Citation Nr: 18156852 Decision Date: 12/11/18 Archive Date: 12/11/18 DOCKET NO. 16-06 752 DATE: December 11, 2018 ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for a kidney disorder is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD), to include other specified trauma and stress related disorder (OSTSD), is denied. Entitlement to an initial rating in excess of 10 percent for hepatitis C is denied. Prior to September 17, 2015, entitlement to an initial rating in excess of 50 percent for major depressive disorder is denied. From September 17, 2015 onward, entitlement to a rating of 70 percent, but no higher, for major depressive disorder is granted. Entitlement to an effective date prior to July 3, 2013 for the grant of service connection for major depressive disorder is denied. Entitlement to an effective date prior to July 3, 2013 for the grant of service connection for hepatitis C is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s hypertension began during active service, or is otherwise related to an in-service injury, event, or disease. 2. The preponderance of the evidence is against finding that the Veteran’s kidney disorder began during active service, or is otherwise related to an in-service injury, event, or disease. 3. The preponderance of the evidence is against finding that the Veteran’s PTSD is related to an in-service stressor. 4. The preponderance of the evidence is against finding that the Veteran’s OSTSD is related to an in-service stressor during an honorable period of active service. 5. The Veteran’s hepatitis C has been manifested by fatigue; but no malaise, anorexia, and no incapacitating episodes during a 12-month period have been shown. 6. Prior to September 17, 2015, the Veteran’s major depressive disorder has been manifested by depressed mood; anxiety; racing thoughts; chronic sleep impairment; mild memory loss; flattened affect; disturbances in motivation or mood; difficulty adapting to stressful circumstances; and isolation. 7. From September 17, 2015 onward, the Veteran’s major depressive disorder has been manifested by suicidal ideation with no plan or intent, depressed mood; anxiety; chronic sleep impairment; disturbances in motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances; panic attacks that occur weekly or less often; mild memory loss; an inability to establish and maintain effective relationships; and serious impairment in occupational functioning. 8. No claim, formal or informal, seeking service connection major depressive disorder was filed prior to July 3, 2013. 9. No claim, formal or informal, seeking service connection for hepatitis C was filed prior to July 3, 2013. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for service connection for a kidney disorder are not met. 38 U.S.C. §§ 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for service connection for PTSD, to inlcude OSTSD, are not met. 38 U.S.C. §§ 1111, 1131, 5107(b); 38 C.F.R. §§ 3.1, 3.12, 3.102, 3.303(a), 3.304. 4. The criteria for an initial rating in excess of 10 percent for hepatitis C is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.114, Diagnostic Code (DC) 7354. 5. Prior to September 17, 2015, an initial rating in excess of 50 percent for major depressive disorder is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code (DC) 9434. 6. From September 17, 2015 onward, the criteria for a rating of 70 percent, but no higher, for major depressive disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code (DC) 9434. 7. The criteria for the assignment of an effective date prior to July 3, 2013, for establishing service connection for a major depressive disorder have not been met. 38 U.S.C. §§ 5110, 5103A; 38 C.F.R. §§ 3.159, 3.400. 8. The criteria for the assignment of an effective date prior to July 3, 2013 for establishing service connection for hepatitis C have not been met. 38 U.S.C. §§ 5110, 5103A; 38 C.F.R. §§ 3.159, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from August 1975 to August 1978. The Veteran has further service from July 1979 to December 1980, however this service was found to be dishonorable for VA purposes and a bar to benefits administered by VA due to the Veteran’s pattern of willful and persistent misconduct in service. See February 2014 Administrative Decision. 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; 38 C.F.R. § 3.303(a). 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). In addition, service connection for certain chronic diseases, including arthritis, 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; 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumption 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). For the showing of chronic disease in 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; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert. v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. Entitlement to service connection for hypertension. The Veteran asserts that he is entitled to service connection for hypertension on a direct basis. However, as outlined below, the preponderance of the evidence of record demonstrates that the Veteran’s hypertension did not manifest during, within the year following, or as result of active service. As such, service connection cannot be established on a direct basis. The service treatment records (STRs) are silent for any indication of elevated blood pressure or a diagnosis of hypertension. The earliest indication of hypertension in post-service VA treatment records is in July 2012. The Veteran stated on a May 2014 authorization for release of information form that he was diagnosed with hypertension in August 2012. Based on the foregoing, there is no evidence that the Veteran’s hypertension was manifested in service or to a compensable degree in the first year following his separation from service. Consequently, service connection for hypertension on the basis that such became manifest in service and persisted, or on a presumptive basis (as a chronic disease under 38 U.S.C. § 1112), is not warranted. Notably, the Veteran has not submitted competent evidence to show that he has suffered from elevated blood pressure or hypertension continuously since service. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). There is also no evidence that the Veteran’s hypertension is otherwise related to service. The Veteran’s post service treatment records are silent for an opinion relating his hypertension to service. Further, the Veteran’s own statements relating his hypertension to service are not competent evidence, as he is a layperson and lacks the training to provide adequate opinion regarding medical etiology. Specifically, the Veteran lacks the training to opine whether hypertension, in the absence of credible evidence of continuity, as here, is related to service. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (Whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the Veterans Court). Also, hypertension is a disease of the vascular system, and the record does not show that the Veteran has training or education in this medical field; therefore, lay evidence of the etiology is not competent nexus evidence as it is not capable of lay observation. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007); Layno v. Brown, 6 Vet. App. 465, 469-70. Thus, the Veteran is not competent or qualified, as a layperson, to render an opinion on medical causation. The Board acknowledges that the Veteran has not been afforded a VA examination for the hypertension claim, but finds that no such examination was required because the evidence does not indicate that the claimed disability exhibited symptoms, treatment, or diagnosis in service or since the Veteran’s active service. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Although the Veteran has a current diagnosis of hypertension, there is no competent and credible evidence of hypertension in service or that persisted from service until diagnosis in 2012. As, such, the Board finds that a VA examination was not required. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for hypertension. Accordingly, it must be denied. 2. Entitlement to service connection for a kidney disorder. The Veteran asserts that he is entitled to service connection for a kidney disorder. However, as outlined below, the preponderance of the evidence of record demonstrates that the Veteran’s kidney disorder did not manifest during, within the year following, or as a result of active service. As such, service connection cannot be established on a direct basis. The STRs are silent for any symptoms or diagnosis of a kidney disorder. Post-service VA treatment records demonstrate that the Veteran experienced kidney failure in August 2012 as a result of the Veteran ingesting anti-freeze. Based on the foregoing, there is no evidence that the Veteran’s kidney disorder was manifested in service or to a compensable degree in the first service year following his separation from service. Consequently, service connection for kidney disorder on the basis that such became manifest in service and persisted is not warranted. Notably, the Veteran has not submitted competent evidence to show that he has suffered from a kidney disorder continuously since service. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). There is also no evidence that the Veteran’s kidney disorder is otherwise related to service. The Veteran’s post-service VA treatment records are silent for an opinion relating his kidney disorder to service. The only competent evidence in the record that addresses the etiology of the Veteran’s kidney disorder in August 2012 VA treatment record where the medical provider indicated that the Veteran’s kidney failure had its onset when the Veteran ingested anti-freeze. As there is no other evidence to the contrary, and the medical provider’s statement was based on an in-person examination of the Veteran, the Board finds it persuasive. Further, the Veteran’s own assertion relating his kidney disorder to service is not competent evidence, as he is a layperson and lacks the training to provide adequate opinion regarding medical etiology. Specifically, the Veteran lacks the training to opine whether kidney failure, in the absence of credible evidence of continuity, as here, is related to service. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Also, a kidney disorder is a disease of the renal system, and the record does not show that the Veteran has training or education in this medical field; therefore, lay evidence of the etiology is not competent nexus evidence as it is not capable of lay observation. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007); Layno v. Brown, 6 Vet. App. 465, 469-70. Thus, the Veteran is not competent or qualified, as a layperson, to render an opinion on medical causation. The Board acknowledges that the Veteran was not afforded a VA examination for his kidney disorder claim, but finds that no such examination was required because the evidence does not indicate that the claimed disability exhibited symptoms, treatment, or diagnosis since the Veteran’s active service. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Although the Veteran has a current diagnosis of kidney failure, there is no competent and credible evidence of symptoms in service or a persistence of symptoms since separation from service. As such, the Board finds that a VA examination was not required. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for a kidney disorder. Accordingly, it must be denied. 3. Entitlement to service connection for PTSD, to include OSTSD. The Veteran asserts that he is entitled to service connection for PTSD. However, as outlined below, the preponderance of the evidence of record demonstrates that the Veteran’s PTSD was not the result of an in-service stressor. As such, service connection cannot be established. There are particular requirements for establishing service connection for PTSD in 38 C.F.R. § 3.304 (f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD requires: (1) a medical diagnosis of PTSD utilizing the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria, in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. See 38 C.F.R. § 3.304(f). The Board notes that the DSM-IV has been recently updated with a Fifth Edition (DSM-V). Effective August 4, 2014, VA issued an interim rule amending the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to refer to certain mental disorders in accordance with DSM-V. The provisions of the interim final rule only apply, however, to all applications received at the Agency of Original Jurisdiction (AOJ) on or after August 4, 2014, but not to claims certified to or pending before the Board, the Court, or the United States Court of Appeals for the Federal Circuit (Federal Circuit). 79 Fed. Reg. 45,093, 45,094-096 (Aug. 4, 2014). The Veteran’s psychiatric claim was pending before the Board prior to that date. Under 38 C.F.R. § 3.304(f)(3), if a stressor claimed by a veteran is related to the veteran’s fear of hostile, military, or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD, and the veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places and circumstances of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, “fear of hostile military or terrorist activity” means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Post-service treatment VA treatment records indicate that the Veteran was diagnosed with PTSD, with a positive PTSD screening in October 2011. In November 2014, VA requested from the Veteran information regarding his in-service stressor, included a VA Form 21-0781 statement in support of claim for service connection for PTSD. The Veteran did not respond as of December 2014. As a result, a December 2014 VA administrative decision made a formal finding of lack of information required to corroborate a stressor associated with the claim of service connection for PTSD. On the December 2015 VA examination, the examiner diagnosed the Veteran with OSTSD, which is a progression of a previously diagnosed PTSD. The examiner commented that given the nature of the Veteran’s reported stressor, the Veteran did not qualify for a PTSD diagnosis and corrected to a diagnosis of OSTSD which he does qualify for per the Veteran’s reported symptoms. The Veteran reported that the Veteran’s exposure was not to actual or threatened death, serious injury or sexual violence, but involved a state of heightened alert during the period of the Iran hostage crisis, occurring from November 1979 to January 1981. Upon review of the record, the Board finds that the preponderance of the evidence is against the claim. The Veteran did not respond to VA’s request to confirm his stressor in November 2014. The Veteran’s failure to respond deprives VA the ability to assist the Veteran in producing credible supporting evidence that an in-service stressor occurred. “The duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence.” Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Based on the foregoing, there is no evidence of an in-service stressor. Consequently, service connection for PTSD is not warranted. In regard to OSTSD, the Veteran stated that the stress from the Iran hostage crisis from 1979 to 1981 caused his OSTSD. In December 2014, VA characterized the Veteran’s service from 1979 to 1980 as dishonorable. For benefits purposes, a “veteran” is a person discharged or released from active service under conditions other than dishonorable. 38 U.S.C. § 101 (2); 38 C.F.R. § 3.1 (d). VA benefits are not payable unless the period of service upon which the claim is based was terminated by discharge or release under conditions other than dishonorable. 38 C.F.R. § 3.12 (a). A claimant receiving a discharge under conditions other than honorable may be considered to have been discharged under dishonorable conditions in certain circumstances. 38 U.S.C. § 5303; 38 C.F.R. § 3.12. A discharge under dishonorable conditions bars the payment of benefits. 38 C.F.R. § 3.12 (b). There is no competent and credible evidence of record to establish that the Veteran’s OSTSD had its onset in, or is otherwise related to the Veteran’s honorable first period of service. Although medical evidence confirms that the Veteran is currently diagnosed and treated for OSTSD, the evidence demonstrates that the onset of OSTSD began during the Veteran’s dishonorable second period of service. Accordingly, the Veteran’s claim must be denied. There is also no evidence that the Veteran’s PTSD and OSTSD is otherwise related to honorable service. The Veteran’s VA and private treatment records are silent for an opinion relating his PTSD and OSTSD to honorable service. The only competent evidence in the record that addresses this question is the December 2015 VA medical opinion, which stated that the Veteran’s PTSD was not related to an acceptable reported stressor and the OSTSD was related to a stressor during the Veteran’s dishonorable period of service. As there is no other evidence to the contrary, and the December 2015 VA medical opinion was based on a full review of the record as well as an interview and examination of the Veteran, the Board finds it persuasive. Further, the Veteran’s assertion relating his PTSD and OSTSD to honorable service are not competent evidence, as he is a lay person and lacks the training to provide adequate opinion regarding medical etiology. Specifically, the Veteran lacks the training to opine whether PTSD and OSTSD, in the absence of an in-service stressor or event, as here, is related to honorable service. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Also, PTSD and OSTSD are psychiatric disorders, and the record does not show that the Veteran has training or education in this medical field; therefore, lay evidence of the etiology is not competent nexus evidence as it is not capable of lay observation. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007); Layno v. Brown, 6 Vet. App. 465, 469-70. Thus, the Veteran is not competent or qualified, as a layperson, to render an opinion on medical causation. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for PTSD and OSTSD. Accordingly, it must be denied. Increased Rating Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). In addition, the Court has determined 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. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board notes that the effective date of an award of increased compensation is the earliest date as of which it is factually ascertainable that an increase in disability has occurred, if the claim is received within one year from such date; otherwise, it is the date of receipt of the claim. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2); see also Hazan v. Gober, 10 Vet. App. 511 (1997). 4. Entitlement to an initial rating in excess of 10 percent for Hepatitis C. For the period on appeal, the Veteran’s hepatitis C was rated as 10 percent disabling pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7354. Under the General Rating Formula, a 10 percent rating is warranted when the veteran has serologic evidence of hepatitis C infection and the following signs and symptoms due to the hepatitis infection: intermittent fatigue, malaise, and anorexia, or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12-month period. 38 C.F.R. § 4.114, Diagnostic Code 7354. A 20 percent rating is warranted when symptoms include daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication; or for incapacitating episodes (with symptoms described above) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. Id. A 40 percent rating is warranted when symptoms include daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly; or for incapacitating episodes (with symptoms described above) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period. Id. A 60 percent rating is warranted when symptoms include daily fatigue, malaise, and anorexia, with substantial weight loss (or other indication of malnutrition), and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12-month period, but not occurring constantly. A 100 percent rating is assigned for near- constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). 38 C.F.R. § 4.114, Diagnostic Code 7354. The term “substantial weight loss” means a loss of greater than 20 percent of the individual’s baseline weight, sustained for three months or longer; and the term “minor weight loss” means a weight loss of 10 to 20 percent of the individual’s baseline weight, sustained for three months or longer. The term “inability to gain weight” means that there has been substantial weight loss with inability to regain it despite appropriate therapy. “Baseline weight” means the average weight for the two-year-period preceding onset of the disease. 38 C.F.R. § 4.112. Note 1 under Diagnostic Code 7354 states: Evaluate sequelae, such as cirrhosis or malignancy of the liver, under an appropriate diagnostic code, but do not use the same signs and symptoms as the basis for evaluation under Code 7354 and under a diagnostic code for sequelae. Note 2 defines an “incapacitating episode” as “a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician.” 38 C.F.R. § 4.114, Diagnostic Code 7354. In the January 2015 VA examination, the examiner indicated that continuous medication was not required for control of the Veteran’s hepatitis C. The examiner indicated that the Veteran experienced intermittent fatigue attributable to the hepatitis C. Further, the examiner noted that the Veteran has not had any incapacitating episodes during the past 12-months. In a March 2015 VA treatment record the examiner indicated that the Veteran had a history of hepatitis C that has never been treated. The examiner observed that the Veteran had no weight loss, weight gain, weakness, anorexia, fever, chills, or night sweats. In a May 2015 VA treatment record the Veteran reported that his weight was stable and denied symptoms of liver disease. In a June 2015 VA treatment record the Veteran reported trouble sleeping, persistent headaches, and difficulty acquiring an erection. The Veteran stated that he did not experience these symptoms prior to starting hepatitis C treatment. He stated that he appetite was good and weight was stable. In the December 2015 VA examination, the examiner indicated that the Veteran’s hepatitis C did not require medication and the Veteran did not currently have signs or symptoms attributable to chronic or infectious liver diseases. Further, the examiner found that the Veteran has not had any incapacitating episodes due to hepatitis C during the past 12-months. In a September 2015 and May 2016 VA treatment record, the Veteran stated that he discontinued taking his Hepatitis C medication because he did not like the way it made him feel. He stated that he was severely fatigued and lost approximately 20 pounds. On examination, the medical provider observed that the Veteran had no weight loss, weight gain, weakness, anorexia, fever, chills, or night sweats. Upon review of the record, the Board concludes that the evidence does not support a finding that the Veteran is entitlement to a disability rating in excess of 10 percent for hepatitis C. On the January 2015 VA examination, the examiner found that the Veteran experience intermittent fatigue, but did not experience any incapacitating episodes during the past 12-month period. The March 2015 VA treatment records indicated that the Veteran did not experience weight loss, weight gain, weakness, or anorexia. The December 2015 VA examination indicated that the Veteran did not require medication for hepatitis C and did have any current symptoms. Further, the Veteran did not experience any incapacitating episodes during the past 12-month period. In September 2015 and May 2016 VA medical providers observed that the Veteran had no weight loss, weight gain, or anorexia. In September 2015 and May 2016 VA treatment records, the Veteran stated that he was severely fatigued. The Board finds that the Veteran’s symptoms, or lack of symptoms, do not warranted a 20 percent disability rating, for the reasons described above. The Veteran has simply not demonstrated daily fatigue, malaise, and anorexia or incapacitating episodes. The Board acknowledges the Veteran’s present complaints of fatigue, however, the Board finds compelling that there was no indication that the Veteran experienced malaise and anorexia, as required for a higher 20 percent rating. Further, the Board points out that there is no evidence of record that the Veteran experienced incapacitating episodes of any duration. The Board thus finds that the Veteran’s hepatitis C has more closely approximate the criteria for a 10 percent rating. 5. Entitlement to an initial rating in excess of 50 percent for major depressive disorder. For the period on appeal, the Veteran’s major depressive disorder was rated as 50 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9434. The Veteran’s major depressive disorder is currently rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9434. Ratings are assigned according to the manifestation of particular symptoms. 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. VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). When determining the appropriate disability evaluation to assign for psychiatric disabilities, however, the Board’s “primary consideration” is the Veteran’s symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). Under the General Rating Formula for Mental Disorders, 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 judgement; 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 9434. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal 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 work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss of names of close relatives, own occupation, or own name. Id. The Board also considers the Veteran’s Global Assessment of Function (GAF) scores assigned during the course of the appeal. The GAF is a scale indicating the psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness. GAF scores ranging from 41 to 50 reflect 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 score between 51 and 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 coworkers). GAF scores of 61 to 70 are indicative of 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 score is highly probative as it relates directly to the Veteran’s level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). In a July 2013 VA treatment record, the medical provider found the Veteran’s GAF to be 30 at admission to the hospital and 48 at discharge. The Veteran stated that he stopped taking his medication. The Veteran stated that he reported to VA voluntarily because he had a suicidal ideation and plan to drive his car off a bridge. He complained of depressed mood. On examination, the medical provider observed that the Veteran was dressed in hospital apparel with normal hygiene; cooperative attitude with intermittent eye contact; goal directed thought process; speech with regular rate, rhythm, and volume; affect was congruent with mood; depressed mood; poor insight and judgment; and alert and oriented. In an August 2013 VA treatment record, on admission to the hospital, the medical provider recounted that in July 2013 the Veteran presented with suicidal ideation with an active plan. He was admitted to psychiatry service for stabilization and discharged in the last day in July. A day after discharge, the Veteran reported that he developed severe anxiety and depression and he began to hyperventilate. He stated that he had fleeting suicidal ideations with no active plan and felt safe at the hospital. The medical provider observed that Veteran’s mood and affect to be flat, judgment and insight fair, and memory to be good. In an August 2013 VA treatment record the social worker observed that the Veteran had good hygiene and was dressed in hospital attire; was pleasant and cooperative; had clear and coherent speech of normal rate and volume; “fine” mood with congruent affect; and anxiousness when he spoke of “overwhelming problems.” In an August 2013 VA treatment record for initial psychiatric admission assessment, the Veteran’s chief complaint was overwhelming thoughts, depression, and anxiety. The medical provider observed that the Veteran appeared older than his stated age; was dressed appropriately in hospital attire with fair grooming and hygiene; demonstrated psychomotor agitation; fair eye contact; spontaneous and fluent speech with normal rate, tone, and volume; anxious mood; restricted and congruent affect; organized and goal directed thoughts; alert and orient to person, place, and time; and fair insight and judgment. A GAF of 31-40 was assigned. In an August 2013 VA treatment record, the medical provider assessed that the Veteran presented with complaints of increasing depression and anxiety with fleeting suicidal thoughts. The Veteran stated that his mood was much improved since admission to the hospital and he denied any depressive symptoms, anxiety was improved, and he denied any suicidal or homicidal ideations, intents, or plans. The provider assigned a GAF of 31-40. In an August 2013 VA treatment record, the medical provider observed that the Veteran appeared older than his stated age; was dressed appropriately in a hospital attire with good grooming and hygiene; no psychomotor agitation; good eye contact; spontaneous and coherent speech with normal rate, tone, and volume; good mood; expressive and euthymic affect; organized and goal directed thoughts; alert and oriented to person, place, and time; and good insight and judgment. In an August 2013 VA treatment record the medical provider indicated that the Veteran had a GAF of 41-50. The Veteran’s chief complaint was, “overwhelming thoughts, depression, and anxiety.” The Veteran stated that his anxiety has progressively worsened. He stated that he has experienced palpitations, diaphoresis, hyperventilation, and difficulty sleeping. He also stated that he has difficulty concentrating, focusing, feeling hopeless and helpless. He stated that he was unable to control his racing thoughts. The Veteran denied any plan or intent to commit suicide. The medical provider observed the Veteran demonstrate psychomotor agitation. On examination, the medical provider observed that the Veteran was dressed appropriately in hospital attire with good grooming and hygiene; no psychomotor agitation; good eye contact; spontaneous, coherent, and fluent speech with normal rate, tone, and volume; full and euthymic affect; organized and goal directed thoughts; alert; oriented to person, place, and time; and good insight and judgment. In an August 2013 VA treatment record the medical provider observed the Veteran to have an anxious mood and affect. In other records from August 2013, the medical provider observed the Veteran to have a calm mood and affect. In an August 2013 VA treatment record, the Veteran was seen after discharge from a voluntary mental health hospital treatment. The Veteran stated that he developed suicidal ideation after he stopped taking his medication. In an October 2013 VA treatment record the Veteran stated that he has been doing significantly better. He stated that he has not had significant nightmares or flashbacks and his overall anxiety level was low. In a January 2014 VA treatment record the Veteran reported increased anxiety. In an April 2014 VA treatment record the Veteran reported that things were going “pretty well.” He stated that had poor sleep, had a “fairly good” mood, and racing thoughts. The medical provider observed that he was well groomed; well dressed with good hygiene; made good eye contact; was cooperative; had normal speech in rate, tone, quantity, and latency; linear and goal directed thought process; good mood; appropriate affect; good insight and judgement; and was alert and oriented. In a July 2014 VA treatment record, the Veteran reported that he was sleeping fairly well and his energy and concentration were good. The medical provider observed that he was well groomed; well dressed with good hygiene; made good eye contact; was cooperative; had normal speech in rate, tone, quantity, and latency; linear and goal directed thought process; good mood; appropriate affect; good insight and judgement; and was alert and oriented. In a November 2014 VA treatment record, the Veteran reported that he had less anxiety being around other people and less anxiety generally, but he has difficulty sleeping. The medical provider observed that the was well groomed; well dressed with good hygiene; made good eye contact; was cooperative; had normal speech in rate, tone, quantity, and latency; linear and goal directed thought process; good mood; appropriate affect; good insight and judgement; and was alert and oriented. In a January 2015 VA examination, the medical provider indicated that the Veteran’s current depressive symptoms include: feeling overwhelmed, worry, impatience, periods of lower mood and isolation. The Veteran reported that he goes two to three days without eating and frequent interrupted sleep. He stated that he was more depressed when he stayed in his home. The Veteran denied current suicidal ideation, but stated that he has attempted suicide in the past. The examiner concluded that the Veteran’s depressive disorder was best summarized as occupational and social impairment with reduced reliability and productivity. The examiner indicated that the Veteran experiences depressed mood, anxiety, chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events), flattened affect, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances (including work or a worklike setting). In a March 2015 VA treatment record the Veteran stated that he was doing “very well.” The medical provider observed that the Veteran was well groomed; well dressed with good hygiene; made good eye contact; was cooperative; had normal speech in rate, tone, quantity, and latency; linear and goal directed thought process; good mood; appropriate affect; good insight and judgement; and was alert and oriented. In a September 2015 VA treatment record the Veteran stated that he was doing well. The medical provider observed that the Veteran was well dressed; well groomed; had good hygiene; good eye contact; cooperative; had normal speech in rate, tone, quantity and latency; linear and goal directed thought process; good mood; appropriate affect; good judgment and insight; and was alert and oriented. In a September 2015 private psychiatric evaluation, the private psychiatrist reported that the Veteran would miss three or more days per month due to mental problems; needs three or more days per month to leave early for mental problems; would have trouble with concentration with simple repetitive tasks more than three days per month and would not stay focused for at least seven hours of an eight hour workday; and if subjected to the pressures of constructive criticism the Veteran would respond inappropriately or in an angry manner more than once per month, but would not actually become violent. On the September 2015 mental disorder disability benefits questionnaire (DBQ), the private psychiatrist noted that the Veteran was diagnosed with unspecified depressive disorder. The private psychiatrist concluded that the Veteran’s symptoms result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The private psychiatrist indicated that the Veteran experienced depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, near-continuous panic or depression, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances; and an inability to establish and maintain effective relationships. The private psychiatrist also observed that the Veteran’s attention was normal; concentration appeared variable; increased complaint of short-term memory and basic information; appropriate thought content; goal directed thought; average fund of knowledge; average intellectual abilities; below average capacity for abstraction; average ability to interpret proverbs; and average judgment. Further, the psychiatrist observed the Veteran had an anxious and nervous mood; restricted affect; depression; suspiciousness; and paranoia. The private psychiatrist stated that she reviewed the Veteran’s VA records and the mental status examination prepared by her. In the December 2015 VA examination, the examiner found that the Veteran’s depressive disorder has progressed to major depressive disorder that is recurrent and moderate because of the Veteran’s report of episodic experience of depression since the prior VA examination. The examiner noted that the Veteran had symptoms of low mood, crying spells, guilt, low self-esteem, diminished sense of pleasure, suicidal ideation with no plan or intent, markedly diminished interest in significant activities, feeling detached or estranged from others, restricted range of affect, and difficulty sleeping. The examiner concluded that the Veteran’s depression caused occupational and social impairment with reduced reliability and productivity. The examiner explained that the Veteran’s depression caused moderate difficulty in social and serious impairment in occupational functioning. The examiner found that the Veteran’s symptoms were depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events, and disturbances of motivation and mood. The examiner observed that the Veteran experienced crying spells, guilt, low self-esteem, and diminished sense of pleasure. The examiner explained that these symptoms coupled with low mood and low motivation indicate a moderately depressed episode. In a May 2016 VA treatment record the medical provider observed that the Veteran was alert, made good eye contact, and was cooperative. In another May 2016 VA treatment record, the medical provider observed that the Veteran was well dressed; well groomed; had good hygiene; good eye contact; was cooperative; normal speech in rate, tone, quantity and latency; linear and goal directed thought process; good mood; appropriate affect; good insight and judgement; and alert and oriented. Based on all the evidence of record, the Board finds the Veteran’s disability picture more nearly approximates the criteria for a disability rating of 50 percent prior to September 17, 2015, the date of the private psychiatric evaluation. The symptoms exhibited by the Veteran throughout this period include depressed mood; anxiety; racing thoughts; chronic sleep impairment; mild memory loss; flattened affect; disturbances in motivation or mood; difficulty adapting to stressful circumstances; and isolation. Prior to September 17, 2015, VA treatment records demonstrate that the Veteran was oriented to time, place and person; alert; cooperative; had good judgment and insight; had normal speech; and had good hygiene. The Veteran’s symptoms and their effects are contemplated within the criteria for a 50 percent rating. Prior to September 17, 2015, the Board does not find that the Veteran’s symptoms more nearly approximate a rating of 70 percent, as they have not been of such severity or frequency to result in occupational and social impairment with deficiencies in most areas (such as work, family relations, judgment, thinking, or mood). The evidence of record shows that although the Veteran’s depressive disorder caused difficulty in adapting to stressful circumstances and social isolation, the Veteran was able to communicate effectively with treatment providers, had intact impulse control, and logical speech and goal directed thought processes. The VA treatment records how that the Veteran was consistently appropriately groomed and cooperative. In sum, there is insufficient evidence of such symptoms as obsessional rituals; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or inability to establish and maintain effective relationships, nor are other psychiatric symptoms shown to have resulted in the required level of impairment. Vazquez-Claudio. Given the foregoing, the Board finds that the Veteran’s symptoms are not of such severity to approximate, or more nearly approximate, the criteria for a 70 percent evaluation and that the findings do not support a conclusion that his symptoms are productive of a “similar severity, frequency, and duration” as those required for a 70 percent evaluation. See 38 C.F.R. § 4.7; Vazquez-Claudio (38 C.F.R. § 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). From September 17, 2015 onward, the Board finds the Veteran’s disability picture more nearly approximates the criteria for a disability rating of 70 percent. The symptoms exhibited by the Veteran on and after September 17, 2015 include suicidal ideation with no plan or intent, depressed mood; anxiety; chronic sleep impairment; disturbances in motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances; panic attacks that occur weekly or less often; mild memory loss; an inability to establish and maintain effective relationships; and serious impairment in occupational functioning. Further, the December 2015 VA examiner indicated that the Veteran’s depressive disorder progressed to major depressive disorder that was recurrent and moderate. The Veteran’s symptoms and their effects are contemplated within the criteria for a 70 percent rating. The Board further finds, for the entire period on appeal, that the Veteran’s disability picture does not approximate the criteria for a 100 percent rating because the Veteran does not exhibit total occupational and social impairment. As discussed above, the Veteran has consistently been found able to exhibit intact judgment, have normal speech, and the ability to perform self-care. Additionally, the records reflect that the Veteran’s GAF score in VA treatment records range from 30 to 50. The Board has considered the Veteran’s assigned GAF scores. Although these GAF scores indicate symptoms that are serious, the scores that indicate serious symptoms prior to September 17, 2015 are not persistent and consistent with objective observations form the VA records. The serious GAF scores were briefly present during a time of hospitalization in August 2013 and did not persist when the Veteran was stabilized and released. Further, as noted above, GAF scores alone do not support the assignment of any higher rating during the appeal. An examiner’s classification of the level of psychiatric impairment, by words or by GAF score, is to be considered but is not determinative of the percentage rating to be assigned. See 38 C.F.R. § 4.130; Barr v. Nicholson, 21 Vet. App. 303 (2007). Rather, it is considered in light of all of the evidence of record. GAF scores alone are not determinative, and the entire record must be considered. Based on the evidence of record, the Board finds that the Veteran’s symptomatology has most closely approximated the criteria for 50 percent prior to September 17, 2015, and had most closely approximated 70 percent thereafter. Effective Date 6. Entitlement to an effective date prior to July 3, 2013 for the grant of service connection for major depressive disorder. 7. Entitlement to an effective date prior to July 3, 2013 for the grant of service connection for Hepatitis C. In general, the effective date for a grant of service connection is the day following the date of separation from active service or the date entitlement arose, if the claim is received within one year after separation from service. Otherwise, it is the date of receipt of claim, or the date entitlement arose, whichever is later. 38 U.S.C. 5110 (a), (b); 38 C.F.R. 3.400 (b). (Continued on the next page)   For the claims of entitlement for an earlier effective date for the grant of service connection for major depressive disorder and hepatitis C, the Board finds that an earlier effective date is not warranted for establishing service connection for the claims. Although the Veteran experienced symptoms of and a diagnosis for the claims prior to his filing the claim, the Veteran did not file a claim for service connection until July 3, 2013. Pursuant to 38 C.F.R. § 3.400 (b), the effective date of a claim is the date of receipt of claim or the date entitlement arose, whichever is later. Therefore, even if the evidence was sufficient to establish entitlement to service connection on a date prior to July 3, 2013, an earlier effective date is unwarranted. Moreover, none of the exception prescribed under 38 C.F.R. § 3.400 or under 38 C.F.R. § 3.816 are applicable here. Therefore, an effective date prior to July 3, 2013 for establishing service connection for major depressive disorder and hepatitis C are denied. See 38 C.F.R. § 3.400. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Thompson, Associate Counsel