Citation Nr: 18153357 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 17-00 112 DATE: November 27, 2018 ORDER New and material evidence has been received to reopen a claim of entitlement to service connection for residuals of gunshot wound to the left leg, and the claim is reopened. Entitlement to service connection for residuals of a gunshot wound on the left posterior thigh is granted. Entitlement to service connection for residuals of a right elbow fracture is granted. Entitlement to service connection for gout is denied. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is denied. Entitlement to service connection for a heart disorder, to include coronary artery disease and claimed as congestive heart failure, is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for diabetes mellitus is denied. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED The claim of entitlement to service connection for bilateral hearing loss is remanded. The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. The claim of entitlement to special monthly compensation based on the need for the regular aid and attendance of another person or housebound status is remanded. FINDINGS OF FACT 1. In May 1972 rating decision, the RO denied service connection for residuals of a bullet wound of the left leg. The Veteran was notified of the decision that same month and did not appeal or submit new and material evidence within the one-year period thereafter. 2. Evidence received since the May 1972 rating decision, by itself, or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the underlying claim of entitlement to service connection for residuals of a left leg bullet wound. 3. Residuals of a gunshot wound on the left posterior thigh are related to service. 4. Residuals of a right elbow fracture are related to service. 5. Gout did not manifest during active service and is not otherwise related to active service. 6. COPD did not manifest during active service and is not otherwise related to active service. 7. The most probative evidence weighs against a finding that the Veteran's heart disorder, to include coronary artery disease and claimed as congestive heart failure, had onset during active service, manifested within one year of service discharge, or is otherwise related to active service. 8. The most probative evidence weighs against a finding that the Veteran’s hypertension had onset during active service, manifested within one year of service discharge, or is otherwise related to active service. 9. The most probative evidence weighs against a finding that the Veteran’s diabetes mellitus, type 2, had onset during active service, manifested within one year of service discharge, or is otherwise related to active service. 10. The Veteran’s PTSD was manifested by occupational and social impairment with reduced reliability and productivity, and not deficiencies in most areas. CONCLUSIONS OF LAW 1. The May 1972 rating decision denying service connection for residuals of a bullet wound to the left leg is final. 38 U.S.C. § 7105 (c) (2012); 38 C.F.R. §§ 3.104, 3.156, 20.200, 20.201, 20.302, 20.1103 (2018). 2. The evidence received since the April 2015 rating decision is new and material as to the claim for service connection for residuals of a bullet wound to the left leg and the claim is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a) (2018). 3. The criteria for service connection for residuals of a gunshot wound on the left posterior thigh have been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018). 4. The criteria for service connection for residuals of a right elbow fracture are met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018). 5. The criteria for service connection for gout 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 COPD have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018). 7. The criteria for service connection for a heart disorder, claimed as congestive heart failure, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018). 8. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018). 9. The criteria for service connection for diabetes mellitus have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018). 10. The criteria for an initial disability rating in excess of 50 percent for service-connected PTSD are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code (DC) 9411 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1941 to November 1945. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from June 2014 and January 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran passed away in June 2015. The appellant is his surviving niece who was substituted as the claimant on the Veteran’s pending appeals as the person who bore the expense of last sickness and burial. 38 U.S.C. § 5121(a); 38 C.F.R. § 3.1000(a). Therefore, while the appeals have been titled as entitlement to benefits for accrued benefits purposes, the appellant is a valid substitute, and she has been substituted as the claimant for the purposes of all claims that were pending on the date of the Veteran’s death. Duties to Notify and Assist The appellant has not raised any issues with the 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 a duty to assist argument). The RO was notified by the National Personnel Record Center (NPRC) in August 2014 that the Veteran’s service treatment records (STRs) were “fire-related” and that the best available copies of all available requested documents were mailed. In situations where STRs are completely or partially unavailable, the Board has a heightened obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. O’Hare v. Derwinski, 1 Vet. App. 365 (1991). The legal standard is not lowered for proving a claim for service connection, but rather the Board’s obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the veteran is increased. Russo v. Brown, 9 Vet. App. 46 (1996). There is no presumption, either in favor of the claimant or against VA, arising from missing records. Cromer v. Nicholson, 19 Vet. App. 215 (2005). Next, the Board acknowledges that VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The RO did not provide the Veteran with an examination for his claims of service connection for gout, COPD, congestive heart failure, hypertension, and diabetes mellitus. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, and discussed further below, though the evidence demonstrates present disabilities during the claim period, in-service injuries, events, or diseases are not shown. Further, there is no indication that any of these claimed conditions are associated with the Veteran’s service. Accordingly, the Board finds that the VA’s duty to assist does not require examinations for the claims of entitlement to service connection for gout, COPD, congestive heart failure, hypertension, and diabetes mellitus New and Material Evidence In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. 38 U.S.C. §§ 7104, 7105 (2012); 38 C.F.R. §§ 3.104, 20.1100, 20.1103 (2018). A finally disallowed claim, however, may be reopened when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108 (2012). Regardless of the action taken by the RO, the Board must determine whether new and material evidence has been received subsequent to an unappealed RO denial. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). As part of this review, the Board considers evidence of record at the time of the previous final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim, and evidence submitted since a prior final disallowance. Evans v. Brown, 9 Vet. App. 273, 285-86 (1996). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (2018). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary’s duty to assist or consideration of a new theory of entitlement. Shade, 24 Vet. App. at 117-18. Additionally, new and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Furthermore, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed but were not associated with the claims file when VA first decided the claim, VA will reconsider the claim, rather than requiring new and material evidence. 38 C.F.R. § 3.156(c)(1). A claim is not reconsidered, however, where VA could not have obtained the records when it initially decided the claim because the records did not exist at that time, or because the claimant failed to provide sufficient information to identify and obtain the records from the respective service department, the Joint Services Records Research Center, or any other official source. 38 C.F.R. § 3.156(c)(2). To establish service connection, 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 - the so-called nexus requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). In a May 1972 rating decision, the RO denied service connection for residuals of a bullet wound to the left leg because it found no evidence of an in-service incurrence. The Veteran did not appeal that decision nor submit new and material evidence within one year. The rating decision is thus final based on the evidence then of record. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Evidence of record at the time of the 1972 decision includes the Veteran’s service treatment records and his claim. The service treatment records documented that the Veteran underwent an appendectomy after suffering acute appendicitis, but no gunshot wound. Evidence submitted after the 1972 decision includes 1) the Veteran’s December 2013 claim; 2) a December 2014 VA examination and January 2015 VA opinion; and 3) associated statements from the Veteran. In pertinent part, the VA opinion explains why the Veteran’s STRs may have excluded mention of a gunshot wound, and provide a favorable etiological opinion. The Board finds that new and material evidence has been presented. The evidence is new because it was not previously submitted to VA. The evidence is material because it relates to unestablished facts necessary to establish the claim - evidence of a nexus and an in-service incurrence. See 38 C.F.R. § 3.303(a); Shedden, 381 F.3d at 1167. Additionally, the evidence is neither cumulative nor redundant as that evidence was not of record at the time of the prior denial. See 38 C.F.R. § 3.156(a). Further, new evidence is to be presumed credible for purposes of deciding whether a previously denied claim may be reopened. Justus, 3 Vet. App. at 513. Moreover, when considering the new evidence in conjunction with the evidence already of record, combined with VA assistance including an examination, it raises a reasonable possibility of substantiating the claim. Shade, 24 Vet. App. at 117. Accordingly, for all of the above reasons, the Veteran’s claim is reopened. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (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 - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2018). In addition, service connection for certain chronic diseases, including coronary artery disease, diabetes, and hypertension, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2018); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309 (2017); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Entitlement to service connection for a right arm disorder and residuals of a gunshot wound to the left leg. The appellant alleges that the Veteran had right arm and left leg disorders that began during service and existed since that time. In a December 2013 statement, the Veteran reported that he sustained a gunshot wound in the left leg during service while in combat in the Philippines. In reaction to being struck in the leg, he indicates that he struck a tree with his right arm, sustaining an injury there. Over the course of his medical treatment for these conditions, he underwent an appendectomy after suffering form appendicitis. First, the Board finds that there are current disabilities. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). In December 2014 VA provided an examination that documented residual complications of a gunshot wound to the Veteran’s left posterior thigh. A posterior thigh scar was noted. At the same examination, X-rays of the right forearm showed a healed right radial head neck junction fracture and an ulnar styloid spur. Contemporaneous radiographs of the right elbow showed the same finding and a possible fracture through the distal humerus. The interpreting provider reached an impression of right radial head neck fracture, healed, and degenerative changes of the humeral olecranon junction. Other radiographs of the humerus showed degenerative changes without definite fracture lines or distortion of the humerus. Second, the Board finds that there was an in-service event, injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran’s STRs do not document injuries to his left leg and right arm. However, as noted by a VA examiner in a January 2015 opinion, the Veteran had reported that he had suffered from appendicitis after sustaining his injuries to his left leg and right arm. The examiner found the Veteran’s account to be plausible in that he stated he was sent to a hospital for care of both a gunshot wound and elbow fracture and that, at the end of his recuperation, he developed the acute appendicitis. The examiner noted that there were no notes form the appendectomy, just a transfer note to a more distant military hospital for further recuperation. If the leg and arm wounds were essentially resolved, they could have easily been overlooked. This explanation of the STRs not documenting any injuries holds merit. Further, the Veteran served in combat. See DD 214. The Veteran’s lay statements are accepted as sufficient proof of his in-service injuries, notwithstanding the fact that there was no official record of such incurrence in service, because the Veteran’s account is consistent with the circumstances, conditions, or hardships of his service. Accordingly, resolution of reasonable doubt in the Veteran’s favor is proper in the instant matter and the in-service events are conceded. Third, the Board finds that the evidence of record does support a finding that the Veteran’s right elbow and left hip disorders are related to active service. As noted above, a VA examination was provided in December 2014. In a January 2015 opinion, after accounting for the absence of STRs documenting the Veteran’s injuries, the examiner opined that the Veteran’s right elbow fracture, or residuals thereof, were sustained as he reported. Similarly, the examiner opined that it was at least as likely as not that the Veteran’s gunshot wound to the left posterior thigh was sustained as he reported. As all three elements are met for the Veteran’s left thigh and right elbow disorders, service connection is warranted. Entitlement to service connection for gout, COPD, a heart disorder, hypertension, and diabetes mellitus. The Board condenses the analyses for the claims for service connection for gout, COPD, congestive heart failure, hypertension, and diabetes mellitus, for economy’s sake. The appellant continues the Veteran’s argument that his gout, COPD, congestive heart failure, hypertension, and diabetes mellitus are related to his service. See December 2013 First, the Board finds that there is a current disability shown for these conditions. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). See e.g. October 2005 private treatment records showing diabetes mellitus type 2, gout, hypertension, August 2014 VA primary care note showing diagnoses of diabetes mellitus, type 2, coronary artery disease and congestive heart failure, hypertension, and COPD. The primary cause of death listed on the Veteran’s June 2015 Certificate of Death is congestive heart failure. Present disabilities for the purposes of service connection are thus shown. Second, the Board finds that there were not an in-service event, injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). Neither the Veteran nor the appellant have advanced any specific contentions or theories of entitlement regarding the claims for service connection. The Veteran’s STRs do not show treatment for or diagnoses of diabetes, gout, hypertension, a heart disorder, or COPD. Accordingly, an in-service event, disease, or injury is not shown for the claims. Third, the Board finds that the evidence of record does not support a finding that the gout, COPD, congestive heart failure, hypertension, and diabetes mellitus are related to active service. As noted above, no examinations have been provided for the Veteran and the appellant’s claims. VA has not done so because there is no evidence indicating that gout, COPD, congestive heart failure, hypertension, and diabetes mellitus type 2 may be associated with his service in the 1940s. The available evidence indicates that these conditions were not present until many years after the Veteran’s service. The only evidence that purports to link the Veteran’s claimed disorders to service are his own statements and statements submitted by the appellant. To the extent the statements submitted assert that the Veteran’s gout, COPD, congestive heart failure, hypertension, and diabetes mellitus are etiologically related to service, these contentions are not competent lay evidence. Although it is error to categorically reject a lay person as competent to provide a diagnosis, not all such questions are subject to non-expert opinion. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Whether a layperson is competent to provide a medical opinion depends on the facts of the particular case. “Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (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, 1377 (Fed. Cir. 2007). Lay witnesses are competent to report that which they have observed with their own senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). But here, the etiology of gout, COPD, congestive heart failure, hypertension, and diabetes mellitus type 2, which is an internal medical process not capable of lay observation, is clearly distinguishable from ringing in the ears, a broken leg, or varicose veins. See Jandreau, 492 F.3d at 1377; Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002). The statements therefore do not carry any probative value. Accordingly, absent any competent and probative evidence linking the Veteran’s disorders to his service, a nexus is not shown. Finally, the diagnoses of coronary artery disease, hypertension, diabetes mellitus, may be service-connected on presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 C.F.R. §§ 3.307, 3.309(a) (2018). However, the evidence does not demonstrate these conditions within one year of the Veteran’s discharge in November 1945. Accordingly, service connection is denied on a presumptive basis for the Veteran’s heart disorder, hypertension, and diabetes mellitus, type 2. Service connection is also denied on a direct basis for these conditions as well as for gout and COPD. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating for PTSD 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 (2017). 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 (2017). 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 (2017). 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 (2017). 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 (2017). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). 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). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). The Veteran’s PTSD was evaluated as 50 percent disabling under 38 C.F.R. § 4.130, DC 9411, effective June 16, 2014. Under this code, a 50 percent evaluation contemplates occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and 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 personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and the inability to establish and maintain effective relationships. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. However, the symptoms recited in the criteria in the rating schedule for evaluating mental disorders 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, 442 (2002). “[A] veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The symptoms shall have caused occupational and social impairment in most of the referenced areas. Vazquez-Claudio, 713 F.3d 112. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126. In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126. 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, this Court, or the U.S. Court of Appeals for the Federal Circuit 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 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. This appeal was certified to the Board after to August 4, 2014. As such, the DSM-IV applies and the GAF scores will not be noted. Prior to discussing the factual history, the Board notes that all psychiatric symptoms identified during the claim and appeal period will be considered as part of the service-connected PTSD. A May 2014 VA examination diagnosed adjustment disorder with mixed anxiety and depressed mood, and not PTSD. That diagnosis was later changed to PTSD in a subsequent VA examination. To the extent symptoms may have been attributed to a disorder other than PTSD, there is not sufficient evidence of record to delineate which symptom belongs to which disorder. As such, the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Accordingly, reasonable doubt will be resolved in the Veteran and the appellant’s favor and all psychiatric symptoms will be attributed to PTSD. Factual History VA provided two examinations for the Veteran’s psychiatric disorder prior to his death. On VA examination in May 2014, the examiner found that the Veteran’s psychiatric disorder resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran denied every seeking mental health treatment. However, over the last year he had developed anxiety, depression, and irritability of mild to moderate intensity. He also reported having difficulty sleeping and a history of having bad memories of combat-related traumatic situations. He had not experienced recent difficulties with this symptom, however. Symptoms identified included depressed mood, anxiety, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, and impaired impulse control, such as unprovoked irritability with periods of violence. At the second examination conducted in December 2014, a VA examiner diagnosed PTSD and found that the disorder resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner indicated that the Veteran’s PTSD resulted in anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a worklike setting. In his April 2015 Notice of Disagreement, the Veteran asserted that the severity of his psychiatric symptoms warranted a total disability rating. He reported that his depression was so severe he cried much of the time, affecting the quality of his life and his ability to function on the job. He also reported that he did not possess enough concentration to focus on any job requiring multiple steps or tasks. Finally, he reported high levels of stress that would cause stress and yelling. He reported not being able to hold it in and lashing out verbally or crying. Analysis The Board finds that an initial rating in excess of 50 percent is not warranted. The Veteran’s PTSD was manifested by depressed mood, anxiety, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, impaired impulse control, such as unprovoked irritability with periods of violence, and difficulty in adapting to stressful circumstances, including work or a worklike setting. Only one of those symptoms, the impaired impulse control, is specifically contemplated by the rating criteria for a 70 percent evaluation for PTSD. However, while the May 2014 VA examiner identified this symptom, the evidence does not demonstrate periods of violence. In the April 2015 Notice of Disagreement, the Veteran reported lashing out verbally or crying as a result of his inability to cope with stress. This does not approximate impaired impulse control, such as unprovoked irritability with periods of violence. The other symptoms fall squarely within the rating criteria for a 50 percent evaluation under DC 9411. More significant, both VA examiners from the May and December 2014 examinations found that the Veteran’s psychiatric symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. This finding actually supports a rating of 30 percent under DC 9411, not a 50 percent evaluation. 38 C.F.R. § 4.130, DC 9411. That is, the VA examiners found that the level of psychiatric impairment more closely approximated a 30 percent evaluation by their findings, not a 70 percent evaluation. The May 2014 VA examiner indicated that the Veteran could socially function as well as he could within the parameters of his physical limitations. The examiner found no more than mild to moderate impairment in psychosocial functioning. In short, the Board finds that there is not such an approximate balance of the positive evidence and the negative evidence to permit a more favorable determination. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The evidence does not support the award of a higher rating for the Veteran’s service-connected PTSD. REASONS FOR REMAND 1. Entitlement to service connection for bilateral hearing Remand is required for an adequate opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for a hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service (as opposed to intercurrent causes). Hensley v. Brown, 5 Vet. App. 155, 157 (1993). VA provided an examination that showed bilateral hearing loss in May 2014. The examiner opined that it was less likely than not that the Veteran’s hearing loss was caused by or a result of an event in military service. The examiner explained that the Veteran’s hearing was normal at separation from military service, though the Veteran’s STRs had not been reviewed. The examiner opined that the Veteran’s hearing loss was most likely related to presbycusis, or hearing loss with aging. This opinion is inadequate. It focuses on post-service age related hearing loss but does not address the possibility that bilateral hearing loss could have had onset after service but nonetheless as a result of service. Remand is thus warranted for an adequate opinion. 2. Entitlement to TDIU and SMC As the Veteran’s service-connected disability picture is unresolved, the claims for SMC based on the need for aid and attendance or housebound status and TDIU are inextricably intertwined with the service connection claim remanded herein. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). Thus, adjudication of these issues must be deferred until after completion of the actions requested below. The matter is REMANDED for the following action: 1. Obtain an addendum opinion regarding the etiology of the Veteran’s bilateral hearing loss from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral hearing loss had onset in, or was otherwise related to, active service, to include acoustic trauma sustained therein. The examiner is reminded that VA law and regulation does not preclude service connection for post-service hearing loss where hearing was within normal limits at the time of separation from service. It is requested that the examiner record a detailed history of in-service and post-service noise exposure, to the extent this is possible. 2. After the requested development has been completed, together with any additional development as may become necessary, readjudicate the Appellant’s claims. If the benefits sought on appeal remain denied, issue the Appellant a supplemental statement of the case and give an opportunity to respond thereto. The Appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C. §§ 5109B, 7112. K. A. KENNERLY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Steve Ginski, Associate Counsel