Citation Nr: 18157879 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 18-09 734 DATE: December 13, 2018 ORDER New and material evidence has been received to reopen a claim of entitlement to service connection for a sleep apnea. Entitlement to service connection for sleep apnea is granted. Entitlement to a rating in excess of 20 percent for a lumbar spine disability is denied. Entitlement to an initial compensable rating for bilateral hearing loss is denied. Entitlement to a rating in excess of 10 percent for sciatic nerve peripheral neuropathy of the left lower extremity is denied. Entitlement to a rating in excess of 10 percent for sciatic nerve peripheral neuropathy of the right lower extremity is denied. Entitlement to a rating in excess of 10 percent for femoral nerve peripheral neuropathy of the left lower extremity is denied. Entitlement to a rating in excess of 10 percent for femoral nerve peripheral neuropathy of the right lower is denied. Entitlement to an increased rating of 70 percent, but not higher, for posttraumatic stress disorder (PTSD) is granted. Entitlement to an earlier effective date of February 23, 2016, but not earlier, for a 20 percent rating for a lumbar spine disability is granted. Entitlement to an earlier effective date of February 23, 2016, but not earlier, for a 70 percent rating for PTSD is granted. Entitlement to an earlier effective date than June 6, 2014, for service connection for sciatic nerve peripheral neuropathy of the right lower extremity is denied. Entitlement to an earlier effective date of February 23, 2016, but not earlier, for service connection for sciatic nerve peripheral neuropathy of the left lower extremity with a 10 percent rating is granted. Entitlement to an earlier effective date of February 23, 2016, but not earlier, for service connection for femoral nerve peripheral neuropathy of the left lower extremity with a 10 percent rating is granted. Entitlement to an earlier effective date of February 23, 2016, but not earlier, for service connection for femoral nerve peripheral neuropathy of the right lower extremity with a 10 percent rating is granted. Entitlement to a totally disability rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. An unappealed September 2015 statement of the case continued the denial of service connection for sleep apnea, and the September 2014 decision became final. Since that decision, the Veteran has provided new and material evidence regarding the possible etiology of the claimed sleep apnea. 2. Resolving all reasonable doubt in favor of the Veteran, the probative evidence of record shows that the Veteran’s sleep apnea is etiologically related to, or aggravated by service-connected PTSD. 3. For the entire claim period, the Veteran’s back disability has been manifested by pain of the lower back, with range of motion, at worst, limited to 60 degrees of flexion, and a combined range limited to 200 degrees, and x-ray evidence of arthritis, without ankylosis. 4. The preponderance of the competent and credible evidence of record indicates that the Veteran’s bilateral hearing loss has been manifested by no worse than a Level IV hearing impairment in the right ear and a Level I hearing impairment in the left ear. 5. The Veteran’s bilateral lower extremity peripheral neuropathy was manifested by no more than disability most nearly approximating a mild level of incomplete paralysis of the bilateral sciatic nerve. 6. The Veteran’s bilateral lower extremity peripheral neuropathy was manifested by no more than disability most nearly approximating a mild level of incomplete paralysis of the bilateral femoral nerve. 7. Resolving all reasonable doubt in favor of the Veteran, for the pendency of the appeal, the Veteran’s PTSD was productive of occupational and social impairment, with deficiencies in most areas, such as work, family relations, and mood, manifested by reported sleep disturbance; hypervigilance; depressed mood; severe irritability; angry outbursts; panic attacks; and memory and concentration impairment. 8. The evidence of record contains an earlier informal claim filed within a year prior to January 25, 2017, on February 23, 2016, for increased rating for a low back disability, peripheral neuropathy of the bilateral lower extremities, and PTSD; and service connection for sleep apnea. 9. The evidence does not show any claim prior to June 6, 2014, for lumbar spine disability or sciatic neuropathy of the right lower extremity that would establish an earlier effective date for service connection. 10. The Veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities. CONCLUSIONS OF LAW 1. New and material evidence having been submitted, the claim for service connection for sleep apnea is reopened. 38 U.S.C. §§ 5108, 7104(b), 7105. 2. The criteria for service connection for a sleep apnea disability, as secondary to service-connected PTSD, have been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385. 3. The criteria for a rating in excess of 20 percent for a back disability have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71(a), Diagnostic Code 5242. 4. The criteria for a compensable rating for hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 1155, 5107; 38 C.F.R. §§ 3.102, 3.150, 3.321, 3.385, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. 5. The criteria for an initial rating in excess of 10 percent for sciatic peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5017; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.31, 4.120, 4.123, 4.124a, Diagnostic Code 8622. 6. The criteria for an initial rating in excess of 10 percent for sciatic peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5017; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.31, 4.120, 4.123, 4.124a, Diagnostic Code 8622. 7. The criteria for an initial rating in excess of 10 percent for femoral peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5017; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.31, 4.120, 4.123, 4.124a, Diagnostic Code 8622. 8. The criteria for an initial rating in excess of 10 percent for femoral peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5017; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.31, 4.120, 4.123, 4.124a, Diagnostic Code 8622. 9. The criteria for an increased rating of 70 percent, but not higher, for PTSD, during the period of appeal, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411. 10. The criteria for an effective date of February 23, 2016, for a 20 percent rating for a back disability, have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400; 38 C.F.R. § 3.155. 11. The criteria for an effective date of February 23, 2016, for a 70 percent rating for PTSD, have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400; 38 C.F.R. § 3.155. 12. The criteria for an effective date prior to June 6, 2014, for service connection for sciatic peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400; 38 C.F.R. § 3.155. 13. The criteria for an effective date of February 23, 2016, for service connection for femoral peripheral neuropathy of the left lower extremity with a 10 percent rating have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400; 38 C.F.R. § 3.155. 14. The criteria for an effective date of February 23, 2016, for service connection for sciatic peripheral neuropathy of the left lower extremity with a 10 percent rating have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400; 38 C.F.R. § 3.155. 15. The criteria for an effective date of February 23, 2016, for service connection for femoral peripheral neuropathy of the right lower extremity with a 10 percent rating have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400; 38 C.F.R. § 3.155. 16. The criteria for TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.340, 4.1, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1976 to February 1997. Duties to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C. §§ 5103, 5103A, 5107; 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from any notice error. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing an error is harmful or prejudicial falls on party attacking agency decision); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and representative suggest actual knowledge of the elements necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by claimant or representative that demonstrate awareness of what is necessary to substantiate claim). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the December 2017 and May 2018 statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has obtained an examination with respect to the claims. Thus, the Board finds that VA has satisfied the duty to assist. No further notice or assistance to the Veteran is required to fulfill VA’s duty to assist in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a sleep apnea A September 2014 rating decision denied service connection for sleep apnea. The Veteran filed a timely notice of disagreement, and a September 2015 statement of the case was issued. The Veteran did not file a timely substantive appeal and that decision became final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. In February 2016, the Veteran filed a Form 9, Appeal to Board of Veterans’ Appeals, in an attempt to appeal the previously denied claim. That was interpreted as a request for a claim form and the Veteran followed that informal claim with a January 2017 formal application for benefits, to include reopening a claim for service connection for sleep apnea. A March 2017 rating decision found no new and material evidence had been received, and declined to reopen the claim for service connection. The new evidence submitted by the Veteran includes an examination opinion from a physician, who, after a review of the Veteran’s medical history, opined that the Veteran’s sleep apnea was etiologically related to, or at least aggravated by, service-connected PTSD. The Board finds that evidence is both new and material, as the evidence was submitted after the previous denial, and tend to establish a causal link between sleep apnea and a service-connected disability. Accordingly, the Board finds that new and material evidence sufficient to reopen the claim has been submitted, and the claim is reopened. 38 C.F.R. § 3.156. Service Connection Generally, service connection may be granted for disability or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection is also warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for sleep apnea The Veteran claims that he has sleep apnea due to active service, or in the alternative, secondary to service-connected PTSD. The Board finds that competent medical evidence of record demonstrates that the Veteran’s diagnosed sleep apnea is at least as likely as not etiologically related to, or aggravated by, service-connected PTSD. Therefore, the Board finds that service connection for a sleep apnea disability is warranted, and the claim must be granted. The Veteran has established service connection for PTSD, and medical records, to include VA examinations show a diagnosed disability of obstructive sleep apnea. There are two separate medical opinions addressing the etiology of sleep apnea, to include as it relates to active service and PTSD. At an August 2014 VA examination, the examiner, after diagnosing sleep apnea, and conducting a full comprehensive review of the claims file and medical history, ultimately concluded that sleep apnea was less likely than not related to any aspect of active service. The VA examiner opined that a careful observation of the service medical records showed that any incident of lack of sleep or fatigue, as complained about by the Veteran, was not related to any diagnosis of a sleep disorder. Specifically, in the report and rationale, the examiner noted that the medical professional at the time expressly dismissed sleep disorder as the cause of the few documented incidents of fatigue during service. Therefore, the VA examiner ultimately concluded that the Veteran’s currently diagnosed sleep apnea was not incurred, or caused by, any aspect of his active service. In a November 2015 sleep examination, completed on a VA Disability Benefits Questionnaire, VA Form 21-0960L-2, a Dr. H. S., conducted a comprehensive review of the Veteran’s claims file and medical history, to include a physical examination. Upon examining the Veteran’s condition, Dr. H. S. diagnosed obstructive sleep apnea with periodic limb movement. The examiner noted that sleep apnea was diagnosed in 2008, and that the Veteran had been prescribed and using a CPAP machine. However, upon reviewing the relevant medical evidence and appropriate medical treatises and studies, the examiner concluded that while there was no evidence that the Veteran’s condition was related to active service, there was evidence of an etiological relationship between sleep apnea and service-connected PTSD. The examiner found that PTSD and other psychiatric disorders are commonly associated with the development of sleep apnea, to especially include trauma survivors, such as the Veteran. The examiner ultimately found that based on his exert opinion, and referencing supporting literature and clinical studies, that it was as likely as not that the Veteran’s PTSD “aided” in the development of, or at least permanently aggravated, the Veteran’s sleep apnea. The examiner acknowledged that Veteran’s nonservice-connected deviated septum, but concluded that condition only contributed in part to the condition, but was not the sole cause. The Board finds that the evidence of record supports a finding that service connection is warranted on a secondary basis. Specifically, the Board finds that the November 2015 examination to be highly probative in establishing that the Veteran’s currently diagnosed sleep apnea is etiologically caused, or at least aggravated, by service-connected PTSD. The earlier VA examination addressed direct service connection to active service and does not disagree with the November 2015 opinion. Therefore, as the positive secondary opinion was concluded from a comprehensive review of the Veteran’s medical history and sound rationale, based on the records and supporting medical literature, the Board finds the favorable opinion to be dispositive of the claim. Accordingly, resolving reasonable doubt in favor of the Veteran, service connection for sleep apnea, secondary to PTSD, must be granted. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). Consideration must be given as to whether staged ratings should be assigned to compensate entitlement to a higher rating at any point during the pendency of the claim. When the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two ratings is to be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When rating disabilities using Diagnostic Codes which provide a rating on the basis of loss of range of motion, VA must consider, to the extent possible, the degree of additional loss of function due to pain, weakened movement, excess fatigability, or incoordination. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45. 3. Entitlement to a rating in excess of 20 percent for a lumbar spine disability The rating criteria use a General Rating Formula for Diseases and Injuries of the Spine for diagnostic codes 5235 to 5243 unless 5243 is rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The General Rating Formula provides a schedule of ratings for spine disabilities with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Unfavorable ankylosis of the entire spine warrants a 100 percent rating. Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent rating. Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine warrants a 40 percent rating. Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine warrants a 30 percent rating. Forward flexion of the thoracolumbar spine greater than 20 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis warrants a 20 percent rating. Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, the combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or, vertebral body fracture with loss of 50 percent or more of the height warrants a 10 percent rating. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. The rater is instructed to rate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. §§ 4.71, 4.71a, Plate V, General Rating Formula for Diseases and Injuries of the Spine, Note (2). Each range of motion measurement is rounded to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (4). In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion. Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (3). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (0 degrees) always represents favorable ankylosis. Each range of motion measurement is rounded to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). Disability of the thoracolumbar and cervical spine segments is separately rated, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Each range of motion measurement is rounded to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (6). The Veteran claims that a service-connected low back disability is more severe than contemplated by the current 20 percent rating. A review of the competent medical evidence of record, to include VA medical records and VA examinations, shows evidence of a decreased range of motion, with the Veteran’s forward flexion limited to 60 degrees, and diagnoses of intervertebral disc syndrome (IVDS). Therefore, the Board finds that a higher rating for the Veteran’s back disability is not warranted under the General Rating Formula for Diseases and Injuries of the Spine, and the claim must be denied. Under the General Rating Formula, the next higher rating of 30 percent rating requires forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted upon the finding of unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. In a March 2017 VA examination of the back disability, the examiner provided a physical examination of the Veteran and diagnosed degenerative arthritis of the lumbar spine. The examiner noted the forward flexion of the Veteran’s thoracolumbar spine to be limited to 70 degrees and a combined range of motion of 220 degrees. However, upon repetitive testing, the examiner noted that the Veteran’s range of motion was reduced to 60 degrees of forward flexion and a combined range of motion of 200 degrees. The Veteran reported several flare-ups a week, usually due to the activity, and normally lasting less than 20 minutes. Further physical examination identified no objective evidence of localized tenderness and pain on palpation, and no evidence of ankylosis of any type. With regard to IVDS, the March 2017 VA examiner also found no report or evidence of episode of acute signs or symptoms the required bed rest prescribed by a physician in the past 12 months. The Board finds that, even considering the Veteran’s reduced range of motion after repetitive testing, that the results of the March 2017 VA examination remain in excess of that required to warrant a higher rating. In that examination, the Veteran’s combined range of motion remained at 210 degrees, and forward flexion of only 60 degrees, with no evidence of ankylosis, pursuant to the General Rating Formula, a 40 percent rating is not warranted. 38 C.F.R. § 4.71 (a). The Board finds no additional evidence of record, to include the Veteran’s lay statements and the VA treatment records, to demonstrate that the Veteran’s current back disability to be distinct from those of the March 2017 VA examination. The Board notes that a review of all the medical evidence of record shows no objective testing or measurement of the Veteran’s range of motion or any diagnosis of ankylosis of the Veteran’s lumbar spine since the Veteran’s last examination. The Board notes that the Veteran has not asserted that level of functional limitation to his range of motion, that would approximate to half of his measured range of motion during his March 2017 VA examination, and certainly nothing equivalent to an ankylosed thoracolumbar spine. During the most recent examination, the Veteran only reported pain when bending forward, and an inability to stand or sit for long period of time. Therefore, the Board finds that the preponderance of the evidence is against a finding that the Veteran has ankylosis, or that the Veteran’s thoracolumbar spine range of motion is limited to 30 degrees of flexion, and a 40 percent rating is not warranted. In arriving at this determination, the Board is cognizant of the fact that when rating disabilities rated on the basis of limitation of motion, VA must consider a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Here, however, the Board notes that any additional functional loss or limitation of motion caused by pain has already been considered by the Board. Specifically, the examiner noted that upon repetitive testing there the Veteran’s range of motion was only further limited by 10 degrees, to 60 degrees of forward flexion, and an overall decrease of 20 degrees for the combined range of motion of the lumbar spine. The Board finds that, even considering such objective decreases in motion, due to pain and repeat motion, the Veteran’s range of motion does not meet the requisite severity as required for a higher 40 percent rating. Therefore, the Board finds that the evidence does not show that the Veteran has functional loss in excess of that already encompassed by a 20 percent rating. DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board finds that all symptomatology alleged by the Veteran during this period, has been contemplated within the 20 percent rating, and no higher rating is warranted. The evidence does not show that any additional factors cause functional loss to an extent that the Veteran would meet the criteria for a higher rating of being limited in flexion to 30 degrees or less, or having ankylosis. Accordingly, the Board finds that a rating in excess of 20 percent, is not warranted for a back disability and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to an initial compensable rating for bilateral hearing loss The Veteran asserts that bilateral hearing loss is worse than that represented by the current 0 percent rating. The Veteran has been provided VA audiology examinations to assess the nature and severity of hearing loss during the claims period. A review of the results of those examinations, and other relevant evidence, to include lay statements and VA medical records, shows that the Veteran’s hearing loss, at worst, does not meet the criteria for a compensable rating under the appropriate Diagnostic Code. Therefore, the claim for a compensable rating for hearing loss must be denied. In rating service-connected hearing loss, disability ratings are derived from a mechanical application of the rating schedule to numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Ratings of bilateral hearing loss range from 0 percent to 100 percent based on impairment of hearing acuity. To rate the degree of disability from defective hearing, the rating schedule establishes eleven auditory acuity levels designated from I for essentially normal acuity, through XI for profound deafness. 38 C.F.R. § 4.85, Tables VI, VII. Audiological examinations used to measure impairment must be conducted by a state-licensed audiologist and must include both a controlled speech discrimination test (Maryland CNC) and pure tone audiometric tests. 38 C.F.R. § 4.85(a). The Ratings Schedule provides a table for rating purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, based upon a combination of the percent of speech discrimination (horizontal rows) and the pure tone threshold average (vertical columns), which is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. 38 C.F.R. § 4.85, Diagnostic Code 6100. The Roman numeral designation is located at the point where the percentage of speech discrimination and puretone threshold average intersect. 38 C.F.R. § 4.85(b). When the pure tone threshold at each of the four specified frequencies of 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). When the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(b). Table VII is used to determine the percentage rating by combining the Roman numeral designations for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. The percentage rating is located at the point where the row and column intersect. 38 C.F.R. § 4.85 (e). The Board finds that a review of all the VA and private audiological examinations and medical records, show that pure-tone threshold results from the Veteran’s July 2014 audiological examination to represent the most severe assessment of the Veteran’s hearing acuity. The Veteran’s pure tone thresholds from a July 2014 examination, in decibels, were: HERTZ 1000 2000 3000 4000 Average RIGHT 15 40 80 85 55 LEFT 15 35 60 60 40.25 The examination included speech recognition ability test results, to include under the Maryland CNC guidelines. Speech recognition was evaluated at 80 percent for the right ear and 92 percent for the left ear. Applying the findings of the July 2014 VA examination to the rating criteria for hearing impairment, the Board finds that the criteria for a compensable rating for hearing loss have not been met. The Veteran’s hearing acuity was measured using 38 C.F.R. § 4.85, Table VI, considering an audiological examination testing with speech audiometry (Maryland CNC). 38 C.F.R. § 4.86 (a). Under Table VI, the right ear hearing acuity was manifested by a level IV impairment, and the left ear was manifested by a hearing acuity of no more than a level I impairment. Applying those findings to 38 C.F.R. § 4.85, Table VII of the Rating Schedule results in a 0 percent rating for hearing loss. The Board notes that the results from a VA audiological examination during this relevant time period also include an March 2017 examination. Specifically, the Veteran’s pure tone thresholds from the March 2017 examination, in decibels, were: HERTZ 1000 2000 3000 4000 Average RIGHT 20 50 80 80 58 LEFT 20 45 55 60 45 The examination found speech recognition ability using the Maryland CNC test to be 96 percent for the right ear, and 96 percent for the left ear. Applying the findings of the March 2017 VA examination to the rating criteria for hearing impairment, the Board finds that the criteria for a compensable rating for hearing loss have not been met. The Veteran’s hearing acuity was measured using 38 C.F.R. § 4.85, Table VI, considering an audiological examination testing with speech audiometry (Maryland CNC). 38 C.F.R. § 4.86(a). Under Table VI, the right ear hearing acuity was manifested by a level II impairment, and the left ear was manifested by a hearing acuity of no more than a level I impairment. Applying those findings to 38 C.F.R. § 4.85, Table VII of the Rating Schedule results in a 0 percent rating for hearing loss. Both the VA examinations of record, represent the Veteran’s hearing acuity at worst during the claims period, and remain below the criteria for a compensable rating. 38 C.F.R. § 4.85(f). The Board finds that the probative evidence of record, to include any VA medical records, does not show a more severe hearing loss disability than is contemplated by the 0 percent rating assigned. The Board has considered the Veteran’s statements regarding the severity of hearing loss. The Board acknowledges that the Veteran is competent to attest to the occurrence of lay-observable events or the presence of a disability or symptoms of a disability subject to lay observation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). However, the clinical findings reported on examination are more probative than the Veteran’s statements as he is not shown to have the requisite education, experience, and training to determine the severity level of service-connected hearing loss as it applies to the rating schedule. Smith v. Derwinski, 1 Vet. App. 235 (1991). The Board finds the VA examinations are more probative in establishing the specific level of hearing loss in light of the rating schedule, which is determined by objective levels of hearing acuity. Therefore, considering the Veteran’s subjective report, and weighing the probative medical evidence, the Board finds that the preponderance of the relevant evidence remains against the claim. In providing its findings, the Board acknowledges the Veteran’s complaints regarding impact of his hearing loss on his daily activities, and the VA’s obligations of resolving reasonable doubt in favor of the Veteran. However, the Board notes that the assignment of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometry evaluations are made. There is no doubt as to the proper ratings to assign, and thus not doubt to resolve in favor of the claimant. Lendenmann v. Principi, 3 Vet. App. 345 (1992); 38 C.F.R. § 4.85, Tables VI, VIA, VII, Diagnostic Code 6100. The RO and the Board are bound by applicable laws and regulations promulgated by the VA. 38 U.S.C. § 7104(c); 38 C.F.R. § 20.101(a). Consideration of factors wholly outside the schedular rating criteria would constitute error as a matter of law. Massey v. Brown, 7 Vet. App. 204 (1994); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, reasonable doubt shall be resolved in favor of the claimant. The Board finds that the preponderance of the evidence is against the assignment of a compensable rating for hearing loss and that claim must be denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to increased ratings in excess of 10 percent for sciatic and femoral peripheral neuropathy of the left and right lower extremities The Veteran claims that his bilateral peripheral neuropathy of the lower extremities, both sciatic and femoral, are worse than that represented by the current disability ratings. The Board notes that two separate rating decisions in March and December 2017 assigned separate ratings for peripheral neuropathy of the bilateral lower extremities for both sciatic and femoral nerves, respectively. The RO assigned four separate 10 percent ratings for mild incomplete paralysis of the right and left sciatic and femoral nerves. The Veteran contends that his disability in both lower extremities are worse than contemplated by the 10 percent ratings. The Veteran’s service-connected nerve disabilities are currently rated under Diagnostic Codes 8620 (sciatic) and 8626 (femoral). Under either Diagnostic Code a 10 percent rating is warranted for mild incomplete paralysis, a 20 percent rating is warranted for moderate incomplete paralysis, and a 30 percent is warranted for severe incomplete paralysis. 38 C.F.R. § 4.124a, Diagnostic Codes 8620, 8626. The term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The rating schedule does not define the terms mild, moderate, or severe as used in the diagnostic codes. Instead, adjudicators must evaluate all of the evidence and make a decision that is equitable and just. 38 C.F.R. § 4.6. The Board finds that, after a review of the competent medical evidence of record, to include VA examinations and VA medical records, that the Veteran’s peripheral neuropathy of the right and left lower extremities, for both sciatic and femoral, more nearly approximated, at worst, mild incomplete paralysis, with symptoms such as pain, numbness, burning, and swelling. Therefore, the Board finds that the Veteran’s claim for increased ratings must be denied. During the pendency of the claim, the Veteran was provided a VA examination in March 2017. In that examination report, the VA examiner accounted for the Veteran’s subjective reports, and conducted a full review of the Veteran’s medical history and claims file. The examiner diagnosed peripheral neuropathy due to the Veteran’s back disability, to include intervertebral disc syndrome. Reported symptoms of the disability included mild intermittent pain, paresthesias, and numbness. Upon nerve testing, the examiner found that the Veteran had mild incomplete paralysis of both the sciatic and femoral nerves, bilaterally. The examiner noted that the condition caused some functional impact to include preventing prolonged walking, standing, heavy lifting, climbing, and bending. During the pendency of the claim, that was the only VA examination provided to the Veteran specific to the Veteran’s nerve conditions. However, in the same time period, the Veteran’s back disability was separately evaluated. The Board notes that in that separate report, also conducted in March 2017, the Veteran’s nerve conditions, to include both his sciatic and femoral, were identified to being as part, or etiologically related to the back disability, and were also explicitly found to be of mild severity. In addition to the VA examinations, the record includes VA medical records for the claims period. A review of those records shows no real evaluation that speaks to the specific functional affect or severity of the Veteran’s nerve condition of the lower extremities. No explanation or testing results were provided in the contemporaneous records. No further testing of the Veteran’s condition specific to the service-connected peripheral neuropathy was conducted until a March 2017 VA examination. The Board finds that the competent medical evidence of record supports a finding that the Veteran’s peripheral neuropathy disability, both femoral and sciatic, has not risen to the point where it more nearly approximates a moderate incomplete paralysis. The Board finds that the VA examinations to be exceptionally probative in providing an adequate picture of the severity of the Veteran’s condition. Most significantly, the Board notes that the Veteran has not provided even lay statements or assertions specifically identifying those symptoms and manifestations other than those noted by the VA examinations. The record is relatively sparse with any assertion with regard to the functional impairment specifically caused by the Veteran’s peripheral neuropathy, that would cause the Board to conclude that such conditions are of moderate severity. The symptoms and manifestations noted of record only include those identified by the March 2017 VA examination, to include numbness, pain, and burning, with increased symptoms only after long periods of standing or walking. That symptomology has already been considered by a medical professional and evaluated as only amounting to a mild condition. Accordingly, the Board finds that the preponderance of evidence is against the assignment of ratings greater than 10 percent for peripheral neuropathy of the left or right lower extremity for both sciatic and femoral nerves. Therefore, the claims must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 6. Entitlement to an increased rating in excess of 50 percent for posttraumatic stress disorder (PTSD) The Veteran claims that his service-connected psychiatric disability, to include PTSD and depression, is more severe than that contemplated by the current 50 percent rating. The Veteran’s PTSD is rated under Diagnostic Code 9411, the General Rating Formula for Mental Disorders. A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is assigned 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 worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. 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 or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. That portion of VA’s Schedule for Rating Disabilities that addresses service-connected psychiatric disabilities was based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) IV prior to a change effective August 4, 2014. 38 C.F.R. § 4.130. The regulation has been changed to incorporate the current DSM, the DSM-5. However, that change does not apply to this claim, which was pending at the time of the change. The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between 0 and 100, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. This case involves assignment of GAF scores and those assignments are relevant to the Veteran’s level of impairment due to his PTSD. In evaluating the evidence, the Board also considers the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). A GAF score of 61 to 70 indicates some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, but generally reflects that a person is functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates moderate symptoms or moderate difficulty in social, occupational or school functioning. A GAF score of 41 to 50 indicates there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals), or any serious impairment in social, occupational, or school functioning (e.g., no friends, inability to keep a job). The Board notes that an examiner’s classification of the level of psychiatric impairment, by words or by a GAF score, is to be considered, but is not determinative in and of itself, of the percentage rating to be assigned. The Board observes that to adequately evaluate and assign the appropriate disability rating to the Veteran’s service-connected psychiatric disability, the Board must analyze the evidence as a whole, including the Veteran’s GAF scores and the enumerated factors listed in 38 C.F.R. § 4.130, Diagnostic Code 9411. Mauerhan v. Principi, 16 Vet. App. 436 (2002) (rating specialist is to consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment). The claimant seeks entitlement to a higher rating than 50 percent for PTSD. The Board finds that an assessment of the relevant medical evidence of record shows that the Veteran’s psychiatric disability, was manifested with symptoms of depressed mood, anxiety, sleep disturbance, hypervigilance, panic attacks, detachment, and irritability. The Board finds that the Veteran’s psychiatric symptoms have combined to be productive of occupational and social impairment, with deficiencies in most areas, such as work, family relations, and mood, which warrants a higher 70 percent rating, but not higher. Therefore, the claim for an increased rating must be granted. A review of the medical records for PTSD shows that the Veteran’s PTSD, generally manifested symptoms of depressed mood, sleep disturbance, anxiety, irritability, and angry outbursts. The Veteran tended to isolate himself, although some measured social contact has been noted on examinations, to include with his spouse. Both VA psychologists and social workers, on various occasions have expressly noted the Veteran’s irritability, angry outburst, and overall inability to work, or routinely be around others in a social or professional setting. The Board highlights the medical evidence of record showing that the Veteran was provided psychiatric examinations to assess the nature and severity of PTSD in November 2015, and March 2017. Additionally, the Veteran has submitted opinion letters from his spouse and daughter, speaking to the severity of his condition. At a November 2015 VA examination, the VA examiner noted that the Veteran was cooperative with good eye contact, and normal speech. However, the Veteran’s condition was noted to be manifested by weekly panic attacks, flattened affect, disturbance in motivation, inability to handle stressful situations, sleep disturbance, and hypervigilance, and an inability to maintain meaningful social and occupational relationships. The Veteran was also noted to have issues with his personal hygiene during the examination. The Veteran’s affect was depressed with anxiety during the examination. There examiner found no evidence or reports of suicidal thoughts or ideation. In addition to the manifestations of the Veteran’s psychiatric condition, the VA examiner also noted extensively the Veteran’s relative irritability, to include angry outbursts. The Veteran was noted to be suspicious and vigilant when speaking to examiner, and was insecure and unsure of himself, especially in social interaction. Most importantly, the examiner found that the Veteran had increased trouble with short- and long-term memory, and variable concentration. The examiner noted that the Veteran struggled with remembering most basic information. As a result, the examiner ultimately found that the Veteran’s condition was productive of occupational and social impairment with deficiencies in most areas, such as work, family relations, judgement, thinking, and mood. A March 2017 VA psychiatric examination diagnosed PTSD. The VA examiner noted much of the same consistent symptoms and manifestations of the Veteran’s psychiatric disability as the previous examination. Specifically, the examiner noted ongoing issues with irritability, anger, sleep problems, depression, social withdrawal, general isolation, anxiety, panic attacks, memory loss, disturbance in motivation and mood, and difficulty adapting the stressful circumstances. In addition, the examiner noted that the Veteran had hallucinations, some obsessive or ritualistic behavior, startle response, hypervigilance, and suspiciousness. The examiner noted that the Veteran did not endorse any indications of suicidal or homicidal ideations, and was a low risk of hurting himself. However, while much of the same symptoms and manifestations were identified as the prior VA examination, the examiner ultimately found that the Veteran’s condition caused social and occupational impairment with only occasional decrease in work efficiency and ability to perform occupational tasks, although generally functioning. In addition to those examination reports, the record includes some treatment sessions and counselling by the VA throughout the claims period. The Board notes that an exhaustive review of the session notes and mental progress assessments shows very little evidence of assessing actual social and occupational impairment caused by PTSD. Overall, the medical evidence only notes, albeit sparsely, a fairly consistent array of complaints of symptoms such as irritability, nightmares, flashbacks, hypervigilance, depression, and social isolation, with no mention or evidence of suicidal or homicidal ideations. The Veteran has also submitted lay statements from his spouse and daughter, regarding his manifestations of his PTSD throughout the years. Both account a similar litany of symptoms to include the Veteran’s overall irritability and ange, with outbursts that were considered verbally abusive. The Veteran’s daughter notes the angry outbursts happened unpredictably and could be triggered with even the smallest of incidents. While there is no evidence of the outbursts being violent, specific examples set forth by the daughter noted angry yelling and screaming. The Veteran’s spouse noted the same type of irritability and angry outbursts from the Veteran over trivial matters. Additionally, the spouse noted deteriorating memory, sleep disturbance, and nightmares. In both letters, the Veteran’s spouse and daughter expressed that the condition had put a strain on their relationship. The Board finds that evaluating the totality of the evidence, both medical and lay, there is an overall consensus on the array of symptoms that most affect the Veteran’s social and occupational impairment. These repeating symptoms include irritability, to include angry outbursts, sleep disturbance with nightmares, depression, memory loss, inability to deal with stressful situations, isolation, panic attacks, and an overall inability to establish social relationships. The lay statements from the two of the closest people in the Veteran’s life, his spouse and daughter, expressed a strained and struggling relationship with the Veteran due to the symptoms and manifestations of the mental disorder. In addition to that evidence, the Veteran, through his representative, provided a private vocational expert opinion from Dr. S. B., finding that the Veteran is not able to obtain or maintain substantial employment due to his physical and psychiatric condition. With specific regard to the Veteran’s PTSD, the vocational examiner noted the Veteran’s inability to sustain even light work, or sedentary employment based on his inability to interact appropriately with others, or maintain focus and concentration to sustain the demands of any such work. However, different examiners have concluded different levels of impairment due to similar symptoms. The November 2015 examiner found the symptoms to amount to occupational and social impairment with deficiencies in most areas, equating to a 70 percent rating, and the March 2017 VA examiner found that the symptoms only equated to, only occasional social and occupational impairment, equating only to a 50 percent rating. The Board finds that considering the totally of the Veteran’s disability picture for the appeal period, to include the examinations and the letters from the Veteran’s family members, the Board must find that the evidence is at least in equipoise with regard to demonstrating that the Veteran’s PTSD amount to deficiencies in most areas such as judgment, work, and relationship. The Board notes that the Veteran’s severe irritation, angry outbursts, and isolation cause difficulty in creating or maintaining social relationships, or from obtaining employment. The Board finds that while examination reports noted that the Veteran had normal speech, appropriate eye contract, and was properly oriented, his condition has led to significant distress in most areas such as impairment in both social and occupational functions, as exemplified by his inability to work and his tense relationship with his family. A 70 percent rating under the appropriate Diagnostic Code requires symptoms productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran’s condition has been manifested by social isolation, severe irritability, depression, sleep disturbance, and anger outbursts, which has demonstrated to limit the ability to create social or occupational relationships. The evidence demonstrated that even with familial relationships, e.g. his wife and daughter, maintaining such relationships is a daily struggle, with much strain. The Veteran has also shown impaired impulse control, to include severe irritability over small and trivial matters, that turn into shouting and screaming. Therefore, the Board finds that an assessment of the relevant evidence of record shows that the severity of Veteran’s PTSD for the entire claims period, has been productive of occupational and social impairment, with deficiencies in most areas, such as work, family relations, and mood, consistent with the latter staged period of this claim, and warranting a higher 70 percent rating, but not higher. Bankhead v. Shulkin, 29 Vet. App. 10 (2017). The Board finds that the Veteran’s PTSD does not meet the criteria for a higher, 100 percent rating, for any part of the claims period. The Board notes that a 100 percent rating is only 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 for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. Here, the Board finds that the preponderance of the evidence is against a finding that the Veteran has total social impairment. The Veteran has never been noted to be grossly inappropriate during any treatment, evaluation, or examination session of record. In fact, in all VA examinations or VA medical records, the Veteran was explicitly noted to be well-oriented, appropriately dressed, polite, and coherent, with clear speech, good eye contact, and unimpaired throughout process and judgment. At no point during the claims period has there been evidence of persistent delusions or hallucinations, with no evidence of memory loss. In addition, the Veteran maintains a spousal relationship, although it is shown to be strained. Therefore, the Board finds that total social impairment is not shown, and the Board finds that a 100 percent rating was not warranted. Consequently, as the evidence is at least in equipoise with regard to the severity of the Veteran’s service-connected condition, the claim for a higher 70 percent rating, but not higher, for PTSD, must be granted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Effective Date Unless specifically provided otherwise, the effective date of an award based on a claim for service connection benefits shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application for such benefits. The effective date shall be the later of either the date of receipt of claim, or the date entitlement arose. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i). The terms “claim” and “application” mean a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). Generally, the date of receipt of a claim is the date on which a claim, information, or evidence is received by VA. 38 C.F.R. § 3.1(r). A specific claim in the form prescribed by VA must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151(a). Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, his duly authorized representative, a Member of Congress, or a person acting as next friend of the claimant who is not sui juris may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. 38 C.F.R. § 3.155(a). The Board notes that on March 24, 2015, VA amended its adjudication regulations to require that all claims governed by VA’s adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. 79 Fed. Reg. 57660 (Sept. 25, 2014). The amendments are only effective for claims and appeals filed on or after March 24, 2015. As the appeal in this case was filed after that date, the amendments are applicable in this instance. An informal claim must be (1) a communication in writing that (2) expresses an intent to apply for benefits, and (3) identifies the benefits sought. Brokowski v. Shinseki, 23 Vet. App. 79 (2009); Brannon v. West, 12 Vet. App. 32 (1998) (before VA can adjudicate original claim for benefits, the claimant must submit a written document identifying the benefit and expressing some intent to seek it). 7. Entitlement to an earlier effective date prior for a back disability, peripheral neuropathy, PTSD, and sleep apnea In this case, the record shows that the Veteran initially filed a claim on a VA Application for Disability Compensation Form, VA Form 21-526EZ, dated January 25, 2017. In that claim for benefits, the Veteran noted claims for PTSD, hearing loss, a back disability, neuropathy, and sleep apnea. A March 2017 RO decision established service connection for right and left lower extremity sciatic peripheral neuropathy with 10 percent ratings, assigned a higher 50 percent rating for PTSD, and assigned a higher 20 percent rating for a back disability, effective on January 25, 2017, the date of receipt of the Veteran’s claim. Prior to January 25, 2017, a similar list of claims was previously denied by the RO in September 2014, to include claims for increased rating for the back, PTSD, hearing loss, sleep apnea, and peripheral neuropathy. The Veteran filed a subsequent notice of disagreement, and a September 2015 statement of the case was issued. However, the Veteran did not file a timely substantive appeal, VA Form 9, and the prior denials became final. The Board notes that while there is a VA Form 9 on record, dated February 23, 2016, that substantive appeal was not timely. Therefore, the previous decision became final, and the Veteran’s current appeal cannot be considered a continuation of the pervious claim, for the purposes of establishing an earlier effective date. However, the Board finds that the February 23, 2016, VA Form 9, although untimely to perfect an appeal, constitutes an informal claim for benefits to include those outlined in his formal January 2017 claim, or a request for claim form. In that informal claim or request for claim form, the Veteran outlined claims for increased rating for his PTSD, lower extremity peripheral neuropathy, hearing loss, a back disability, and service connection for sleep apnea. Therefore, as that informal claim or request for claim form outlines specific entitlements sought under the VA law, and a subsequent formal claim was received on the appropriate form within one year of that informal claim or request for claim form on January 25, 2017, that February 23, 2016, communication shall be established as the date of receipt of the claims subsequently granted by the VA. 38 C.F.R. § 3.155(a). Consequently, the date of claim of record, February 23, 2016, is the controlling date for the effective date assigned under the factual circumstances in this matter. Accordingly, an earlier effective date of February 23, 2016, but not earlier, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, the appeal is granted, and an earlier effective date to February 23, 2016, is applicable to the Veteran’s increased rating of 20 percent for a back disability, increased rating of 70 percent for PTSD, service connection for bilateral femoral and left sciatic neuropathy of the lower extremities with 10 percent ratings, and service connection for sleep apnea. The record shows that the effective date for service connection and a 10 percent rating for right sciatic lower extremity neuropathy is June 6, 2014. That effective date and rating became final when the Veteran did not perfect a timely appeal following the September 2015 statement of the case and the effective date and rating assigned in the September 2014 rating decision became final. Therefore, an earlier effective date for right sciatic lower extremity neuropathy earlier than June 6, 2014, for service connection is not warranted as a free-standing claim for earlier effective date cannot be adjudicated following a finally assigned effective date, in the absence of clear and unmistakable error, which has not been contended or found. Therefore, the claim for earlier effective date for service connection with a 10 percent rating for right sciatic lower extremity neuropathy must be denied. 8. Entitlement to TDIU. Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total if it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of (1) a single service-connected disability rated at 60 percent or more, or (2) as a result of two or more disabilities, provided at least one disability is rated 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). TDIU requires impairment so severe that it is impossible for the average person to obtain and maintain a substantially gainful occupation. Consideration may be given to the Veteran’s level of education, special training, and previous work experience in arriving at a conclusion, but not to age or impairment caused by disabilities that are not service connected. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19. The critical inquiry is whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). As a preliminary matter, the Board finds that the Veteran meets the percentage requirement for consideration for a TDIU. 38 C.F.R. § 4.16(a). The Veteran’s service-connected PTSD is rated 70 percent, and the combined service-connected rating was 80 percent prior to the increases and additional service connection established by this decision. The Board finds that the Veteran’s qualifies for schedular consideration for TDIU. 38 C.F.R. § 4.16(a). The Board also finds that the evidence of record is in the Veteran’s favor with regard to whether he is precluded from obtaining and maintaining a substantially gainful occupation consistent with his education and work experience as a result of his service-connected disabilities. Specifically, the Board notes that the Veteran has been out of work since 2007, and is currently unemployed. The record shows that he previously worked as a carpenter, and has a high school education, with no additional education or specialty training. The Veteran has consistently noted that he no longer can do that job due to his physical disability, to include his back, his lower extremities, and basic inability to do any physical labor. The Board notes that in his most recent back and neurological examination for the lower extremities, the VA examiner noted that the due to those service-connected disabilities, the Veteran was unable to stand, walk, or sit for long periods of time. In this respect, the examiner, when speaking to functional loss noted the Veteran was not able to do physical labor, to include bending, kneeling, or lifting. The Board finds that the evidence of record supports a finding that the Veteran is precluded from obtaining and maintaining a substantially gainful occupation consistent with his education and work experience as a result of the service-connected disabilities. In addition to the VA examinations the Veteran has also provided a private opinion letter from a vocational expert, Dr. S. B. Specifically, in an August 2018 vocational assessment, the vocational expert, noted the Veteran’s limited physical disability to stoop, crouch, kneel, or lift, prevented the Veteran from physically demanding occupations, the Veteran’s psychiatric disability, to include his PTSD, also precluded obtaining or maintaining any sedentary occupations. Specific to the latter, the examiner explicitly noted the Veteran’s irritability and general inability to interact appropriately with others, prevents him from any sedentary occupation his physical limitations may allow. Additionally, Dr. S. B. also noted the Veteran’s inability to maintain concentration and memory loss, as other factors that would prevent him from sustaining the demands of any work environment, or to attend work on a regular basis. Overall, the examiner concluded that due to the Veteran’s litany of service-connected disabilities, the Veteran would not be able to obtain or sustain employment. The Board has evaluated the Veteran’s work experience, training, and service-connected disabilities and finds that the evidence demonstrates that his such disabilities prevent him from obtaining and maintaining substantially gainful employment. Looking at the totality of the Veteran’s work experience (carpentry), education (high school), and disability, to include both physical and mental limitations caused by the service-connected disabilities, the Board find that the service-connected disabilities prevent him obtaining and sustaining substantially gainful employment. Therefore, the Board finds that in viewing the totality of the Veteran’s disabilities, to include lay statements and VA examinations, the Veteran’s service-connected disabilities prevent him from obtaining and retaining gainful employment. Resolving reasonable doubt in favor of the Veteran, the Board finds that entitlement to TDIU is warranted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Zi-Heng Zhu, Associate Counsel