidence has not been presented to reopen the claim of entitlement to service connection for right eye twitches; therefore, the appeal is denied. New and material evidence having been received, the claim of entitlement to service connection for a neck disability is reopened; and to that extent only, the appeal is granted. New and material evidence having been received, the claim of entitlement to service connection for a back disability is reopened; and to that extent only, the appeal is granted. New and material evidence having been received, the claim of entitlement to service connection for left knee osteoarthritis (claimed as arthritis) is reopened; and to that extent only, the appeal is granted. New and material evidence having been received, the claim of entitlement to service connection for tinnitus is reopened; and to that extent only, the appeal is granted. Service connection for tinnitus is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for left knee osteoarthritis (claimed as arthritis) is remanded. FINDINGS OF FACT 1. Prior to August 31, 2012, the Veteran’s service-connected PTSD was, at its worst, manifested by symptoms and a disability picture that most closely approximated occupational and social impairment with reduced reliability and productivity. 2. From August 31, 2012 to March 19, 2015, was at its worst, manifested by symptoms and a disability picture that most closely approximated occupational and social impairment with deficiencies in most areas. 3. An unappealed November 2006 rating decision denied entitlement to service connection for bilateral hearing loss, chronic fatigue, chest pain, right middle finger joint pain, shortness of breath, right eye twitches, a neck disability, a back disability, and left knee osteoarthritis (claimed as arthritis). 4. Regarding the Veteran’s petition to reopen the claims of entitlement to service connection for bilateral hearing loss, for a chronic disability manifested by fatigue, or for chronic disabilities manifested by chest pain, right middle finger joint pain, shortness of breath, or right eye twitches, the evidence associated with the record subsequent to the November 2006 rating decision is new; it is not material because it does not raise a reasonable possibility of substantiating those claims. 5. Regarding the Veteran’s petition to reopen the claims of entitlement to service connection for a neck disability, a back disability, left knee osteoarthritis (claimed as arthritis), and tinnitus, the evidence associated with the record subsequent to the November 2006 rating decision is new; it is also material because it raises a reasonable possibility of substantiating those claims. 6. The evidence of record is at least in equipoise as to whether the Veteran’s tinnitus had its onset in service. CONCLUSIONS OF LAW 1. Prior to August 31, 2012, the criteria for rating in excess of 50 percent for service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 2. From August 31, 2012 to March 19, 2015, the criteria for rating in excess of 70 percent (i.e., a 100 percent rating) for service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 3. The criteria for reopening a claim of entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. The criteria for reopening a claim of entitlement to service connection for a chronic disability manifested by fatigue have not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. The criteria for reopening a claim of entitlement to service connection for a chronic disability manifested by chest pain have not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 6. The criteria for reopening a claim of entitlement to service connection for a chronic disability manifested by right middle finger joint pain have not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 7. The criteria for reopening a claim of entitlement to service connection for a chronic disability manifested by shortness of breath have not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 8. The criteria for reopening a claim of entitlement to service connection for a chronic disability manifested by right eye twitches have not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 9. The criteria for reopening a claim of entitlement to service connection for a neck disability have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 10. The criteria for reopening a claim of entitlement to service connection for a back disability have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 11. The criteria for reopening a claim of entitlement to service connection for left knee osteoarthritis (claimed as arthritis) have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 12. The criteria for reopening a claim of entitlement to service connection for tinnitus have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 13. The criteria for granting service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 1131, 1154(a), 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1984 to June 1984, and from April 1985 to March 2001, with service in the Persian Gulf between November 1990 and May 1991. These matters come before the Board of Veterans’ Appeals (Board) on appeal from July 2010, May 2016, September 2016, and June 2018 rating decisions of the Department of Veterans Appeals regional office (RO) in Waco, Texas. In September 2014 and June 2017, the Board remanded the issues on appeal. The Board instructed the RO to determine whether there was clear and unmistakable error (CUE) in its November 2006 rating decision that granted service connection and assigned 30 percent rating for PTSD, effective March 10, 2005, and denied service connection for bilateral hearing loss, tinnitus, lower back pain, arthritis, right eye twitches, chest pain, right middle finger joint pain, neck pain and popping, chronic fatigue, and shortness of breath. In its June 2018 rating decision, the RO determined that the assigment of an initial 30 percent rating for service-connected PTSD was clearly and unmistakably erroneous. The RO then increased the initial rating of the Veteran’s PTSD from 30 percent to 50 percent, effective March 10, 2005, the date the Veteran filed his claim seeking service connection. The RO also determined that the denial of service connection for the other claimed disabilities was not clearly and unmistakably erroneous. The Veteran has not expressed any disagreement with the RO’s actions. As such, the Board finds that the issue of whether there was clear and unmistakable error in its November 2006 rating decision has been resolved and is no longer on appeal. The Board notes that, from January 20, 2015 to March 19, 2015, the Veteran was in receipt of a total disability rating based on individual unemployability (TDIU) due to his service-connected disabilities. Since March 19, 2015, the Veteran has been in receipt of a 100 percent combined disability rating and special monthly compensation under 38 U.S.C. § 1114(s) and 38 C.F.R. §3.350(i). The Board notes that the Veteran is seeking to reopen his claims of entitlement to service connection for “chronic joint pain” and “arthritis.” The Veteran is already being compensated for service-connected right shoulder pain with degenerative arthritis, bilateral knee pain resulting from Osgood-Schlatter’s disease, left ankle strain, and right great toe strain. In its November 2006 rating decision, the RO noted that, aside from his knees and ankle, the only joint in which the Veteran reported experiencing discomfort during service was his right middle finger which was shown to be an acute and transitory complaint during service. Additionally, the Board notes that left knee osteoarthritis was diagnosed during the appeal period, which was a separate and distinct diagnosis from the service-connected Osgood-Schlatter’s disease. For the sake of clarity, and in light of the disabilities for which the Veteran is already being compensated, the Board will consider the claim for “joint pain” as referring to right middle finger joint pain and the claim for “arthritis” as referring to left knee osteoarthritis. Neither the Veteran nor his representative has raised any issues with VA’s duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability demonstrates symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When adjudicating an increased rating claim, the relevant time period for consideration is one year before the claim was filed. Id. at 509. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Entitlement to (1) a rating in excess of 50 percent for service-connected PTSD, prior to August 31, 2012; and (2) to a rating in excess of 70 percent for service-connected PTSD from August 31, 2012 to March 19, 2015. The Veteran’s service-connected PTSD is currently rated as 50 percent disabling prior to August 31, 2012, and as 70 percent disabling from August 31, 2012 to March 19, 2015. These ratings are assigned under 38 C.F.R. § 4.130, Diagnostic Code 9411, which applies the General Rating Formula for Mental Disorders and provides, in pertinent part, the following criteria for evaluating PTSD: A 50 percent rating is warranted for symptoms resulting in 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted for symptoms resulting in 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 worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for symptoms resulting in 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 name. Id. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a veteran’s condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV and, effective August 4, 2014, the DSM-V (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) [DSM-IV] and (5th ed. 2013) [DSM-V]). Id. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5) has been officially released, and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, No. 16-1208, Slip opinion at 5 (Vet. App. Feb. 23, 2018), the Court of Appeals for Veterans Claims (Court) held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. The Court added that it does not hold that the Board commits prejudicial error every time the Board references GAF scores in a decision. This appeal was certified to the Board in October 2013 so it was pending before the Board on August 4, 2014. As such, the DSM-IV applies and the GAF scores, prior to August 4, 2014, will be noted, as appropriate since much of the relevant evidence in this case was obtained during the period that the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) was in effect. According to the DSM-IV, GAF is a scale reflecting the “psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.” There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF scores assigned in a case, like an examiner’s assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the 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). A GAF of 61-70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social occupational or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well with some meaningful interpersonal relationships. A GAF of 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF of 41-50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 31-40 indicates some impairment in reality testing or communication (e.g. speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g. depressed man avoids friends, neglects family, and is unable to work). A GAF of 21-30 indicates behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g. sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g. stays in bed all day; no job, home, or friends). American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) (Fourth Edition). In March 2010, the Veteran filed a claim seeking a disability rating in excess of 30 percent for his service-connected PTSD. In its July 2010 rating decision, the RO increased the rating of the Veteran’s PTSD from 30 percent to 50 percent, effective March 25, 2010. Subsequently, in a May 2013 rating decision, the RO again increased the rating of the Veteran’s PTSD from 50 percent to 70 percent, effective August 31, 2012. In a September 2016 rating decision, the RO increased the rating of the Veteran’s PTSD from 70 percent to 100 percent, effective March 19, 2015. In a June 2018 rating decision, the RO found that the original assignment of a 30 percent rating for PTSD in the November 2006 rating decision was clearly and unmistakably erroneous. The RO increased the initial rating from 30 percent to 50 percent effective March 10, 2005, the date the Veteran filed his claim seeking service connection. In its April 2015 rating decision, the RO granted a total disability rating for individual unemployability (TDIU) from January 20, 2015 to March 19, 2015. This is a full grant of benefits sought by the Veteran for his unemployability and will remain undisturbed herein. Additionally, the Board notes that the RO’s grant of the 100 percent rating for the Veteran’s service-connected PTSD, for the period from March 19, 2015 to the present, is considered fully satisfied and is no longer an issue before the Board for adjudication. For this reason, the Board will not disturb the 100 percent evaluation for PTSD from March 19, 2015 to the present. Therefore, the question before the Board is whether the Veteran is entitled to a disability rating in excess of 50 percent prior to August 31, 2012, and to a rating in excess of 70 percent from August 31, 2012 to March 19, 2015. Rating in excess of 50 percent prior to August 31, 2012 The Board has reviewed the evidence of record and finds that a rating in excess of 50 percent is not warranted for the appeal period prior to August 31, 2012. Specifically, to warrant the next higher 70 percent rating, the evidence would have to show that the Veteran’s psychiatric symptomatology and disability picture during this period were productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. On VA psychiatric examination in September 2006, the Veteran reported sleep impairment, with nightmares of his Iraq experiences, sleep-walking, and difficulty with both falling asleep and staying asleep. The Veteran reported that he often avoided closed spaces and fireworks. He endorsed intrusive memories, hypervigilance, and an exaggerated startle reflex. He denied being depressed. He indicated that he felt detached from others, had minimal social contact, and had no close friends. He reported that he was a truck driver by occupation, and that his leisure activities were solitary ones: reading, watching movies, and watching the news. He reported that he was irritable and angry most of the time. The examiner found no evidence of impaired impulse control. The Veteran appeared for the examination showing no impairment of personal hygiene, and he was oriented to time, place, and person. Thought processing and oral communication was normal. No evidence of memory impairment was observed. The Veteran denied having panic attacks. There was no evidence of delusions, hallucinations, suicidal/homicidal ideation or intent, or obsessive/ritualistic behavior. The Veteran was found to be competent to manage his own finances. A GAF score of 55 (for moderate impairment) was assigned. The May 2010 VA psychiatric examination shows that the Veteran experienced significant reduction in quality of life resulting from his PTSD, primarily in the form of severe sleep impairment, frequent nightmares and intrusive memories, and relationship difficulties. The examiner also found that the Veteran had reduced interest or enjoyment in recreational activities, also lowering his quality of life. The examiner found that the Veteran’s self-care abilities had been affected, his work functioning had been impaired more by his physical injuries, and he had lost driving jobs because of substance abuse. During the evaluation, the Veteran stated that he uses marijuana to reduce his pain, rather than to manage PTSD symptoms, and so occupational interference due to substance use would also be attributable more too physical injuries than to PTSD. The examiner also observed the following: PTSD has directly caused nightmares, intrusive memories, and significant sleep impairment (2-3 hours of sleep per night). PTSD has also caused him to avoid social situations he used to enjoy, as such situations make him anxious and uncomfortable, as he feels the need to monitor and be watchful. PTSD has also caused him to have increased irritability and anger outbursts, which have served to impair his social, family, and occupational relationships. His sleep disturbance causes excessive drowsiness and inattention during the day. Reexperiencing symptoms also have impaired work functioning somewhat, as intrusive memories have caused him distress while driving. Family functioning is impaired as a consequence of detachment and restricted range of affect, as well as increased irritability. He has started treatment relatively recently, and derives a modest degree of benefit from it. A primary focus should be on improving his sleep quality and duration and reducing nightmares. This is influenced by his chronic pain, which would disrupt his sleep if nightmares were not doing so. He will experience modest, gradual improvement with continued treatment. Overall, the examiner found that the Veteran did not demonstrate impairment of thought processes or communication, no delusions or hallucinations, no inappropriate behavior, no suicidal/homicidal ideation, and no memory loss or impairment. The examiner found that the Veteran was able to maintain his personal hygiene and basic activities of daily living. The examiner found that the Veteran did not demonstrate any obsessive or ritualistic behavior that interfered with his routine activities. The examiner found that the Veteran’s rate and flow of speech was normal and that he does not experience panic attacks. The examiner found that the Veteran was mildly to moderately depressed and that he had severe sleep impairment. The examiner assigned a GAF score of 55 (for moderate impairment). While the VA treatment record during this period show a fluctuation in the Veteran’s reported symptoms, these records do not demonstrate that the Veteran’s symptoms ever resulted in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In fact, medical records prior to August 31, 2012 do not show that the Veteran ever exhibited any of the following symptoms that would tend to demonstrate occupational and social impairment, with deficiencies in most areas: 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); or inability to establish and maintain effective relationships. Significantly, evidence of occupational and social impairment, with deficiencies in most areas, was not seen on evaluation until the August 31, 2012 VA psychiatric examination. The Board has carefully considered the evidence of record prior to August 31, 2012. However, the Board finds no basis upon which to grant a 70 percent disability rating during this period. The Board finds that the Veteran’s symptomatology and disability picture during this period most closely approximate the criteria for a 50 percent rating. Accordingly, a rating in excess of the previously assigned 50 percent rating prior to August 31, 2012 is not warranted. Rating in excess of 70 percent from August 31, 2012 to March 19, 2015 The Board has reviewed the evidence of record and finds that a rating in excess of 70 percent is not warranted for the appeal period from August 31, 2012 to March 19, 2015. To warrant the maximum 100 percent rating, the evidence would have to show that the Veteran’s psychiatric symptomatology and disability picture during this period would have to result in total occupational and social impairment. The August 2012 VA psychiatric examination shows that the Veteran’s service-connected PTSD was manifested by symptoms of depressed mood, anxiety, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. Based on a review of the evidence of record and a thorough evaluation of the Veteran, the VA examiner opined that the Veteran’s PTSD symptoms resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. A GAF score of 53 (for moderate impairment) was assigned. While the VA treatment record during this period show a fluctuation in the Veteran’s reported symptoms, these records do not demonstrate that the Veteran’s symptoms ever resulted in total occupational and social impairment. In fact, medical records from August 31, 2012 to March 19, 2015 do not show that the Veteran ever exhibited any of the following symptoms that would tend to demonstrate total occupational or social impairment: 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; or memory loss for names of close relatives, own occupation, or name. Significantly, evidence of total occupational and social impairment was not seen on evaluation until the March 19, 2015 VA psychiatric examination. Specifically, the March 2015 VA examiner found that the Veteran’s service-connected PTSD was manifested by depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, flattened affect, disturbances in motivation and mood, difficulty in adapting to stressful circumstances, including work or a worklike setting, and the inability to establish and maintain effective relationships. The examiner found these symptoms resulted in total occupational and social impairment. The Board has carefully considered the evidence of record from August 31, 2012 to March 19, 2015. However, the Board finds no basis upon which to grant a maximum 100 percent disability rating during this period. The Board finds that the Veteran’s symptomatology and disability picture during this period most closely approximate the criteria for a 70 percent rating. Accordingly, a rating in excess of the previously assigned 70 percent rating from August 31, 2012 to March 19, 2015 is not warranted. As a final matter, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). New and Material Evidence Generally, if a claim for service connection was previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108. “New” evidence is defined as existing evidence not previously submitted to agency decisionmakers. “Material” evidence means 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 previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court of Appeals for Veterans Claim (Court) has interpreted the language of 38 C.F.R. § 3.156(a) as creating a “low” threshold, and viewed the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). In its November 2006 rating decision, the RO denied the Veteran’s claims seeking entitlement to service connection for bilateral hearing loss, chest pain, right middle finger joint pain, shortness of breath, right eye twitches, neck pain and popping, lower back pain, arthritis, tinnitus, and chronic fatigue. Essentially, the RO determined that the Veteran did not have current diagnoses of these disabilities or chronic disabilities associated with the symptoms that he claimed to have experienced. The Veteran did not appeal the rating decision and it became final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156(b), 20.302, 20.1103. In March 2010, the Veteran submitted a request to reopen the previously denied claims. In a July 2010 rating decision, the RO denied the Veteran’s request and indicated that new and material evidence had not been received to reopen the claims. Again, the RO determined that the Veteran did not have current diagnoses of these disabilities or chronic disabilities associated with the symptoms that he claimed to have experienced. The Veteran timely appealed this determination. Despite the prior determination reached by the RO, the Board must find new and material evidence in order to establish its jurisdiction to review the merits of a previously denied claim. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Whether new and material evidence has been received to reopen the claims of entitlement to service connection for: (3) bilateral hearing loss; (4) chronic fatigue (5) chest pain; (6) right middle finger joint pain; (7) shortness of breath; (8) right eye twitches; (9) a neck disability; (10) a back disability; (11) left knee osteoarthritis (claimed as arthritis); and (12) tinnitus. Claims 3-8 Evidence received since the November 2006 rating decision includes VA treatment records, social security administration records, lay statements from the Veteran, and VA examination reports from April 2013 and June 2016. This evidence is “new” because it was not of record at the time of the prior final rating decision. However, this evidence is not material because it does not raise a reasonable possibility of substantiating the claim. Regarding the Veteran’s claimed bilateral hearing loss, the June 2016 VA examination report shows that the Veteran has normal hearing in both ears. See 38 C.F.R. § 3.385. While the Veteran may believe that he currently has bilateral hearing loss, it has not been shown that the Veteran has specialized training sufficient to diagnose a hearing loss disability or determine whether particular symptoms are the result of a bilateral hearing loss disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting that a veteran has general competence to testify as to symptoms but not to provide medical diagnosis). Specific criteria must be met for a diagnosis of bilateral hearing loss for VA purposes. The new evidence received since the November 2006 rating decision, including the June 2016 VA examination report, simply does not demonstrate that the Veteran has a current hearing loss disability. As the evidence does not raise a reasonable possibility of substantiating the claim, it cannot be reopened. Regarding the Veteran’s claimed chronic fatigue, the Board notes that the Veteran is currently being compensated for his service-connected sleep apnea, rated 50 percent disabling since July 14, 2016. Additionally, his chronic sleep impairment is being compensated as a symptom associated with his service-connected PTSD. Therefore, the issue before the Board is narrowly limited to whether the new evidence demonstrates that the Veteran has chronic fatigue syndrome or another chronic disability manifested by fatigue resulting from his military service. Unfortunately, the new evidence received since the November 2006 rating decision, which includes June 2016 VA chronic fatigue syndrome and Gulf War general medical examination reports, does not demonstrate that the Veteran has current diagnoses of either chronic fatigue syndrome or a chronic Gulf War-related illness manifested by fatigue. Moreover, the new evidence received since the November 2006 rating decision does not show that the Veteran was diagnosed with such disabilities at any time during the appeal period. As the evidence does not raise a reasonable possibility of substantiating the claim, it cannot be reopened. Regarding the other claimed disabilities – chest pain, right middle finger joint pain, shortness of breath, and right eye twitches – the Board finds that the new evidence received since the November 2006 rating decision does not demonstrate that the Veteran has been clinically diagnosed with any chronic disabilities manifested by symptoms of chest pain, right middle finger joint pain, shortness of breath, or right eye twitches at any point during the appeal period. Insofar as the Veteran has indicated that he has chest pain and right middle finger joint pain related to his military service, the Board notes that “pain” can be considered a disability under certain circumstances. In Saunders v. Wilkie, No. 2017-1466, 2018 U.S. App. LEXIS 8467 (Fed. Cir. Apr. 3, 2018), the United States Court of Appeals for the Federal Circuit (Federal Circuit) found that the term “disability” as used in 38 U.S.C. 1110 “refers to the functional impairment of earning capacity, not the underlying cause of said disability,” and held that “pain alone can serve as a functional impairment and therefore qualify as a disability.” In other words, where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. The Board finds that the facts of this appeal are distinguishable from those in Saunders because the new evidence does not show that any of the claimed “pain” disorders have caused a functional impairment that affects the Veteran’s earning capacity. As the evidence does not raise a reasonable possibility of substantiating these claims, the criteria for reopening these claims have not been met. Based on the foregoing, the Board finds that, while new evidence has been submitted in relation to the aforementioned claims, that evidence is not “material” as it does not raise a reasonable possibility of substantiating those claims. For the Board to reopen these claims, the evidence received since the November 2006 rating decision needed to demonstrate that the Veteran has current diagnoses of these disabilities or that he has chronic disabilities associated with the symptoms that he has described. As the Veteran has not fulfilled his threshold burden of submitting new and material evidence to reopen the finally disallowed claims for service connection for bilateral hearing loss or chronic disabilities manifested by fatigue, chest pain, right middle finger joint pain, shortness of breath, or right eye twitches, the benefit-of-the-doubt doctrine is not applicable to these claims and they will not be reopened at this time. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). Claims 9-12 Evidence received since the November 2006 rating decision includes VA treatment records, social security administration records, lay statements from the Veteran, and VA examination reports from April 2013 and June 2016. This evidence is “new” because it was not of record at the time of the prior final rating decision. Moreover, this evidence demonstrates that the Veteran has a current neck disability (degenerative arthritis of the cervical spine), a current back disability (degenerative arthritis of the thoracolumbar spine), and a current left knee joint osteoarthritis disability. See June 2016 VA neck, back, and knee examination reports. Moreover, the Veteran has also indicated that he was involved in a motor vehicle accident, fell while playing basketball, and was a parachutist with 15+ jumps while in the military. Id. This evidence suggests that a possible relationship exists between the Veteran’s current neck, back, and left knee disabilities and his military service. Accordingly, the Board finds that the new evidence is “material” as it raises a reasonable possibility of substantiating the neck, back, and left knee claims on appeal. See Shade, 24 Vet. App. at 110. Regarding the Veteran’s request to reopen the claim of entitlement to service connection for tinnitus, the Board observes that tinnitus is a disability that is capable of lay observation. The Veteran has indicated that he experiences bilateral intermittent tinnitus and that he has experienced this tinnitus for more than twenty years. This evidence suggests that a possible relationship exists between the Veteran’s current tinnitus and his military service. Accordingly, the Board finds that the new evidence is “material” as it raises a reasonable possibility of substantiating the tinnitus claim on appeal. Id. Thus, the Board finds that new and material evidence has been received to reopen the Veteran’s claims of entitlement to service connection for a neck disability, a back disability, left knee osteoarthritis, and tinnitus. These claims are reopened. The reopened claim of entitlement to service connection for tinnitus is addressed on the merits below. Additionally, while the record is sufficient to warrant reopening of the Veteran’s neck disability, back disability, and left knee osteoarthritis claims, it is not sufficient to allow the grant of the benefits sought for those claims. Once a claim is reopened, the statutory duty to assist is triggered. See 38 U.S.C. § 5103. For reasons explained in the Remand section below, additional development is necessary before these claims can be adjudicated on the merits. Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. (13) Entitlement to service connection for tinnitus. The Veteran contends that service connection is warranted for his tinnitus as the onset of tinnitus began during service. See June 2016 VA hearing loss and tinnitus examination report (the Veteran reported that he has experienced bilateral intermittent tinnitus for 20+ years). Here, the Veteran is competent to state that he currently has tinnitus and that his tinnitus had its onset in service as this is within his lay observation. See Charles v. Principi, 16 Vet. App. 370 (2002). His statements regarding onset of tinnitus in service are credible as they are consistent with the nature and circumstances of his service as a motor transport operator and his participation in combat operations in Iraq during Desert Storm. See DD Form 214; July 2016 deferred rating decision. The June 2016 VA examiner indicated that it is “less likely than not” that the Veteran’s tinnitus is caused by or a result of his in-service military noise exposure. The examiner explained that tinnitus is usually a symptom associated with high-frequency hearing loss but that the Veteran does not have bilateral hearing loss for VA purposes. However, considering the competent and credible statement regarding the onset of tinnitus in service, the Board finds that service connection for tinnitus is warranted. REASONS FOR REMAND (14) Entitlement to service connection for a neck disability; (15) Entitlement to service connection for a back disability; and (16) Entitlement to service connection for left knee osteoarthritis (claimed as arthritis). In a June 2016 medical opinion, the VA examiner opined that the Veteran’s neck, back, and knee disabilities were “less likely than not” incurred in or caused by his military service. The examiner observed that the mild degenerative changes of the cervical spine, thoracolumbar spine, and bilateral knees if related to parachute jumps during military service would prove to be more severe than what was seen on x-ray findings during the June 2016 VA examination. The examiner further opined that these degenerative changes were “most likely” a natural progression of the aging process. This medical opinion is inadequate because it does not explain why x-ray findings of degenerative changes would be more severe if these degenerative changes were related to parachute jumps during military service (i.e., the examiner did not discuss the impact of the jumps on the subsequent development of osteoarthritis). Similarly, the examiner did not indicate whether the impact from the parachute jumps had the same level of impact on the neck, back, and knees. Lastly, the examiner did not address the Veteran’s lay assertions that he fell during a basketball game during service or that he was involved in a motor vehicle accident and whether these incidents had any impact on the subsequent development in degenerative arthritis and/or osteoarthritis. Under these circumstances, the Veteran must be scheduled for appropriate VA examinations to ascertain the nature and etiology of his diagnosed neck, back, and left knee disabilities. In this regard, in light of the fact that the Veteran has already been found to be 100% disabled, the Veteran may wish, in consultation with his representative, to withdraw his remaining claims (in writing). These matters are REMANDED for the following actions: 1. Contact the Veteran and ask him to identify whether there are any outstanding VA or private medical records reflecting treatment for his claimed neck, back, and left knee disabilities. If such records are identified, then obtain those records and associate them with the electronic claims file. To expedite this action, the Veteran is encouraged to submit any additional VA or private medical records in his possession. 2. Schedule the Veteran for appropriate examinations by qualified physicians to determine the nature and etiology of his previously diagnosed cervical spine degenerative arthritis, thoracolumbar spine degenerative arthritis, and left knee osteoarthritis. After reviewing the electronic claims file, to include the service treatment records and the Veteran’s lay statements, the examiner(s) should provide medical opinions addressing the following: For those previously diagnosed disabilities, and any other disabilities diagnosed after thorough evaluation, the examiner should opine as to whether it is “at least as likely as not” that any such disabilities are related to any verified in-service injury, event, or disease, including the impact from 15+ parachute jumps, motor vehicle accident, and fall while playing basketball. Regarding left knee osteoarthritis, the examiner(s) must indicate whether this disability represents a progression of his Osgood-Schlatter’s disease or whether it represents a separate and distinct disability. The examiner must provide adequate supporting rationale for all medical conclusions reached, to include a discussion of the impact that any in-service traumas had on his current neck, back, and left knee disabilities. JOHN J. CROWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. L. Marcum, Counsel