Citation Nr: 18154863 Decision Date: 11/30/18 Archive Date: 11/30/18 DOCKET NO. 16-03 508 DATE: November 30, 2018 ORDER New and material evidence having been received, the claim of entitlement to service connection for high blood pressure is reopened. To that extent only, the appeal is granted. New and material evidence having been received, the claim of entitlement to service connection for diabetes mellitus is reopened. To that extent only, the appeal is granted. The claim of entitlement to a disability rating in excess of 30 percent, prior to August 28, 2015, and in excess of 50 percent thereafter, for other specified trauma and stressor-related disorder (previously posttraumatic stress disorder (PTSD) and depression) (hereinafter a “psychiatric disorder”), is denied. The claim of entitlement to a disability rating in excess of 10 percent for gastroesophageal reflux disorder (GERD) is denied. REMANDED The claim of entitlement to service connection for high blood pressure is remanded. The claim of entitlement to service connection for diabetes mellitus is remanded. The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is also remanded for additional development. FINDINGS OF FACT 1. On July 27, 2017, the Veteran passed away. Prior to his death, the Veteran had pending claims for entitlement to an increased rating for his service-connected psychiatric disorder and service-connected GERD disability. He also had pending claims as to whether new and material evidence had been received to reopen previously denied claims of entitlement to service connection for high blood pressure and diabetes mellitus. 2. In September 2017, the Appellant, the Veteran’s surviving mother, filed a request for substitution of the Veteran’s pending claims. 3. In September 2018, the Appellant’s substitution request was granted and she was recognized as valid substitute for the Veteran. 4. A March 2014 rating decision, denied the Veteran’s petition to reopen the previously denied claim entitlement to service connection for high blood pressure, and also denied entitlement to service connection for diabetes mellitus. The Veteran did not appeal these denials, and no new and material evidence was submitted within the appeal period as to these issues; thus, the decision became final. 5. The evidence received since the final March 2014 rating decision is not cumulative or redundant of the evidence of record, does relate to unestablished facts, and does raise a reasonable possibility of substantiating the Veteran’s claims of entitlement to service connection for high blood pressure and diabetes mellitus. 6. Prior to August 28, 2015, the Veteran’s psychiatric disorder was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). 7. From August 28, 2015, the Veteran’s psychiatric disorder was productive of occupational and social impairment with reduced reliability and productivity. 8. The Veteran’s GERD is not manifested by a combination of symptoms productive of considerable or severe impairment of health. CONCLUSIONS OF LAW 1. The March 2014 rating decision, which denied Veteran’s petition to reopen the previously denied claim entitlement to service connection for high blood pressure and denied entitlement to service connection for diabetes mellitus, is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence has been received; the claims of entitlement to service connection for high blood pressure and diabetes mellitus are reopened. 38 U.S.C. §§ 5107, 5108, 7105; 38 C.F.R. § 3.156. 3. Prior to August 28, 2015, the criteria for a rating in excess of 30 percent for a psychiatric disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.126, 4.130, Diagnostic Code 9411. 4. From August 28, 2015, the criteria for a rating in excess of 50 percent for a psychiatric disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.126, 4.130, Diagnostic Code 9411. 5. The criteria for a rating in excess of 10 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.114, Diagnostic Code 7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters The Veteran had honorable active duty service with the United States Army from July 1987 to December 1992, including service in the Southwest Asia (SWA) Theater of operations during the Persian Gulf War. The Veteran passed away in July 2017. The Appellant in the present appeal is his surviving mother. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). By way of history, in August 2013, the Veteran filed an increased rating claim for both his service-connected psychiatric disorder and GERD disability. He also submitted a request to reopen his claim of entitlement to service connection for high blood pressure. Additionally, he filed a claim of entitlement to service connection for diabetes mellitus. In a March 2014 rating decision, the RO continued the 30 percent evaluation of the Veteran’s psychiatric disorder, continued its previous denial of the Veteran’s claim for high blood pressure, and denied entitlement to service connection for diabetes mellitus. The Veteran did not appeal this decision; thus, it became final. In June 2015, the RO issued another rating decision, continuing the 30 percent evaluation for the service-connected psychiatric disorder, as well as the previous denials of service connection for high blood pressure and diabetes mellitus. In addition, the RO continued the 10 percent evaluation for the Veteran’s GERD disability. In July 2015, the Veteran submitted a notice of disagreement (NOD), appealing all of the decisions issued in the June 2015 rating decision. In December 2015, during the pendency of the appeal, the RO issued a rating decision which increased the Veteran’s evaluation for his psychiatric disorder to 50 percent disabling, effective as of August 28, 2015. When a Veteran seeks an increased rating, it is generally presumed that the maximum benefit allowed is sought, and a claim remains in controversy where less than the maximum benefit is awarded. AB v. Brown, 6 Vet. App. 35 (1993). As such, the issue has been restated accordingly. In January 2017, the Veteran raised a claim for a TDIU in the context of the increased rating claim for his psychiatric disorder on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Accordingly, that issue has been added to the cover page. In September 2017, the Board dismissed the appeal due to the Veteran’s death. Thereafter, in September 2017, the Appellant filed a Request for Substitution of Claimant Upon Death of Claimant (VA Form 21-0847), and stated her wish to pursue the Veteran’s pending claims. In September 2018, the Appellant was accepted as a valid substitute claimant for the purposes of processing the Veteran’s appeal to completion. See 38 U.S.C. § 5121A (2012). Consequently, the Board has reactivated the appeal. New and Material Evidence Governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing and, after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. Rating actions from which an appeal is not timely perfected become final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. A final decision cannot be reopened unless new and material evidence is presented. 38 U.S.C. § 5108. The Secretary must reopen a finally disallowed claim when new and material evidence is presented or secured with respect to that claim. Knightly v. Brown, 6 Vet. App. 200 (1994). 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 it must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The United States Courts of Appeals for Veterans Claims (Court) has emphasized that the final sentence of 38 C.F.R. § 3.156(a), especially the phrase “raise[s] a reasonable possibility of substantiating the claim,” does not create a third element or separate determination in the reopening process, but is a component of the question of what is new and material evidence. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010) (noting that 38 U.S.C. § 5108 requires only new and material evidence to reopen). Shade further holds that 38 C.F.R. § 3.156 “suggests a standard that would require reopening if newly submitted evidence, combined with VA assistance and considering the other evidence of record, raises a reasonable possibility of substantiating the claim[.]” Id. Further, the Board should not focus solely on whether the evidence remedies the principal reason for denial in the last prior decision, and regulations do not require new and material evidence as to each previously unproven element of a claim. Id. Rather, the Board should focus on whether the evidence, taken together, could at least trigger the duty to assist by providing a medical opinion. Id. The Court has elaborated on what constitutes “new and material evidence.” New evidence is not that which is cumulative of other evidence already present in the record. In determining whether new and material evidence has been submitted, the Board must consider the specific reasons for the prior denial. Evans v. Brown, 9 Vet. App. 273, 283 (1996). See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. at 273. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Appellant seeks to reopen the Veteran’s claims of entitlement to service connection for high blood pressure and diabetes mellitus. As the analysis is similar, the issues will be discussed together. In a March 2014 rating decision, the RO continued its previous denial of the Veteran’s claim for high blood pressure, as no new and material evidence had been submitted in support of this claim. The RO also denied entitlement to service connection for diabetes mellitus, as the medical evidence did not show that the disability was related to service. The Veteran did not appeal this decision or submit additional evidence within one year. Thus, the March 2014 decision became final. See 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.156(b), 20.1103. The evidence associated with the claims file relating to high blood pressure and diabetes mellitus following the March 2014 rating decision includes VA treatment records, private treatment records, and medical records from the Social Security Administration (SSA). The Board finds that this evidence is new, as it was not previously of record, and tends to relate to a previously unestablished fact necessary to substantiate the underlying claims of service connection. Furthermore, this evidence is presumed credible for the purpose of reopening the claims. Consequently, the claims of entitlement to service connection for high blood pressure and diabetes mellitus are reopened. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. The Schedule is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When two evaluations are potentially applicable, VA will assign the higher evaluation when the disability more nearly approximates the criteria for the higher rating. 38 C.F.R. § 4.7. VA will resolve reasonable doubt as to the degree of disability in favor of the Veteran. 38 C.F.R. § 4.1. If the evidence for and against a claim is in equipoise, the claim will be granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. In accordance with 38 C.F.R. §§ 4.1, 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board finds that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disability. Each disability is viewed in relation to its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). The Board notes that where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. 38 C.F.R. §§ 4.1, 4.2 (2016); see also Francisco v. Brown, 7 Vet. App. 55 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), however, the Court held that “staged ratings” are 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 evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. Section 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA must consider all favorable lay evidence of record. 38 U.S.C. § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). The Veteran is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In this case, the Appellant seeks entitlement to increased ratings for the Veteran’s service-connected psychiatric disorder and GERD. Each issue will be discussed in turn. 1. Entitlement to a disability rating in excess of 30 percent, prior to August 28, 2015, and in excess of 50 percent thereafter, for a psychiatric disorder. Service connection for a psychiatric disorder was established by an April 2011 rating decision, at which time a 30 percent rating was assigned, effective February 8, 2011. The Veteran did not appeal this decision; rather, in August 2013, the Veteran filed a claim for an increased rating for his service-connected psychiatric disorder. Thus, the Veteran contended that he was entitled to an increased rating for his psychiatric disorder. The Veteran has been assigned the following staged ratings pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, for his psychiatric disorder during the period on appeal: a 30 percent disability rating for the period prior to August 28, 2015; and a 50 percent disability rating from August 28, 2015. This Diagnostic Code provides the General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the general formula, a 30 percent rating is warranted for occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as a depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, and recent events). Id. 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; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). See 38 C.F.R. § 4.130. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir. 2013), the Federal Circuit stated that “a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” It was further noted that “§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas.” The Board notes that VA implemented DSM-5, effective August 4, 2014, and the Secretary, VA, determined that DSM-5 applies to claims certified to the Board on and after August 4, 2014. 79 Fed. Reg. 45,093, 45, (Aug. 4. 2014). The RO certified the Veteran’s appeal to the Board in July 2016; hence; DSM-5 is for application in this claim. Nonetheless, with the adoption of the DSM-5, the general rating criteria remain the same, aside from no longer assigning a Global Assessment of Functioning (GAF) score. 38 C.F.R. § 4.126(d). After reviewing all the evidence, the Board finds that the overall social and occupational impairment caused by the Veteran’s psychiatric disorder prior to August 28, 2015, most nearly approximates the criteria for a 30 percent rating, and a 50 percent rating thereafter. A. Prior to August 28, 2015 VA records from August 2013 show that the Veteran reported some symptom improvement over the last few weeks, indicating that he had benefited from the last session where he was advised to let go of his wish that things were different and to simply accept things how they were. He indicated that this helped, as he was trying to make the best of things. He endorsed ongoing symptoms including depression, decreased energy and motivation, nightmares, and irritability. Upon mental status evaluation, the Veteran was alert and oriented, his speech was goal directed and normal in rate and rhythm, he strongly denied any suicidal or homicidal ideation, there was no evidence of hallucinations, and his insight, judgement, attention, and concentration were noted to be intact. An October 2013 VA outpatient treatment record shows that the Veteran underwent a mental status examination. The examiner noted that the Veteran’s mood/affect was euthymic and appropriately responsible. His speech was non-pressured and goal-directed. His language was grossly intact, and his associations were intact. His thought process was linear in form. He denied suicidal or homicidal ideation, and there was no evidence of psychosis. Both his insight and judgment were fair. He was fully-oriented. He was aware of current events and past history, and his vocabulary was consistent with average or better knowledge base. He had no apparent deficits with attention/concentration. His recent and remote memory were intact. VA treatment records from November 2013 note that the Veteran was planning a trip to Las Vegas and was in the process of jointing the Masons. He also reported that he was looking at joining his local Disabled American Veterans lodge. The clinician noted that the Veteran was in good spirits, that his mood was under control, and that he was living lift to his ability. Upon mental status examination, there was no evidence of suicidal or homicidal ideation, auditory or visual hallucinations, and the Veteran mood was noted to be euthymic with a congruent affect. The clinician indicated that the Veteran’s depression was “in full remission.” The clinician and Veteran agreed to discontinue the Veteran’s mental health medication and go to therapy on an as needed basis. On VA examination in February 2014, the examiner provided diagnoses of anxiety disorder, not otherwise specified (NOS), as a subthreshold of PTSD, as well as major depressive disorder. The examiner noted symptoms of chronic irritability, depressive cognitions, amotivation, social withdrawal, diminished ability to think or concentrate, mild memory loss, and sleep disturbance. However, the examiner opined that the Veteran’s social withdrawal was directly affected by his physical limitations, that his diminished concentration and memory were impacted by his pain and pain medication, and that his sleep disturbances were multifactorial. The Veteran reported that he lived with his family, indicating that there were six people in the household. He further indicated that his parents lived 14 miles away, and that he last saw them a week ago. He indicated that he had no friends; however, he noted that he had 200 friends on Facebook. The examiner noted that the Veteran had no suicidal ideation since 2010. The examiner further noted that the Veteran had underwent six therapy sessions from July 2013 through November 2013. It was noted during the final session in November 2013 that the Veteran’s major depressive disorder was in full remission. A mental status examination revealed that the Veteran’s speech was at a normal rate and volume. The examiner noted that his affect was mildly irritable. He was intact to person, place, and time. He denied delusions or hallucinations. His thought process was goal-directed, and he had no obsessive-compulsive behaviors. The Veteran reported that he had difficulty falling asleep at night. The examiner noted that the Veteran had passive suicidal ideation with no intent. He had no homicidal ideation. His impulse control and anger management were noted as fair. Based on the findings, the February 2014 VA examiner indicated that the Veteran demonstrated 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. Based on the foregoing evidence, the Board finds that for the period prior to August 28, 2015, the Veteran’s psychiatric disorder most nearly approximates the criteria for a 30 percent rating. The evidence of record reflects that the Veteran’s psychiatric disorder was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, chronic sleep impairment, and mild memory loss. The evidence does not reflect that the Veteran’s psychiatric disorder during this specified period was manifested by symptoms of or such as circumstantial, circumlocutory or stereotype speech, panic attacks, difficulty understanding complex commands, impairment of his short or long-term memory, impaired judgment, or impaired abstract thinking. The Board recognizes that in the February 2014 VA examination, the examiner reported that the Veteran showed symptoms of chronic irritability, depressive cognitions, amotivation, social withdrawal, diminished ability to think or concentrate, mild memory loss, and sleep disturbance. However, the examiner opined that the Veteran’s social withdrawal, sleep impairment, and cognitive issues were, in part, related to his physical health and were not solely attributable to his service connected psychiatric disorder. Accordingly, the Board finds that the frequency, severity and duration of these symptoms were not productive of social and occupational impairment with reduced reliability and productivity, as the evidence relevant to the period prior to August 28, 2015, shows that the Veteran maintained stable social relationships with his family as well as some social interactions with non-family members through fraternal organizations. Additionally, the evidence shows that the Veteran’s speech, mood, language, and thought process were within normal limits. Thus, the Board does not find that the evidence shows that the Veteran demonstrated symptomatology consistent with a higher 50 percent rating. The Board acknowledges that the Appellant contends that the Veteran’s psychiatric disorder warrants a higher evaluation prior to August 28, 2015; however, as discussed in more detail below, the first date that there are factual findings that show that the Veteran exhibited symptoms that would warrant a higher rating of 50 percent was the date of the Veteran’s examination conducted on August 28, 2015. Hart, 21 Vet. App. 505. B. From August 28, 2015 An August 2015 VA mental health record noted that the Veteran continued to have ongoing sleep issues related to both medical issues and psychological symptoms, such as nightmares. Upon mental status examination, the Veteran denied current suicidal or homicidal ideation, auditory or visual hallucination. His mood was euthymic with a variable affect. The clinician noted that the Veteran’s judgement and insight appeared to be affected by his PTSD as he tended to engage in self-blame cognitions. On VA examination in August 2015, the examiner noted that the Veteran was diagnosed with PTSD in April 2011; however, as the Veteran’s condition progressed between 2011 and 2014, his diagnosis was changed to anxiety disorder NOS/trauma-related disorder in 2014. The examiner provided diagnoses of other specified trauma and stressor-related disorder, as well as major depressive disorder. The examiner noted that the Veteran demonstrated the following symptoms: depressed mood, irritability, hypersomnia, psychomotor retardation, fatigue, feelings of worthlessness, and recurrent thoughts of death. The Veteran reported that he continued to live with his family, including his brother, sister-in-law, and their four children. He further reported that he continued to be close to his mother, indicating that he visited her regularly and had helped her a few weeks ago with repairing her roof. The Veteran reported that he went to the grocery store and to his VA appointments; however, he stayed in bed and watched television for most of the day. He indicated that going to his VA appointments was the most fun thing that he did. The examiner noted that depressed pessimism was reflected in the Veteran’s description of his activities. The Veteran did not describe any difficulty or anxiety with these activities. He completed these activities with the company of his brother and sister-in-law. He denied participating in any social activities outside of the family. Regarding his occupational history, the Veteran reported that he last worked in 2012 as a truck driver. He indicated that he stopped working because of his cancer and an accompanying heart problem. A mental status examination revealed that the Veteran understood the reason for the interview and was oriented to person, place, and time. As regards to his memory, the Veteran recalled three out of three items after a period of intervening tasks. Additionally, he was able to produce a clock face with the correct time and gave a concrete explanation of an abstract proverb. The Veteran denied being suicidal. He stated that he would not be at risk unless his cancer resurfaced. The examiner noted that the Veteran had engaged in recent dangerous behavior associated with thoughts of wanting to die. He reported last engaging in these behaviors three months ago, indicating that he had experimented with the dosage of his insulin. The examiner noted that the Veteran had good impulse control, as he denied engaging in any reckless/impulsive behaviors. The Veteran denied inflated self-esteem or grandiosity, decreased need for sleep, being more talkative or pressure to keep talking, flight of ideas or subjective experience of racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. Based on the findings, the August 2015 VA examiner concluded that the Veteran demonstrated occupational and social impairment with reduced reliability and productivity. A September 2015 VA mental health outpatient record notes that the Veteran felt “great” that day as he had learned his lung spot was noncancerous and had recently engaged in a productive conversation with another veteran about letting go of the past. Upon mental status examination, the Veteran was casually dressed, he denied any current suicidal or homicidal ideation as well as auditory or visual hallucinations. His mood as euthymic with a variable effect. An October 2015 VA mental health outpatient record shows that the Veteran reported an improved mood in the last two days. He noted that he got up on time that morning. He indicated that he had spent most of the prior week in bed due to depression-related fatigue. He stated, “I think I’m getting out of my funk.” He further indicated that he did not want to take antidepressants because his depressive episodes were short, and he did not want to take a pill every day for something that only affected him sometimes. The examiner noted that the Veteran was dressed casually. His mood was euthymic, with variable affect. His judgment, insight, and though content appeared to be within normal limits. A December 2015 VA mental health outpatient record shows that on mental examination, the Veteran was casually dressed. His mood was euthymic, with appropriate affect. His judgment, insight, and thought content appeared to be within normal limits. The Veteran was determined as being at individual baseline and presented no imminent risk for suicide. Based on the foregoing evidence, for the period on appeal from August 28, 2015, the Board finds that a rating in excess of 50 percent is not warranted. The Veteran’s psychiatric symptoms recorded during this time period do not more closely approximate the disability picture contemplated by the rating criteria warranting a 70 percent rating, which is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board recognizes that in the August 2015 VA examination, the examiner reported that the Veteran showed symptoms of depression, irritability, and recurrent thoughts of death. However, in the opinion of the Board, the frequency, severity and duration of these symptoms were not productive of occupational and social impairment with deficiencies in work, family relationships, judgment and mood, as the evidence relevant to the period from August 28, 2015, shows that the Veteran maintained intact thought processes. Additionally, the August 2015, September 2015, and October 2015 VA mental health outpatient records show that the Veteran indicated that his depressive episodes were short-lived and that he denied any ongoing suicidal ideation. In addition, he maintained stable relationships with his family and even socialized with other veterans. Furthermore, there is no report or assertion of any obsessional rituals, abnormal speech, near-continuous panic or depression that affected the Veteran’s ability to function, spatial disorientation, neglect of personal appearance and hygiene, or difficulty in adapting to stressful circumstances, or symptoms of the same type and degree. Thus, the Board does not find that the evidence shows that the Veteran demonstrated symptomatology consistent with a higher 70 percent rating. For these reasons, the Board finds that at no time during the periods in question has the disability warranted more than a 30 percent evaluation prior to August 28, 2015, and more than a 50 percent evaluation from August 28, 2015. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In reaching the decisions of each specified period during the appeal, the Board has considered the benefit-of-the-doubt doctrine. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. 49, 55-56 (1990). 2. Entitlement to a disability rating in excess of 10 percent for GERD. The Appellant seeks entitlement to a disability rating in excess of 10 percent for the Veteran’s service-connected GERD. The Veteran was awarded service connection and assigned an initial 10 percent disability rating for GERD, effective December 11, 1992, in a June 1993 rating decision. In August 2013, the Veteran filed a claim for a disability rating in excess of 10 percent for GERD. The Veteran’s claim was denied in a June 2015 rating decision. The Veteran’s GERD disability is evaluated under Diagnostic Code 7346, hiatal hernia. Under Diagnostic Code 7346, a 10 percent evaluation is warranted when there are two or more of the symptoms required for a 30 percent evaluation, but with less severity. A 30 percent evaluation is warranted when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent evaluation is warranted when there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114. On VA examination in June 2014, the examiner noted that the Veteran’s GERD disability had been stable since his last examination, which, as the record reflects, was conducted in February 1993. The examiner further noted that a 2012 esophagogastroduodenoscopy (EGD) showed normal esophageal mucosa. The examiner also indicated that a recent gastrointestinal (GI) appointment showed no GI complaints. It was noted that the Veteran reported taking Omeprazole for his GERD disability. The examiner noted that the Veteran did not demonstrate symptoms of esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. There were no other pertinent physical findings, complications, conditions, or symptoms related to the Veteran’s GERD disability. On VA examination in August 2015, the examiner reviewed the Veteran’s medical history. The examiner noted that there had been no significant changes in the Veteran’s GERD disability since his last examination in June 2014. The examiner noted that during the Veteran’s multiple medical visits, GI complaints were not noted. The examiner specifically indicated that during his last GI appointment in April 2015, there were no GI complaints. The Veteran continued to take Omeprazole for his GERD disability. Just as the June 2014 examiner indicated, the August 2015 examiner noted that the Veteran did not demonstrate symptoms of esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. Furthermore, there were no other pertinent physical findings, complications, conditions, or symptoms related to the Veteran’s GERD disability. A review of the Veteran’s VA treatment records shows that the Veteran continued to take Omeprazole for his GERD disability. The record shows that the Veteran complained on heartburn periodically; however, the records do not reveal any other complaints regarding this disability. To the contrary, VA treatment records throughout the pendency of the appeal indicate that the Veteran consistently denied having abdominal pain, hematemesis, hematochezia, or melena. Based on the foregoing, the Board finds that no more than a 10 percent evaluation of the Veteran’s GERD is warranted. A 30 percent rating for GERD is associated with persistently recurrent epigastric distress with difficulty swallowing, heartburn, regurgitation, and substernal or arm or shoulder pain, which are productive of considerable impairment of health. The record does not reflect that the Veteran experienced recurrent epigastric distress with dysphagia, pyrosis, and regurgitation at any point during the appeal period. Thus, the Board cannot find that the Veteran had symptoms that resulted in a considerable impairment of health at any time. For similar reasons, the Board finds that the Veteran did not demonstrate the symptoms associated with a 60 percent rating of GERD. The Board notes that the record reflects that the Veteran, at times, experienced nausea and vomiting as a result of his chemotherapy treatment for his cancer, as well as his treatment for his diabetes. However, the record does not show the presence of vomiting, material weight loss and hematemesis, melena, any form of anemia, or other symptoms productive of a “severe impairment of health” as a result of his GERD. Thus, the Board cannot find that the totality of the evidence of record supports a finding that the Veteran’s GERD symptoms meet or approximate the criteria associated with a 60 percent rating during the appeal period. To the extent that the Board herein denies a rating in excess of 10 percent, the preponderance of the evidence is against such an award. Therefore, the benefit-of-the-doubt doctrine is not applicable in such regard, and a higher rating is not warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND The Veteran had sought entitlement to service connection for high blood pressure and diabetes mellitus. Regrettably, as discussed below, a remand is required to obtain an additional VA medical opinion. The record reflects that the Veteran was diagnosed with both hypertension and diabetes mellitus following his separation from service. See February 2008 VA treatment record. As regards to the claim for high blood pressure, the Board acknowledges that during the February 1993 VA examination, the examiner indicated that the Veteran did not have hypertension; however, the examiner failed to address the Veteran’s in-service elevated blood pressure readings recorded during a five-day blood pressure check. See February 1991 service treatment record. Furthermore, as regards to the claim for diabetes mellitus, the record does not reflect that an opinion has been obtained as to whether this claimed disability was related to the Veteran’s active service. Thus, a medical opinion addressing whether the Veteran’s diabetes mellitus and high blood pressure were related to service is necessary. Finally, as previously stated, prior to his death, the Veteran raised a claim for a TDIU as part and parcel of the higher rating claim for his psychiatric disorder. The Board finds that based on the record, the Veteran’s work history is unclear. The SSA records indicate that the Veteran reported that he was unable to work as of December 8, 2010; however, the records also indicate that he worked as a truck driver until March 28, 2012. See SSA records. Thus, given the Veteran’s unclear employment history prior to his death, and as the Appellant has not yet submitted a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, on remand, the RO should undertake additional development, to include obtaining a VA Form 21-8940, and the Veteran’s income information for all tax years during the appeal period. The matters are REMANDED for the following actions: 1. Provide the Appellant with a VA Form 21-8940, and instruct her to fill it out with the Veteran’s information and return it to the RO. 2. Forward the claims folder to an appropriate clinician for review and for an addendum opinion addressing the nature and etiology of the Veteran’s high blood pressure and diabetes mellitus. The Veteran’s claims file and a copy of this remand should be provided to the examiner and the addendum report should reflect that these items were reviewed. The examiner must state an opinion for each stated disability as to whether it was at least as likely as not related to service. In rendering the above requested opinion regarding the Veteran’s high blood pressure claim, the clinician must address the in-service elevated blood pressure readings and any in-service pre-hypertension. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 3. After completing all indicated development, the Appellant’s claims should be readjudicated, to include the issue of entitlement to a TDIU, based on the entirety of the evidence. If the benefits sought on appeal are not granted, the Appellant and her representative should be provided a Supplemental Statement of the Case and afforded the requisite opportunity to respond before the case is remanded to the Board. J. A. Anderson Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Y. MacDonald, Associate Counsel