Citation Nr: 1815183 Decision Date: 03/09/18 Archive Date: 03/19/18 DOCKET NO. 13-32 150 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for a left shoulder disability, to include left shoulder dislocation residuals. 2. Entitlement to service connection for a skin disability, to include sebaceous cysts. 3. Entitlement to service connection for obstructive sleep apnea (OSA). 4. Entitlement to an initial disability rating greater than 10 percent for a cervical spine disability. 5. Entitlement to an initial disability rating greater than 10 percent for a thoracolumbar spine disability. 6. Entitlement to an initial disability rating greater than 10 percent for left ankle strain. 7. Entitlement to an initial disability rating greater than 50 percent for posttraumatic stress disorder (PTSD). 8. Entitlement to a compensable initial disability rating for bilateral hearing loss. 9. Entitlement to a total disability rating based on individual employability (TDIU) prior to October 29, 2013. REPRESENTATION Veteran represented by: Margaret A. Matthews, Agent ATTORNEY FOR THE BOARD M. Salazar, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1972 to January 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2011 and May 2011 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, which granted, in pertinent part, the Veteran's claims of service connection for PTSD, assigning a 30 percent rating effective March 8, 2010, bilateral hearing loss, assigning a zero percent (non-compensable) rating effective March 8, 2010, and denied claims of service connection for a left shoulder disability, obstructive sleep apnea (OSA), a skin disability, a cervical spine disability, a thoracolumbar spine disability, and a left ankle disability. Since then, jurisdiction transferred to the RO in Philadelphia, Pennsylvania. See, e.g., January 2018 VA Form 8. In a May 2011 rating decision, the RO granted service connection for a left ankle disability, assigning a 10 percent rating effective March 8, 2010. Because the initial rating assigned to the Veteran's service-connected left ankle disability is not the maximum rating available for this disability, this claim remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In a September 2013 decision review officer (DRO) decision, the RO granted service connection for a cervical and thoracolumbar spine disability, assigning 10 percent ratings effective March 8, 2010. The RO also assigned a higher initial disability rating of 50 percent effective March 8, 2010 for the Veteran's service-connected PTSD. Because the initial ratings assigned to the Veteran's service-connected cervical spine disability, thoracolumbar spine disability, and PTSD are not the maximum ratings available for these disabilities, these claims remain in appellate status. See 6 Vet. App. at 38. In May 2016, the Board remanded the Veteran's claims to the Agency of Original Jurisdiction (AOJ) for further action consistent with the Board's remand directives. The claims are back before the Board for further appellate proceedings. In an October 2017 DRO decision, the Philadelphia, Pennsylvania RO granted entitlement to TDIU, assigning an effective date of October 29, 2013. However, the Veteran's original notice of disagreement (NOD) with the Veteran's initial disability rating for PTSD contained a claim for TDIU that was separately adjudicated by the RO in a January 2013 rating decision. Thus, the Board has jurisdiction to consider the issue of entitlement to TDIU prior to his assigned effective date as part of his claims for increased ratings. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Therefore, TDIU prior to October 29, 2013 remains in appellate status. The issue of service connection for OSA is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. The Veteran's left shoulder disability, diagnosed as left shoulder dislocation residuals, is etiologically related to his time in active service. 2. The Veteran's skin disability, diagnosed as sebaceous cysts, is etiologically related to his time in active service. 3. The Veteran's cervical spine disability was not manifested by ankylosis, whether favorable or unfavorable, of the entire spine or cervical spine, forward flexion of the cervical spine to 30 degrees or less, combined range of motion of the cervical spine less than 170 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or additional functional loss. 4. Prior to March 20, 2017, the Veteran's thoracolumbar spine disability was not manifested by ankylosis, whether favorable or unfavorable, of the entire spine or thoracolumbar spine, forward flexion of the thoracolumbar spine to 60 degrees or less, combined range of motion of the thoracolumbar spine less than 120 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or additional functional loss. 5. As of March 20, 2017, the Veteran's thoracolumbar spine disability was manifested by additional functional loss. The disability was not manifested by ankylosis, whether favorable or unfavorable, of the entire spine or thoracolumbar spine. 6. The Veteran's left ankle disability was not manifested by ankylosis. 7. The Veteran's PTSD was not manifested by symptoms resulting in total occupational and social impairment, or occupational and social impairment, with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. 8. Audiometric evaluations correspond to no greater than a Level II hearing loss in each ear. 9. Prior to June 5, 2011, the Veteran was able to obtain or retain substantially gainful employment due to his service-connected disabilities. 10. As of June 5, 2011, the Veteran was not able to obtain or retain substantially gainful employment due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria to establish service connection for a left shoulder disability, diagnosed as left shoulder dislocation residuals, have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. The criteria to establish service connection for a skin disability, diagnosed as sebaceous cysts, have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 3. The criteria for an initial increased rating greater than 10 percent for a cervical spine disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). 4. Prior to March 20, 2017, the criteria for an initial disability rating greater than 10 percent for a thoracolumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). 5. As of March 20, 2017, the criteria for an initial disability rating of 40 percent, but no higher, for a thoracolumbar spine disability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). 6. The criteria for an initial disability rating of 20 percent, but no higher, for a left ankle disability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2017). 7. The criteria for an initial disability rating greater than 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2017). 8. The criteria for a compensable disability rating for bilateral hearing loss have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.85, Diagnostic Code 6100 (2017). 9. The criteria for entitlement to TDIU prior to June 5, 2011 are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16 (2017). 10. The criteria for entitlement to TDIU as of June 5, 2011 are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in part at 38 U.S.C. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claim. The duty to notify has been met. Neither the Veteran, nor his representative, has alleged prejudice with regard to notice. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[A]bsent extraordinary circumstances . . . it is appropriate for the Board and the [United States Court of Appeals for Veterans Claims] to address only those procedural arguments specifically raised by the veteran . . . ." Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). In light of the foregoing, nothing more is required. The duty to assist includes assisting the claimant in the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The RO associated the Veteran's VA and identified private treatment records with the claims file. Therefore, no other relevant records have been identified and are outstanding. As such, the Board finds VA has satisfied its duty to assist with the procurement of relevant records. During the appeal period, the Veteran was afforded several VA examinations. The Board has carefully reviewed the VA examinations of record and finds that the examinations, along with the other evidence of record, are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As to the musculoskeletal claims in particular, in Sharp v. Shulkin, the Court of Appeals for Veterans Claims (Court) held that a VA examination is inadequate when the VA examiner does not "estimate the [Veteran's] functional loss due to flares based on all the evidence of record (including the [Veteran's] lay information) or explain why [he or she] could not do so." 29 Vet. App. 26, 35 (2017). In this case, the examiner elicited relevant statements from the Veteran and estimated additional functional loss due to repetitive use when appropriate. As noted in the Introduction, the Board last remanded the claim in May 2016. In pertinent part, the Board instructed the AOJ to: (1) send the Veteran a development letter as to his initial increased rating claims; (2) obtain new examinations to address the current severity of his initial increased rating claims; and (3) readjudicate the claims. The AOJ sent the Veteran an appropriate development letter in September 2016. In March 2017, the Veteran obtained new VA examinations to assess the current severity of his PTSD, hearing loss, and musculoskeletal symptoms as prompted in the May 2016 Board remand instructions. The AOJ readjudicated the claims in a November 2017 supplemental statement of the case (SSOC). Thus, the Board's prior remand instructions have been complied with for the purposes of this decision. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure substantial compliance). II. Service Connection A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C. § 1110. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). A. Left Shoulder The first and second Shedden elements are met and not in dispute. The evidentiary record contains a diagnosis for left shoulder dislocation residuals. See March 2017 VA examination report. In service, the Veteran fell in basic and on active duty; the Veteran's deceased wife corroborated this account. See Id.; see also July 2010 L.J.S. statement. As such, the crux of this case centers on whether the Veteran's left shoulder dislocation residuals were attributable to time spent in service. In March 2017, a VA examiner determined that the Veteran's left shoulder condition is at least as likely as not etiologically related to service. He reasoned that the Veteran was injured in boot camp and then was reinjured falling down a ladder while on active duty. As the evidence for and the evidence against the Veteran's claim is in relative equipoise, the Board affords the Veteran the benefit of the doubt, and finds there is expert evidence of record establishing a link between the Veteran's left shoulder dislocation residuals and his injury in service. Accordingly, the Board grants service connection for a left shoulder disability, diagnosed as left shoulder dislocation residuals. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. B. Skin The first and second Shedden elements are met and not in dispute. The evidentiary record contains a diagnosis for sebaceous cysts. See March 2017 VA examination report. In service, the Veteran complained of sebaceous cysts in December 1973. See Id.; see also December 1973 service treatment record. As such, the crux of this case centers on whether the Veteran's sebaceous cyst was attributable to time spent in service. In March 2017, a VA examiner determined that the Veteran's sebaceous cysts were at least as likely as not related to the sebaceous cysts he obtained in service. See March 2017 VA examination report. He reasoned that the Veteran "has had problems since service that have persisted" as a result of the sebaceous cysts. Id. As the evidence for and the evidence against the Veteran's claim is in relative equipoise, the Board affords the Veteran the benefit of the doubt, and finds there is expert evidence of record establishing a link between the Veteran's sebaceous cysts and his injury in service. Accordingly, the Board grants service connection a skin disability, diagnosed as sebaceous cysts. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. III. Initial Increased Rating Here, the Veteran has averred that his service connected disabilities on appeal are more severe than his current disability ratings would indicate. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Where, as here, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a "staged" rating are required. See Fenderson v. West, 12 Vet. App. 199, 125-26 (1999). See also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Importantly, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998); 38 C.F.R. § 3.102. The words "mild," "moderate," "marked," and "severe" as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. A. Musculoskeletal Claims When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting 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. See DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011). Instead, the Court in Mitchell explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45 (2017). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. 1. Cervical and Thoracolumbar Spine Throughout the appellate period, VA rated the Veteran's cervical and thoracolumbar spine under 38 C.F.R. § 4.71a, Diagnostic Code 5242. All spinal disabilities are evaluated under the General Rating Formula for Diseases and Injuries of the Spine. Further, if a Veteran has x-ray evidence to establish degenerative arthritis of the spine with noncompensable limitation of motion, he or she is entitled to a 10 percent disability rating for each major joint or group of minor joints affected by limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. If the Veteran has Intervertebral Disc Syndrome (IVDS), the Veteran may also be evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Ultimately, the Veteran's disability rating will depend on which diagnostic code results in the higher evaluation. The pertinent criteria under the General Rating Formula for Diseases and Injuries of the Spine are as follows: Unfavorable ankylosis of the entire spine - 100 percent disabling. Unfavorable ankylosis of the entire thoracolumbar spine - 50 percent disabling. 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 - 40 percent disabling. Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine - 30 percent disabling. Forward flexion of the thoracolumbar spine greater than 30 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 - 20 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5242 (2017). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides a 60 percent rating for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of least 4 weeks but less than 6 weeks during the past 12 months. A 20 percent rating is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2017). An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1) (2017). For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The normal combined range of motion of the cervical spine is 340 degrees. Further, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 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 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. § 4.71a, Diagnostic Codes 5235 to 5242, Note (2). a. Cervical Spine The Veteran has not exhibited ankylosis of the cervical spine. Further, at no point has the Veteran's forward flexion of the cervical spine been 15 degrees or less. Thus, the Veteran is not entitled to an initial disability rating for his cervical spine disability of 100, 40, or 30 percent. See 38 C.F.R. § 4.71a, Diagnostic Code 5242. The Veteran's forward flexion in September 2013 was normal, while it was impaired to 40 degrees upon testing in March 2017. Combined, the Veteran's cervical spine range of motion testing was normal in September 2013, whereas it decreased to 230 degrees in March 2017. At the March 2017 VA examination, the examiner determined that pain, weakness, fatigability, or incoordination significantly limited functional ability, and expressed the limitation in degrees. Specifically, the limitation amounted to a combined cervical range of motion of 225 degrees. Id. The examiner also determined there were no flare-ups, and that the Veteran had mild spinal tenderness without guarding, muscle spasm, or spinal contour or gait. As such, the Veteran is not entitled to an initial disability rating for his cervical spine disability of 20 percent. See 38 C.F.R. § 4.71a, Diagnostic Code 5242. The Board has also considered whether higher ratings are warranted on the basis of functional loss due to pain, weakness, fatigability, or incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017). Although the evidence does show that the Veteran may experience painful motion, it does not result in a higher rating unless it actually results in additional functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011). Here, the Board considered the Veteran's additional functional loss after three repetitions in terms of degrees; even accounting for the additional functional loss discussed by the March 2017 VA examiner, the Veteran did not exhibit forward flexion to 30 degrees or less or a combined cervical range of motion to 170 degrees or less. Based upon the law of the Court in Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007), the Board has also considered whether staged ratings are appropriate. Since, however, the Veteran's symptoms have remained constant at 10 percent levels for his cervical spine disability, staged ratings are unjustifiable. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The Board finds the evidence of record more closely approximates the criteria for a 10 percent rating. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran is competent to report his symptoms, and the Board does not doubt the sincerity of his belief that his initial disability rating should be higher. Nevertheless, the preponderance of the evidence is against the Veteran's claim and the Board finds that the criteria for an initial disability rating in excess of 10 percent for a cervical spine disability are not met. See Gilbert, 1 Vet. App. at 55; 38 C.F.R. § 3.102. b. Thoracolumbar Spine prior to March 20, 2017 The Veteran has not exhibited ankylosis of the thoracolumbar spine. Further, at no point before March 20, 2017 has the Veteran's forward flexion of the thoracolumbar spine been 30 degrees or less. Thus, the Veteran is not entitled to an initial disability rating for his thoracolumbar spine disability of at least 30 percent. See 38 C.F.R. § 4.71a, Diagnostic Code 5242. The Veteran's range of motion for the thoracolumbar spine in September 2013 was normal, even after repetitive use testing. The evidentiary record did not show any muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour. As such, the Veteran is not entitled to an initial disability rating for his thoracolumbar cervical spine disability of 20 percent. See 38 C.F.R. § 4.71a, Diagnostic Code 5242. The Board has also considered whether higher ratings are warranted on the basis of functional loss due to pain, weakness, fatigability, or incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017). Although the evidence does show that the Veteran may experience painful motion, it does not result in a higher rating unless it actually results in additional functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011). Here, the Board considered the Veteran's additional functional loss after three repetitions; the examiner determined that the Veteran did not have additional limitation in range of motion of the back following repetitive-use testing. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The Board finds the evidence of record more closely approximates the criteria for a 10 percent rating prior to March 20, 2017. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran is competent to report his symptoms, and the Board does not doubt the sincerity of his belief that his initial disability rating should be higher. Nevertheless, the preponderance of the evidence is against the Veteran's claim and the Board finds that the criteria for an initial disability rating in excess of 10 percent for a thoracolumbar spine disability prior to March 20, 2017 are not met. See Gilbert, 1 Vet. App. at 55; 38 C.F.R. § 3.102. c. Thoracolumbar Spine as of March 20, 2017 As stated above, the Veteran has not exhibited ankylosis of the thoracolumbar spine. See March 2017 VA examination. Thus, the Veteran is not entitled to an initial disability rating of 100 or 50 percent. See 38 C.F.R. § 4.71a, Diagnostic Code 5242. However, at his most recent VA examination, the Veteran stated he had problems with "any loading or twisting related activity/work with the spine due to pain and weakness." Id. Importantly, the examiner was unable to test the Veteran's range of motion because of "intractable pain." However, the examiner noted pain in each type of back movement and stated there was moderate lumbar tenderness due to the condition. Even though the Veteran was not examined immediately after repetitive use over time, the examiner determined the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner determined that the Veteran's pain and weakness contributed to pain with instability of station, disturbance of locomotion, sitting and standing. As the Veteran experienced significant additional functional loss due to pain and weakness, he is entitled to a disability rating of 40 percent from March 20, 2017. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The Board finds the evidence of record more closely approximates the criteria for a 40 percent rating. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Thus, the preponderance of the evidence is for the Veteran's claim and the Board finds that the criteria for an initial disability rating of 40 percent, but no higher, for a thoracolumbar spine disability as of March 20, 2017 are met. See Gilbert, 1 Vet. App. at 55; 38 C.F.R. § 3.102. 2. Left Ankle Under Diagnostic Code 5271, a 10 percent rating contemplates moderate limitation of motion of the ankle. In order to warrant a higher, 20 percent rating, marked limitation of motion is required. Normal ankle motion is measured from 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion. 38 C.F.R. § 4.71a, Plate II. Diagnostic Code 5270 pertains to ankylosis of the ankle. Under this diagnostic code, a 20 percent rating is warranted for ankylosis in plantar flexion less than 30 degrees. A 30 percent evaluation is warranted for ankylosis in plantar flexion between 30 degrees and 40 degrees, or in dorsiflexion between 0 degrees and 10 degrees. A 40 percent rating is warranted for ankylosis in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees, or with abduction, adduction, inversion or eversion deformity. 38 C.F.R. § 4.71a, Diagnostic Code 5270. Diagnostic Code 5273 provides the rating criteria for malunion of the os calcis or astragalus. A 10 percent disability rating is warranted for a moderate deformity, and a 20 percent disability rating is warranted for a marked deformity. 38 C.F.R. § 4.71a, Diagnostic Code 5273. Diagnostic Code 5274 provides that a 20 percent disability rating is warranted for astragalectomy. 38 C.F.R. § 4.71a, Diagnostic Code 5274. In this case, the record does not reflect the Veteran has ever been diagnosed with ankylosis of his left ankle. Rather, both the May 2011 and March 2017 VA examinations explicitly found he had no ankylosis. However, the Veteran does have "marked" limitation of motion and corresponding difficulties. At his most recent examination, the Veteran stated that his left ankle experienced more pain, weakness, and "popping." See March 2017 VA examination. The Veteran showed dorsiflexion to 15 degrees and plantar flexion to 35 degrees, even after repeated use over time. Further, when asked whether pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time, the examiner said yes as to the left ankle. Id. Importantly, the examiner was able to describe these limits in degrees. Specifically, because of the enumerated factors listed, the examiner stated that the Veteran would be able to exhibit dorsiflexion to 15 degrees and plantar flexion to 35 degrees. The examiner also found chronic pain during weight-bearing. In contrast, the right ankle was normal. As a result, the examiner determined that the Veteran had instability of station, disturbance of locomotion, and interference with sitting and standing. Id. Therefore, the Veteran is entitled to a 20 percent disability rating under Diagnostic Code 5271. Based upon the law of the Court in Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007), the Board has also considered whether staged ratings are appropriate. Since, however, the Veteran's symptoms have remained constant at 20 percent levels for his left ankle disability, staged ratings are unjustifiable. The Board has considered whether higher evaluations are available under other provisions of the code. However, the Veteran's left ankle disability has not shown to involve any other factor that would warrant evaluation of the disabilities under other provisions of the rating schedule. Specifically, there is no evidence of ankylosis of the subastragalar or tarsal joint, malunion of the os calcis or astragalus, or astragalectomy to warrant ratings under Diagnostic Codes 5272-5274. Id. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The Board finds the evidence of record more closely approximates the criteria for a 20 percent rating. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran is competent to report his symptoms, and the Board does not doubt the sincerity of the Veteran's belief that his initial disability rating should be higher. As such, the preponderance of the evidence is for the Veteran's claim and the Board finds that the criteria for an initial disability rating of 20 percent, but no higher, are met. See Gilbert, 1 Vet. App. at 55; 38 C.F.R. § 3.102. B. PTSD Here, the Veteran has averred that his PTSD is more severe than his current disability rating would indicate. The Veteran has received mental health treatment throughout the appellate period, and he was granted service connection effective March 8, 2010. PTSD is rated under 38 C.F.R. §4.130, Diagnostic Code 9411. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing 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; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Although the Veteran's symptomatology is the primary consideration, the Veteran's level of impairment must be in "most areas" applicable to the relevant percentage rating criteria. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-19 (Fed. Cir. 2013). Effective March 19, 2015, VA amended the portion of the Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to remove outdated references to DSM-IV, and replace them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 80 Fed. Reg. 53, 14308 (March 19, 2015). The provisions of the final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. The provisions of this final rule do not apply to claims that were pending before the Board (i.e., certified for appeal to the Board on or before August 4, 2014), the Court, or the Federal Circuit, even if such claims are subsequently remanded to the AOJ. In October 2010, the Veteran presented for a VA examination to determine the severity of his service-connected PTSD. See October 2010 VA examination report. There, upon mental status examination, the Veteran was considered to be a truthful and reliable historian. His speech and thought processes were goal directed, and his behavior was normal. The examiner found no psychomotor abnormalities and the Veteran was oriented in all spheres. The examiner also determined that the Veteran's memory function was good for three out of three objects at one and fifteen minutes. No memory deficit could be elicited. Mood and affect were anxious, irritable and sad. Importantly, the Veteran was not acutely suicidal, homicidal, violent, psychotic, manic, hypomanic, obsessive or compulsive. Nevertheless, the Veteran continued to "suffer from intermittent fleeting suicidal thoughts, but he [had] no immediate plan to harm himself or others. . . . He is quick to become irritable and angry." Id. The examiner also noted that the Veteran's fund knowledge, abstracting ability, mathematical calculating ability, and insight/judgment were satisfactory. Id. His main symptoms expressed were irritability, conflicts with people around him, and trouble falling/remaining asleep. His mental status remained consistent with this examination through his latest VA examination. See March 2017 VA examination report. There, he expressed similar symptoms, including depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control, such as unprovoked irritability with periods of violence. Id. The Veteran denied suicidal ideation and acute psychotic symptoms such as hallucinations and paranoia. Taking into account all relevant evidence, the Board finds that an initial disability rating in excess of 50 percent for the Veteran's service-connected PTSD is not warranted. The Veteran has shown a consistent pattern of anxiety, inability to sleep, irritability, and social isolation symptoms. However, they do not warrant total occupational and social impairment or occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. The Veteran was married in 1972 to his childhood sweetheart; they raised two children. He enjoyed his family life but described it as chaotic due to his irritability. However, he became a full-time care giver when his spouse was diagnosed with cancer and he "continues to struggle with [her] loss." See June 2017 social and industrial survey. Further, the Veteran describes himself as a loner. As to occupational impairment, the Veteran has not worked since October 2013. See March 2017 VA examination report. During a mental health appointment with VA, a medical professional opined that the Veteran's PTSD symptoms were affecting his social and occupational functioning; specifically, the Veteran "has not been able to maintain his job because of his problem with anger control and irritability." See February 2012 VA treatment record. In May 2010, he was terminated for "continued examples of ineffective leadership." See May 2010 confidential memorandum. The Veteran had been fired multiple times at various jobs before November 2013. See November 2013 representative argument. As to social impairment, the Veteran functions poorly relating to others. He spends his days alone, mainly engaging in household tasks. See June 2017 social and industrial survey. He also has a strained relationship with his son. Id. Nevertheless, the Veteran gave a truck to his son's girlfriend. The Veteran claims that he "fell in love with [her] and wants a relationship. She initially told him that she did not love him 'that way.' However, as they have been communicating by phone and text, she [has] given indication that perhaps there can be a relationship." See December 2017 VA medical treatment record. Further, the Veteran stated that dating since becoming a widower in 2016 was not going well and denied recent irritability or temper outbursts. Id. In May 2010, the Veteran was evaluated in the psychological emergency room due to depressive symptoms and concern about suicidal ideation he expressed to his wife. There, the Veteran denied suicidal ideation, but reported thoughts of shooting himself with a firearm, though he had no ammunition. He displayed good eye contact, periods of good humor, and was found to have strong support with his adult daughter, though his relationship was conflicted with his wife. See May 2010 VA medical treatment record. Although the record includes Global Assessment of Functioning (GAF) scores, the Board has not used these scores to assign a psychiatric rating. See Golden v. Shulkin, No. 16-1208 (decided February 23, 2018) (holding that the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies). As discussed above, the Veteran did not have gross impairment in thought processes or communication evidenced by his relationship with his daughter and former wife. The claims file also does not include evidence of persistent delusions or hallucinations. The Veteran has not engaged in aggressive behavior toward others or grossly inappropriate behavior. Further, the record does not show evidence of the Veteran being a persistent danger of hurting himself or others. No mental health professional has deemed him disoriented as to time or place. Further, the Veteran remembers his own name. In addition, before May 2010, the Veteran did not state he had suicidal ideations. He stated he did not have such thoughts when asked on at least ten occasions between May 2010 and December 2017. In Bankhead v. Shulkin, the Court held that thoughts alone could establish the symptom of suicidal ideation listed in the criteria for a 70 percent evaluation. 29 Vet. App. 10, 20-21 (2017). Nevertheless, the Board is obligated to consider the actual effects of the Veteran's suicidal ideation on his occupational and social situation to determine the severity of that symptom. Id. at 21. The evidentiary record does not show that his suicidal ideation is productive of difficulties in most areas or that the Veteran has an inability to maintain or establish effective relationships. There is no indication that the suicidal ideation affected his employability. Further, the Veteran has not exhibited obsessive rituals which interfered with routine activities, speech intermittently illogical obscure or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, neglect of personal appearance and hygiene, or inability to establish relationships as evidenced above. Though depressed, the evidentiary record has not shown that it affects his ability to function independently, appropriately, and effectively. Thus, the Veteran has shown disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. As such, the Board finds that ultimately, the Veteran's overall disability picture more nearly approximates the criteria for a 50 percent rating. While the Veteran does exhibit some symptoms contemplated in total occupational and social impairment or occupational and social impairment with deficiencies in most areas, the symptomatology is not of sufficient severity, frequency, and duration to result in a higher rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (holding that a Veteran "may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration"). At worst, his symptoms appear consistent with no more than occupational and social impairment with reduced reliability and productivity. The criteria for a finding of a 70 or 100 percent evaluation, the next higher evaluations, are not met. Based upon the law of the Court in Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007), the Board has also considered whether staged ratings are appropriate. Since, however, the Veteran's symptoms have remained constant at 50 percent levels for his PTSD, staged ratings are not warranted. Thus, the preponderance of the evidence is against the Veteran's claim and the Board finds that the criteria for an initial disability rating in excess of 50 percent for PTSD are not met. See Gilbert v. Derwinski, 1 Vet. App 49, 55-57 (1990); 38 C.F.R. § 3.102. C. Hearing Loss Evaluations for defective hearing are based upon organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests, along with the average hearing threshold level as measured by pure tone audiometric tests in the frequencies of 1000, 2000, 3000, and 4000 Hertz. 38 C.F.R. § 4.85, Tables VI, VIA, VII. To evaluate the degree of disability for service-connected bilateral hearing loss, the rating schedule establishes eleven auditory acuity levels, designated from Level I for essentially normal acuity, through Level XI for profound deafness. Table VI is used to determine the Roman numeric designation, based on test results consisting of puretone thresholds and Maryland CNC test speech discrimination scores. The numeric designations are then applied to Table VII to determine the appropriate rating for hearing impairment. Id. Where there is an exceptional pattern of hearing impairment, a rating based on pure tone thresholds alone may be assigned (Table VIA). This alternative method for rating hearing loss disability may be applied if the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz are all at 55 decibels or higher, or if the puretone threshold at 1000 Hertz is 30 or less and at 2000 Hertz is 70 or more. 38 C.F.R. § 4.86. Each ear is to be evaluated separately under this part of the regulations. Ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The Veteran underwent VA examinations (with audiometric evaluations) in May 2010 and March 2017. In May 2010, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 45 40 35 50 LEFT 30 40 35 35 50 The average of the puretone thresholds findings at 1000, 2000, 3000, and 4000 Hertz was 43 decibels in the right ear and 40 decibels in the left ear. The speech recognition scores on the Maryland CNC word list were 84-88 percent for the right ear, and 86-88 percent for the left ear. Applying the test results of the May 2010 VA examination report to Table VI of the Rating Schedule results in a Roman numeric designation of Level II for each ear. 38 C.F.R. § 4.85, Table VI. Applying the Roman numeric designations to Table VII, the result is a non-compensable rating for the Veteran's service-connected bilateral hearing loss. 38 C.F.R. § 4.85, Table VII, Diagnostic Code 6100. In March 2017, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 25 35 45 LEFT 20 25 25 35 45 The average of the puretone thresholds findings at 1000, 2000, 3000, and 4000 Hertz was 33 decibels in the each ear. The speech recognition scores on the Maryland CNC word list were 98 percent for the right ear, and 96 percent for the left ear. Applying the test results of the March 2017 VA examination report to Table VI of the Rating Schedule results in a Roman numeric designation of Level I for each ear. 38 C.F.R. § 4.85, Table VI. Applying the Roman numeric designations to Table VII, the result is a non-compensable rating for the Veteran's service-connected bilateral hearing loss. 38 C.F.R. § 4.85, Table VII, Diagnostic Code 6100. Hence, the new examination shows improved hearing from May 2010 to March 2017. There are no other audiometric testing results for the remainder of the appeal period which comply with the requirements of 38 C.F.R. § 4.85 for rating purposes. Accordingly, the evidence of record does not support a compensable disability rating for hearing impairment. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). IV. TDIU Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that the Veteran meets the schedular requirements. Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the stated purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; and (2) disabilities resulting from common etiology or a single accident. 38 C.F.R. 4.16(a). "Substantially gainful employment" is that employment "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. § 4.16(a) (2017). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by non service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran has alleged that he cannot work in part due to his PTSD symptoms. See August 2010 Veteran statement. The Veteran has a high school education and completed a few college classes without obtaining a degree. Id. The Veteran has met the threshold requirement for entitlement to TDIU on a schedular basis. The Veteran's PTSD has been rated at 50 percent disabling as of March 8, 2010, and his service-connected disabilities combined have exceeded 70 percent since that date. See 38 C.F.R. § 4.16(a). Thus, the narrow issue before the Board is whether the Veteran has been unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. Prior to October 29, 2013, the Veteran was employed from at least March 8, 2010 to May 10, 2010, October 2010 to July 2011, and from at least September 2013 to October 29, 2013. On May 10, 2010, the Veteran, a department head, "[invaded] an employee's privacy by directly contacting her health care professional because [he] wanted to 'investigate' her reason for requesting off to attend in appointment." See May 2010 employment memorandum. The administrator emphasized poor critical thinking and "[mishandling] employee relations issues. . . [to include] temper and lack of professionalism." Id. Nevertheless, after termination, the Veteran found another job in October 2010 in the maintenance department. See June 2011 VA medical treatment record. He was let go in July 2011 for unknown reasons. However, the Veteran maintains it was because of his PTSD symptoms. Two years later, the Veteran took an examination to renew his commercial driver's license. See September 2013 VA medical treatment record. He then got a job driving school buses until October 2013, when he was placed on leave after being involved in a fatal bus accident. It is unclear whether he was driving buses full-time or part-time. Here, the Veteran has been fired for mishandling employee relations issues, but was able to find employment within a few months that lasted almost a year in maintenance. However, after being let go in July 2011, the Veteran filed for and obtained Social Security Disability benefits, with a primary diagnosis of "anxiety disorders" that began on June 5, 2011. The Veteran also has testified that he worked seven jobs in seven years and was typically "fired after [a] year." See June 2017. The Veteran has a high school education and could not obtain substantially gainful employment in part because of his PTSD and service-connected musculoskeletal symptoms. As such, though the Veteran and others provided ample facts to make a decision, the responsibility for making the ultimate TDIU determination is placed on the adjudicator and not a medical examiner. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). A medical examiner's role is limited to describing the effects of disability upon the person's ordinary activity. See Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). The Veteran is competent to testify as to facts he personally observed or described; this includes recalling what he personally felt, saw, smelled, heard, or tasted. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds the Veteran and his medical treatment providers credible as to his functional limitations attributable to his service-connected disabilities. Therefore, the Board finds that the Veteran's service-connected disabilities likely prevented him from obtaining and maintaining gainful employment as of June 5, 2011. Accordingly, resolving all doubt in his favor, the criteria for TDIU has been met as of June 5, 2011, and the claim is granted. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App 49, 55-57 (1990). ORDER Service connection for a left shoulder disability, diagnosed as left shoulder dislocation residuals, is granted. Service connection for a skin disability, diagnosed as sebaceous cysts, is granted. An initial disability rating greater than 10 percent for a cervical spine disability is denied. An initial disability rating greater than 10 percent for a thoracolumbar spine disability prior to March 20, 2017 is denied. An initial disability rating of 40 percent, but no higher, for a thoracolumbar spine disability as of March 20, 2017 is granted. An initial disability rating of 20 percent, but no higher, for a left ankle disability is granted. An initial disability rating greater than 50 percent for PTSD is denied. A compensable initial disability rating for bilateral hearing loss is denied. Prior to June 5, 2011, TDIU is denied. As of June 5, 2011, TDIU is granted. REMAND The Board finds that further development is required prior to final adjudication of the Veteran's OSA claim. The Veteran was afforded a VA examination in December 2014 to assess the etiology of his OSA. However, the Board finds that the VA examiner's opinion as to this issue is inadequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The examiner opined that the Veteran's OSA was less likely than not incurred in or caused or aggravated by the Veteran's active service. The examiner reasoned that the Veteran's sleep apnea was diagnosed after service. Then, after defining the disease, the examiner stated that "[no] event or exposure in military service causes sleep apnea." However, the Veteran's deceased wife previously testified that, while in the military, the Veteran's breath would "sometimes stop so long [she] would nudge him and awake him to get him to breathe because it scared [her] when this would happen. [She] would tell him of his snoring and irregular breathing pattern." See July 2010 L.J.S. statement. Thus, in the December 2014 opinion, the examiner improperly discounted lay testimony and relied primarily on the absence of contemporaneous medical records to render a negative nexus opinion; such an opinion is inadequate for adjudicative purposes. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006). As such, an addendum opinion is required to address this theory. Accordingly, the case is REMANDED for the following action: 1. Obtain any outstanding VA treatment records relevant to the Veteran's claimed OSA, to include updated treatment records from the Williamsport VAMC. All obtained records should be associated with the evidentiary record. The AOJ must perform all necessary follow-up indicated. If the records are not available, or a negative response is received, the AOJ should make a formal finding of unavailability, advise the Veteran and his representative of the status of his records, and give the Veteran the opportunity to obtain the records on his own. 2. After completing the above, and after any records obtained have been associated with the evidentiary record, obtain an addendum opinion from an appropriately qualified VA examiner to determine the nature and etiology of the Veteran's OSA. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The addendum opinion must include a notation that this record review took place. After review, the VA examiner is asked to respond to the following inquiry: Is it at least as likely as not that the Veteran's obstructive sleep apnea was incurred in, or otherwise related to, his time on active duty, to include his breathing and snoring symptoms he suffered in service? In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. Further, the examiner is to discuss the Veteran's claimed symptoms in service as described by his decreased wife in a July 2010 letter to VA. This includes a discussion of the Veteran's continuity of symptomatology since service. The complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. After the above development has been completed, and after undertaking any additional evidence deemed necessary, readjudicate the claim. If any benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case (SSOC), and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ DONNIE R. HACHEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs