Citation Nr: 18159267 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 16-48 769 DATE: December 18, 2018 ORDER Service connection for a back disorder is denied. Service connection for bilateral hearing loss is denied. Service connection for tobacco use disorder/smoking is denied. An initial rating in excess of 20 percent for diabetes is denied. An initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to an initial rating in excess of 60 percent prior to June 13, 2013, and as of October 1, 2013, for coronary artery disease (CAD) is remanded. Entitlement to an effective date prior to March 26, 2011, for the grant of service connection for CAD is remanded. Entitlement to an effective date prior to March 26, 2012, for the grant of service connection for PTSD is remanded. Entitlement to an effective date prior to March 26, 2012, for the grant of service connection for diabetes is remanded. Entitlement to an effective date prior to June 13, 2013, for the grant of service connection for surgical scar status post cardiac surgery is remanded. Entitlement to an initial compensable rating for surgical scar status post cardiac surgery is remanded. Entitlement to total disability based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The weight of the competent and probative evidence is against finding that a current back disorder had its onset during or is otherwise related to the Veteran’s period of active service. 2. The weight of the competent and probative evidence is against finding that the Veteran’s current bilateral hearing loss for VA purposes had its onset during or is otherwise related to the Veteran’s period of active service. 3. Tobacco use disorder/smoking is not a disability for VA purposes. 4. The weight of the competent and probative evidence is against finding that diabetes requires insulin or regulation of activities. 5. The weight of the competent and probative evidence is against finding that the Veteran’s psychiatric symptoms result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a back disorder have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385. 3. The criteria for entitlement to service connection for a tobacco use disorder/smoking have not been met. 38 U.S.C. §§ 1103, 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.300, 3.303. 4. The criteria for entitlement to an initial rating in excess of 20 percent for diabetes have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.10, Diagnostic Code (DC) 7913. 5. The criteria for entitlement to an initial rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1967 to May 1970. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). As a general matter, establishing service connection requires competent evidence of (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Certain chronic diseases, including arthritis and sensorineural hearing loss, will be considered incurred in service if manifest to a degree of ten percent within one year of service. 38 C.F.R. §§ 3.307, 3.309(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing service connection for the chronic diseases listed in Section 3.309(a) is through a demonstration of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was “noted” during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). In relevant part, 38 U.S.C. § 1154(a) requires that VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990). 1. Entitlement to service connection for a back disorder. After review of the record, the Board finds that the criteria for service connection for a back disorder have not been met. The record contains competent diagnoses of arthritis, spondylosis, and degenerative disc disease of the lumbar spine. 09/16/2016, C&P Exam. Accordingly, the Board finds competent evidence of a current back disorder. The Veteran’s service treatment records do not contain complaints of, treatment for, or a diagnosis of a back injury or disorder. 04/17/2015, STR-Medical. After service, a September 2001 treatment note reflects the Veteran’s report of the onset of back pain as two days prior. In October 2002, the Veteran reported acute back pain starting one month prior. Later treatment records reflect the Veteran’s report of chronic low back pain since 1976 or 1977 (six years after separation from active service), with major back pain beginning around September 2002. 04/04/2013, CAPRI. Imaging in September 2004 revealed degenerative disc disease and osteoarthritic changes of the facet joints of the lumbar spine. 04/15/2013, Medical-SSA. A September 2004 letter from a private physician reflects the Veteran’s report that he worked in construction post-service, and that he has had back problems “all his life,” but that he experienced acute, severe back pain in September. 04/15/2013, Medical-SSA. In September 2016, a VA examiner opined that the Veteran’s back disorder was less likely than not incurred in or caused by his active service. The examiner noted that there was no evidence of a chronic of ongoing back condition in service and the Veteran endorsed being in excellent health at the time of separation. The examiner acknowledged the Veteran’s statement that he began experiencing back pain in 1976, but noted that there is no evidence of a back condition until 2002. 09/16/2016, C&P Exam. The Board acknowledges that there is evidence of treatment for back pain in 2001, but finds that this does not materially decrease the probative weight of the examiner’s opinion, as it is only one year prior to the date identified by the examiner as the first evidence of a back condition, which is more than 30 years after service. In light of the foregoing, the Board finds that the weight of the competent and probative evidence is against finding that a current back disorder had its onset during or manifested within one year of service, or that it was noted in service with evidence of symptoms on a continuous basis since. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Specifically, the Board notes that there is no evidence of complaints of, treatment for, or a diagnosis of a back injury or disorder during service, and the Veteran reports that back pain began in 1976, six years after discharge. The Board acknowledges that the Veteran’s initial claim for compensation claimed all conditions as secondary to PTSD. Although the VA examiner did not address whether a current back disorder is proximately due to PTSD, the Board finds that the evidence of record does not indicate such an opinion, as the Veteran has not submitted competent lay or medical evidence indicating any association between PTSD and a back disorder. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (explaining that something more than a Veteran’s conclusory, generalized statement is needed to trigger VA’s duty to assist by providing a medical nexus examination). In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. 2. Entitlement to service connection for bilateral hearing loss. After review of the record, the Board finds that the criteria for service connection for bilateral hearing loss have not been met. In a claim of service connection for impaired hearing, demonstration of the first Shedden element—i.e., the existence of a current disability—is subject to the additional requirements of § 3.385, which provides that service connection for impaired hearing shall not be established until the hearing loss meets pure tone and/or speech recognition criteria. Under this regulation, hearing status will be considered a disability for the purposes of service connection when the auditory thresholds in any of the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In August 2013, the Veteran was given an audiological examination by a VA audiologist, and pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 45 65 85 LEFT 25 30 45 85 80 08/14/2013, C&P Exam. Accordingly, the Board finds that there exists bilateral hearing loss for VA purposes. See 38 C.F.R. § 3.385. A May 1967 audiological examination indicates pure tone thresholds, in decibels, were as follows:   HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 0 X 10 LEFT 0 0 0 X 30 04/17/2015, STR-Medical. Although the entrance examination indicates some degree of hearing loss of the left ear, the presumption of soundness still attaches because the entrance examination pure tone thresholds did not meet the criteria for hearing loss under 38 C.F.R. § 3.385. See McKinney v. McDonald, 28 Vet. App. 15 (2016); see also Hensley v. Brown, 5 Vet. App. 155 (1993) (stating that the threshold for normal hearing is between zero and 20 decibels and higher thresholds show some degree of hearing loss). Audiological testing was not performed in conjunction with the May 1970 separation examination, other than a whisper test, which has been determined as not a valid indicator of hearing acuity. The evidence does not demonstrate any complaints of, treatment for, or diagnoses of hearing loss during service. The Veteran denied hearing loss in March 2006. 04/03/2013, CAPRI. The Veteran was first diagnosed with hearing loss at the time of the August 2013 VA examination. The earliest indication of hearing loss is the Veteran’s claim for service connection for hearing loss, received by VA in March 2012. In September 2016, a VA audiologist opined that it is less likely than not that the Veteran’s bilateral hearing loss is due to his period of service. The VA audiologist recognized that while the whisper test performed at separation is not a valid indicator of hearing loss, there is a more than 40-year gap of audiological treatment. 09/02/2016, C&P Exam. The Board recognizes that the VA audiologist also opined that the Veteran had pre-existing left ear hearing loss; however, as the Board has found that the presumption of soundness attaches, the examiner’s opinion in this regard has no bearing as to the issue on appeal, and does not merit further discussion. In light of the foregoing, the Board finds that the weight of the competent and probative evidence is against finding that bilateral hearing loss had its onset during or manifested within one year of service, or that it was noted in service with evidence of symptoms on a continuous basis since. See 38 C.F.R. §§ 3.303, 3.307, 3.309. Specifically, the Board notes that there is no evidence of complaints of, treatment for, or a diagnosis of hearing loss during service, and the first indication of hearing loss is the Veteran’s claim received in March 2012, more than 40 years after service. Additionally, the Veteran denied hearing problems in March 2006, and has not contended that his hearing loss began during service. The Board acknowledges that the Veteran’s initial claim for compensation claimed all conditions as secondary to PTSD. Although the VA examiner did not address whether hearing loss is proximately due to PTSD, the Board finds that the evidence of record does not indicate such an opinion, as the Veteran has not submitted competent lay or medical evidence indicating any association between PTSD and hearing loss. See Waters, 601 F.3d at 1278-79. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. 3. Entitlement to service connection for tobacco use disorder/smoking. After review of the record, the Board finds that the criteria for service connection for tobacco use disorder/smoking have not been met. The Veteran has not claimed that he has a diagnosed condition due to smoking tobacco. The record reflects a diagnosis of tobacco use disorder, which is not a disability for VA purposes. In fact, for claims filed after June 9, 1998, Congress has prohibited the grant of service connection for disability due to the use of tobacco products during active service. 38 U.S.C. § 1103(a); see also 38 C.F.R. § 3.300(a). Accordingly, service connection for tobacco use disorder/smoking is denied as a matter of law. Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Additionally, staged ratings are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the course of the appeal. Id. at 126-27; Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3; see Gilbert, 1 Vet. App. at 57-58. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the disorder. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau, 492 F.3d at 1377; 38 C.F.R. § 3.159(a). 4. Entitlement to an initial rating in excess of 20 percent for diabetes. The Veteran contends that a rating in excess of 20 percent is warranted for diabetes, evaluated under Diagnostic Code 7913. Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes requiring insulin and a restricted diet, or oral hypoglycemic agents and a restricted diet. A 40 percent rating is warranted when diabetes requires insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities). A 60 percent rating is warranted for diabetes requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, DC 7913. The United States Court of Appeals for Veterans Claims (Court) has explained that the term “regulation of activities” means that a claimant must have a medical need to avoid not only strenuous occupational activity, but also strenuous recreational activity. Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). Medical evidence is required to show that occupational and recreational activities have been restricted. Id. at 364. Additionally, the criteria in DC 7913 are conjunctive. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (noting the use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). As such, the Board notes that § 4.7 is not applicable, but § 4.3 is for application. See Tatum v. Shinseki, 23 Vet. App. 152 (2009) (holding that 38 C.F.R. § 4.7 is not applicable when the ratings criteria are successive and not variable); see also Johnson v. Wilkie, No. 16-3808, 2018 U.S. App. Vet. Claims LEXIS 1253, at *20 (Vet. App. Sep. 19, 2018) (“Unlike §§ 4.7 and 4.21, § 4.3 presents nothing that is incompatible with the nature of successive rating criteria.”). After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that a rating in excess of 20 percent is not warranted for diabetes. The Board finds that the weight of the competent and probative evidence is against finding that diabetes requires insulin or regulation of activities. The Veteran has not contended that he takes insulin or that diabetes requires regulation of activities and there is no indication that the Veteran has been prescribed insulin or advised by a medical professional to avoid strenuous occupational and/or recreational activities, or that occupational and recreational activities have been restricted due to diabetes. In fact, the treatment records reflect ongoing advice to exercise for 20 to 30 minutes three times a week. See 09/19/2016, CAPRI. Further, a June 2016 primary care note reflects an assessment that the Veteran’s diabetes is stable and diet controlled. In light of the above, the Board finds that the weight of the competent and probative evidence is against finding that the Veteran’s diabetes requires insulin or regulation of activities; thus, a rating in excess of 20 percent is not warranted under Diagnostic Code 7913. See 38 C.F.R. § 4.119, DC 7913. All possibly applicable diagnostic codes have been considered in compliance with Schafrath, 1 Vet. App. at 593, but the Veteran could not receive a higher and/or additional evaluation for diabetes based on the evidence. See 38 C.F.R. § 4.119, DC 7913. Indeed, when a condition is listed in the schedule, rating by analogy is not appropriate. Copeland v. McDonald, 27 Vet. App. 333, 336-37 (2015). The Board notes that the benefit of the doubt has been applied, where applicable. 5. Entitlement to an initial rating in excess of 50 percent for PTSD. The Veteran contends that he is entitled to an initial rating in excess of 50 percent for PTSD, evaluated under Diagnostic Code 9411. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings based on a spectrum of symptoms. “A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). 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: Diagnostic and Statistical Manual of Mental Disorders (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The Court has observed that the listed symptoms are examples of the type and degree of the manifestations of a mental disability required for a given disability rating, and that “the presence of all, most, or even some, of the enumerated symptoms” is not required to support a disability rating. Mauerhan, 16 Vet. App. at 442. Accordingly, it is not sufficient for the Board to simply match the symptoms listed in the rating criteria against those exhibited by a veteran. Rather, “VA must engage in a holistic analysis” of the severity, frequency, and duration of the signs and symptoms of the veteran’s mental disorder, determine the level of occupational and social impairment caused by those signs and symptoms, and assign an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula, a 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130. The criteria for a 30 percent rating are as follows: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is assigned 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. 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; obsessive rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. Id. The criteria for a 100 percent rating are as follows: 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; and memory loss for names of close relatives, own occupation, own name. Id. After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial rating in excess of 50 percent for PTSD is not warranted. In July 2013, a VA psychologist noted the following symptoms: depressed mood; anxiety; suspiciousness; chronic sleep impairment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a work-like setting. The Veteran’s PTSD also resulted in markedly diminished interest in or participation in significant activities; feeling of detachment or estrangement from others; restricted range of affect; irritability or outbursts of anger; difficulty concentrating; hypervigilance; and exaggerated startle response. At that time, the Veteran reported being in a supportive relationship, but he is not close to his two children, and does not have friends. Based on the examination, the VA psychologist concluded that the Veteran has occupational and social impairment due to mild or transient symptoms which decrease work efficiency and an ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. 07/26/2013, VA Examination. A June 2016 treatment note indicated impaired memory, but also noted that speech and language were fluent with good recall of recent and remote events. 11/07/2016, Medical-Non-Government. The Board finds the July 2013 VA examination to be competent, credible, and highly probative, as it is supported by an in-person examination, mental health expertise, review of the relevant medical records, and proper consideration of lay statements. Accordingly, the Board finds that the weight of the competent and probative medical and lay evidence is against finding that the Veteran’s mental health symptoms result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Board engaged in a holistic analysis of the severity, frequency, and duration of the signs and symptoms of the Veteran’s psychiatric disability, but finds that his mental health symptoms do not more nearly approximate a 70 percent rating. In fact, the Veteran’s symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships are specifically contemplated under the rating criteria for a 50 percent (or lower) evaluation. See 38 C.F.R. § 4.130. Regarding social impairment, the Veteran’s 50 percent rating accounts for his lack of friends and diminished interest in hobbies. Additionally, the Veteran reported being in a supportive romantic relationship. In finding that the weight of the competent evidence does not support occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, the Board has also considered as a factor that the evidence does not demonstrate symptoms such 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; spatial disorientation; neglect of personal appearance and hygiene; or an inability to establish and maintain effective relationships. See 38 C.F.R. § 4.130. Additionally, the lack of ongoing mental health treatment weighs against entitlement to a higher rating. All possible applicable diagnostic codes have been considered, but the Veteran could not receive a higher or separate rating for a psychiatric disability during the period on appeal. See 38 C.F.R. § 4.130. Indeed, when a disorder is listed in the Rating Schedule, such as the Veteran’s service-connected PTSD, rating by analogy is not appropriate. Copeland, 27 Vet. App. at 336-37. REASONS FOR REMAND 1. Entitlement to an initial rating in excess of 60 percent prior to June 13, 2013, and as of October 1, 2013, for CAD is remanded. 2. Entitlement to an effective date prior to March 26, 2011, for the grant of service connection for CAD is remanded. 3. Entitlement to an effective date prior to March 26, 2012, for the grant of service connection for PTSD is remanded. 4. Entitlement to an effective date prior to March 26, 2012, for the grant of service connection for diabetes is remanded. 5. Entitlement to an effective date prior to June 13, 2013, for the grant of service connection for surgical scar status post cardiac surgery is remanded. In correspondence received by VA in October 2013, the Veteran indicated his disagreement with all issues in the September 2013 rating decision, including the ratings and effective dates of service connection assigned for PTSD, diabetes, and surgical scar status post cardiac surgery. The Board will liberally construe the October 2013 correspondence to constitute an NOD as to the rating and effective date assigned for CAD in the September 2013 rating decision. Although a September 2016 rating decision assigned earlier effective dates for the grants of service connection for PTSD, diabetes, and CAD, it did not constitute full grants of the benefits sought; thus, the issues remained in appellate status. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). The AOJ has not issued a statement of the case (SOC) as to entitlement to an increased rating for CAD, or earlier effective dates for the grants of service connection for PTSD, diabetes, CAD, and surgical scar. As such, the Board has no discretion, and those issues must be remanded for such a purpose. Manlincon v. West, 12 Vet. App. 238, 240 (1999); 38 C.F.R. § 19.9(c). 6. Entitlement to an initial compensable rating for surgical scar status post cardiac surgery is remanded. The record indicates incisions of the chest and left leg due to a June 2013 cardiac procedure, but the September 2013 rating decision only discusses a scar of the chest. Accordingly, the AOJ should schedule an examination to identify all surgical scars due to the June 2013 cardiac surgery, and describe the severity of all identified scars. 7. Entitlement to TDIU is remanded. The Board deems TDIU to be a component of the claims for increased ratings in light of the Veteran’s statement that he is unable to work due, at least in part, to his service-connected disabilities. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Board will remand the claim for TDIU for appropriate development. The matters are REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records from June 2016 to the present. 2. After completing directive #1, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of all scars due to the June 2013 cardiac procedure, to include of the chest and left leg. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria, including whether any scars are painful and/or unstable. To the extent possible, the examiner should identify any symptoms and functional impairments due to the scar(s) alone and discuss the effect of the Veteran’s scar(s) on any occupational functioning and activities of daily living. If it is not possible to provide an opinion regarding symptoms or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. Send the Veteran and his representative a statement of the case that addresses the issues of entitlement to an increased initial rating for CAD, and earlier effective dates for the grants of service connection for PTSD, diabetes, CAD, and surgical scar. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issues should be returned to the Board for further appellate consideration. (Continued on the next page)   4. Send appropriate notice to the Veteran regarding TDIU and complete any necessary development. This should include sending the Veteran an application form (VA Form 21-8940) and advising the Veteran of the necessity of notifying the AOJ of his employment history and his educational background for proper adjudication of this matter. Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J.A. Gelber, Associate Counsel