Citation Nr: 1823329 Decision Date: 04/18/18 Archive Date: 04/25/18 DOCKET NO. 12-23 861 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a gastrointestinal disability, claimed as acid reflux, hiatal hernia, and irritable bowel syndrome, as secondary to service connected disease or injury. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD B. Bodi, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1966 to August 1968. This appeal to the Board of Veterans' Appeals (Board) is from a July 2011 and January 2018 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In February 2015, the Board denied the Veterans' claim seeking a higher initial rating for PTSD, and remanded the matter of service connection for a gastrointestinal disability for further development. The Veteran appealed that denial to the United States Court of Appeals for Veterans Claims (Court). In September 2015, the Court granted a Joint Motion for Remand which vacated that denial and remanded it back to the Board for action in compliance with the Joint Motion. In February 2016, the matter was again remanded to comply with the Court's September 2015 order. In August 2016, the Board remanded the issues for further development. The case is again before the Board. FINDINGS OF FACT 1. The Veteran's PTSD is manifested by no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; difficulty in establishing and maintaining effective work and social relationships; and anxiety, suspiciousness, chronic sleep impairment, and neglect of personal appearance and hygiene. 2. The Veteran's gastrointestinal disability is not related to service, nor was caused or aggravated by a service-connected disability. 3. The Veteran's service connected PTSD and diabetes do not preclude him from securing or following substantially gainful employment. Rather, the Veteran is currently self-employed as a rancher. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. § 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 3.400, 4.1, 4.126, 4.130, 4.2, 4.3, 4.7; Diagnostic Code (DC) 9411 (2017). 2. Service connection for a gastroinstestinal disability including as secondary to a service-connected disability, is not warranted. 38 U.S.C.A. §§ 1110, 5103, 5103A (2012); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2017). 3. The criteria for a TDIU are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2017). The Board's August 2016 remand required the RO to take appropriate steps to request any updated treatment records and to afford the Veteran new VA examinations. In compliance with the remand directives, VA examinations and VA medical opinions were obtained. A March 29, 2017 statement from the Veteran and his representative dated March 7, 2017 asserted that the VA examiner did not identify all medications prescribed, past or present, for PTSD and diabetes. However, a list of the Veteran's prescription medications is also associated with the claims file. The directives having been substantially complied with, the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). Regarding development of the TDIU claim, the Board notes that on June 15, 2017 VA wrote and asked the Veteran and his representative to complete and return a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. Neither the Veteran nor his representative has complied with VA's request for current employment information. The Board concludes that the Veteran was properly notified of the scheduled additional development. See Ashley v. Derwinski, 2 Vet. App. 307 (1992) (regarding the presumption of regularity that public officers have properly discharged their official duties in absence of clear evidence to the contrary); Mindenhall v. Brown, 7 Vet. App. 271 (1994) (regarding the applicability of the presumption of regularity to RO actions). Proper notice was provided. Thus, the Board will continue adjudicating his TDIU claim based on the evidence of record. The Veteran has not raised any other issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). II. Increased Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. 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 condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, a staged rating is not warranted. A. PTSD The Veteran's PTSD has been initially rated at 50 percent pursuant to 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411, since August 23, 2010. The Veteran and his representative assert that the 50 percent initial rating for PTSD does not accurately depict the severity of his disability. Specifically, he contends that his PTSD symptomatology, long standing chronicity, and lack of coping skills entitle him to a higher rating for PTSD (and to a TDIU). DC 9411 and other DC's addressing psychiatric disabilities are addressed under 38 C.F.R. § 4.130, the General Rating Formula for Mental Disorders: A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 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 worklike setting); inability to establish and maintain effective relationships. A rating of 100 percent 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. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013) the Federal Circuit stated that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. It was further noted that § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. The such symptoms as language means for example, and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Effective March 19, 2015, VA adopted as final, without change, an interim final rule amending the portion of its Schedule for Rating Disabilities dealing with mental disorders. The interim final rule replaced outdated references with references to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and updated the nomenclature used to refer to certain mental disorders in accordance with DSM-5. Specifically, the rulemaking amended 38 C.F.R. §§ 3.384, 4.125, 4.126, 4.127, and 4.130. However, the provisions of this final rule do not apply to claims that were certified to the Board on or before August 4, 2014, even if such claims are subsequently remanded to the agency of original jurisdiction. As this appeal was first certified to the Board in September 2012, the previous versions of the regulations including references to the previous edition, DSM-IV, apply. The DSM-IV criteria include a provision for assignment of a Global Assessment of Functioning (GAF) score by treating examiners to reflect the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266 (1996). GAF scores ranging between 61 and 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). See 38 C.F.R. § 4.130. i. History A June 2011 VA Initial PTSD Examination showed symptoms of anger, depression, flashbacks, distrust, and sleep disorder. The Veteran's anger, depression, and distrust were daily. Flashbacks were at least once a month. His sleep disorder was twice a week on average. A July 2012 VA examination found the Veteran's PTSD to be productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The psychologist found that the Veteran's symptoms were anxiety, suspiciousness, mild memory loss, such as forgetting names, directions, or recent events, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, including work or a worklike setting, and neglect of personal appearance and hygiene. The VA examiner assigned a GAF score of 60. The Board's November 2013 remand found the July 2012 psychiatric examination report lacking because its conclusions were inconsistent with the specific findings noted therein. The remand required in part, "The AOJ should request the previous examiner who provided the July 2012 VA examination explain the basis for the GAF rating assigned given the findings reported at the examination." Thus, the Board remanded that matter for clarification. An August 2014 VA examination was conducted pursuant to that remand. The Veteran reported that he goes out to eat with his sons, and they also come over and help him with tasks at his house. The VA examiner found that the Veteran's level of occupational and social impairment was most closely summarized as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The VA examiner found that PTSD was manifested by depressed mood, anxiety, suspiciousness, chronic sleep impairment, and disturbances of motivation and mood. The Veteran was pleasant, and affect was stable. Speech was of average rate, tone, and prosody. Upon direct questioning, no immediate suicidal or homicidal ideation was reported. No hallucinations were indicated. The Veteran was cooperative during the session. The VA examiner noted that a GAF was requested for this evaluation. The current GAF was 58 based on: sleep issues, occasional depressed mood, occasional irritability, occasional social withdrawal, hypervigilance, avoidance of trauma-related stimuli and triggers, negative beliefs, and cognitive effects related to traumatic stressors, and heightened arousal. The VA examiner opined that these symptoms constituted some functional limitations to starting and completing both sedentary and physical tasks. A June 18, 2015 VA treatment record shows that the Veteran denied being depressed or anxious, but had impaired sleep. A related risk assessment screen note from that same day showed that the Veteran had a negative screening for depression. The Board's February 2016 remand directed that further clarification be provided. The Court's September 2015 order and the Joint Motion had found the August 2014 examination report lacking because it (1) failed to "fully set forth [the examiner's] own notation as to [the Veteran's] history based on a thorough and contemporaneous review of [the Veteran's] records," (2) failed to provide an adequate rationale underlying the assignment of a Global Assessment of Functioning (GAF) score beyond "a mere listing of symptoms," and (3) appeared that the examiner was "given only one possible response" regarding the level of occupational and social impairment demonstrated, noting that it was "unclear whether the examiner was provided additional response options." The February 2016 remand directed that an explanation for the GAF score found at the July 2012 VA examination be provided. A January 8, 2016 VA treatment record shows that the Veteran denied depression, hallucination, or mood changes. A March 2016 VA examination shows that the Veteran had occupational and social impairment with reduced reliability and productivity. It found that PTSD was manifested by depressed mood, anxiety, suspiciousness, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, impaired impulse control, such as unprovoked irritability with periods of violence, and neglect of personal appearance and hygiene. The clinical psychologist reviewed the claims file and opined that a GAF of 55 seemed to be more illustrative of Veteran's functioning in July 2012 based on the VA examination and evidence of record. The support for GAF of 55 was that the Veteran was experiencing anxiety with more than one panic attack per week, suspiciousness, flattened affect, impairments in judgment and memory, mood and motivation disturbances, difficulty adjusting to stressful circumstances, neglect of personal appearance and hygiene, re-experiencing of the trauma, avoidance of trauma reminders, emotional detachment and restricted affect, heightened arousal, irritability, hypervigilance, and exaggerated startle response. The August 2016 remand indicated that while the resulting March 2016 psychiatric examination report did include a detailed historical report, it again failed to indicate whether additional options were made available to the examiner. Furthermore, the examiner opined that the July 2012 examination report more appropriately supported a GAF of 55, but again cited only to a list of symptoms as support for such finding. Finally, the Board noted that the examination report indicated it was conducted pursuant to the DSM-5 but, as the Veteran's appeal in this matter was certified prior to August 4, 2014, the DSM-IV (rather than the DSM-5) applied to his claim. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). Therefore, the Board found that further development was needed to ensure compliance with the September 2015 Court order. A February 2017 VA examination showed that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran reported that he goes to a restaurant every morning for coffee and meets his friends there. Most of them are Veterans. He worked on his own farm to earn money, sometimes hiring help. He read newspapers and watched TV in his free time, including watching the Superbowl with friends at their house. The VA examiner found that the Veteran's symptoms included anxiety, suspiciousness, chronic sleep impairment, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The Veteran had no immediate suicidal or homicidal ideation. He had no audio or visual hallucinations. He was cooperative during the session. A March 2017 VA addendum medical opinion shows that the entire record was reviewed and the evaluation was conducted in a manner that agreed with the DSM-IV diagnostic criteria. The psychologist reviewed the record and opined that the GAF that related to the current evaluation was 60. This GAF score was based on the Veteran's level of current functioning in daily activities. He was able to work on his farm most days, and he spent time working with livestock. He worked several hours per day, and he reported that he could complete most chores on the farm by himself. He denied having any difficulties in completing the farm work, and he stated that he usually enjoys spending time outside. Despite his PTSD symptoms, he was able to meet his Veteran friends at a local restaurant each morning to have coffee. They also sometimes get together to do other activities, including watching a football game on TV at someone's house. The Veteran reported that he avoided some activities in public due to hypervigilance and other PTSD symptoms, but he was able to do these selected activities and was able to enjoy them. The VA examiner also found that the GAF score given for the July 2012 evaluation was 60, and opined that this seems to have been appropriate for this time period. In addition, the March 2017 VA psychologist explained that the Veteran's current level of occupational and social functioning was most closely summarized by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The VA examiner opined that contributing symptoms that indicate support this level of functioning included: directly experiencing the traumatic event(s), recurrent, involuntary, and intrusive distressing memories of the traumatic event(s), recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s), intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s), avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s), avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s), persistent and exaggerated negative beliefs or expectations about oneself, others, or the world, persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame), and irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. He also had hypervigilance, exaggerated startle response, and sleep disturbance. The VA examiner also noted that further contributing symptoms included anxiety, suspiciousness, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. A September 5, 2017 letter from the Social Security Administration (SSA) indicated that the medical records could not be obtained because the records have been destroyed. Information received from the Social Security Administration indicated a disability onset date of September 14, 1985. A July 26, 2017 VA treatment record shows that the Veteran denied depression or anxiety. A January 18, 2018 VA treatment record shows that the Veteran denied, depression, hallucination, or mood changes. ii. Analysis - PTSD The Veteran is competent to report his feelings, including anxiety, suspiciousness, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. He is competent to report that he has been diagnosed with PTSD. The Board finds these reports credible as they are uncontradicted. The Veteran competently and credibly endorsed symptoms of difficulties related to social isolation, mood swings, anxiety, and difficulty managing daily stress. The Board assigns significant probative weight to the Veteran's lay reports of his symptoms, including those exhibited at the time of the February 2017 VA examination and related March 2017 VA addendum medical opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the recent January 18, 2018 VA treatment record also shows that the Veteran denied depression, hallucination, or mood changes, so there is not probative lay evidence in support of those additional symptoms. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the veteran). The February 2017 VA examination found that the Veteran goes to a restaurant every morning for coffee with his friends. He works on his own farm to earn a living, sometimes hiring help. He reads newspapers and watches TV in his free time, including watching the Superbowl with friends at their house. The Board finds this to be highly probative. Such findings are consistent with those exhibited at the July 2012 VA examination. Similarly, the March 2017 VA medical opinion showed that PTSD was manifest by anxiety, suspiciousness, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. Overall, the March 2017 VA opinion provides highly probative evidence against the claim for a higher rating, as the examiner stated the Veteran currently demonstrates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Importantly, this closely matches the 30 percent rating for mental disorders under the General Formula, so it is probative evidence against, not in support of, the claim. The weight of competent lay and medical evidence indicates that a higher evaluation is not warranted. A higher evaluation of 70 percent is not warranted unless there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Here, the Board finds the most probative evidence is the results of the February 2017 VA examination and related March 2017 VA addendum medical opinion. Together, these reports present a consistent description of the Veteran's symptomatology that most closely approximates a 50 percent rating. The Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. VA treatment records show that the Veteran denied depression and anxiety at times. In addition, the Veteran has consistently denied suicidal ideation, and there is no indication that suicidal ideation has significantly interfered with the Veteran's occupation or social functioning. While the Veteran's specific symptoms and GAF score wax and wane across the appeal period, the Board finds that these records, taken together, describe a consistent picture of symptomatology associated with the Veteran's PTSD. Additionally, the Board notes that GAF scores are also not necessarily dispositive, and rather, must be considered in light of the actual symptoms of the Veteran's disorder. See 38 C.F.R. § 4.126 (a). Here, the Veteran's lowest GAF scores are in the range between 51 and 60, which reflects moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). The Board notes that this degree of impairment is most closely approximated by the current 50 percent rating for PTSD. The contemporaneous VA treatment records and VA examinations have reflected that the Veteran's PTSD results in occupational and social impairment with reduced reliability and productivity. Notwithstanding these limitations, the Veteran is still able to hire others to work with him, go out to eat, socialize, and attend auctions, even if his work is usually isolated in nature. As such, there is not sufficient evidence that the Veteran's symptoms are of the severity and frequency to cause the level of occupational and social impairment associated with a higher disability rating. See Bankhead v. Shulkin, No. 15-2404, slip op. at 10 (U.S. Vet. App. Mar. 27, 2017); Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). Consequently, a rating in excess of 50 percent for PTSD is not warranted. III. Service Connection - Gastrointestinal Disability To establish service connection a Veteran must generally show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection may be established on a secondary basis for disability that is proximately due to or the result of a service-connected condition. See 38 C.F.R. § 3.310(a). Secondary entitlement is also available when a service-connected condition has chronically - meaning permanently - aggravated the disability in question, but compensation is limited to the degree of disability (and only that degree) over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.310(b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). A. History The Veteran's October 1966 separation examination was clinically normal for the genitourinary system, and abdomen, and viscera. The Veteran's August 1968 separation examination was clinically normal for the genitourinary system, and abdomen and viscera. In his related Report of Medical History, he denied frequent indigestion, stomach, liver, or intestinal trouble. The Veteran was afforded a July 6, 2006 Gastroenterology Consult at the VA Heartland - West Medical Center (VAMC). The Veteran was first referred to GI for hepatitis C treatment at this time. He was there for his first education class related to this. The Veteran was instructed regarding no further alcohol use and that he must be free and clear of illegal drugs and alcohol for six months before starting therapy for hepatitis. On April 1, 2011, VA received a copy of a prescription from the Veteran. It shows he was prescribed Omeprazole. One of the possible listed uses is for treating certain stomach and esophagus problems. An April 6, 2012 VA primary care note shows, "Has stomach upset for a week was nauseated for a week loose stools no vomiting but felt queasy went away yesterday." A November 20, 2013 VA treatment record shows "GERD stable on meds." The issue was remanded by the Board in November 2013 to obtain a VA examination and etiology opinion. A May 19, 2014 VA treatment record shows "GERD - controlled." A June 11, 2014 VA treatment record shows that the Veteran called reporting upset stomach since starting Metformin. The Veteran reported that he felt like he was constantly on the verge of throwing up or having diarrhea, and often just lays around with upset stomach. The Veteran reported that he was still taking two Glyburide twice daily in addition to the Metformin. He feared this may be too much medication for his stomach. An addendum from that same day shows that Veteran would discontinue metformin. The Veteran was afforded a July 2014 VA examination. The Veteran denied having or being diagnosed with IBS or any other intestinal condition. The Veteran reported having an adjustment problem with medication for diabetes, Metformin, when it was first proscribed to him. The Veteran reported that he would have stomach upset with frequent bowel movements. The Veteran reported that after getting back on it for the second time, he did not have any problems as previously described. The VA examiner opined that the claimed conditions (GERD, IBS, and Hiatal Hernia) were less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was that the service record did not produce diagnosis or the contingency of the treatment for the conditions. The VA examiner elaborated that it appeared the acid reflux might have been an episodic occurrence until 2011, when Veteran was proscribed medication Omeprazole, which he then used daily. The VA examiner also noted diet may have affected this. The VA examiner also noted the Veteran's past medical history of smoking and heavy alcohol use that could easily be the culprit for at least occasional episodes of gastric reflux. The VA examiner noted that hiatal hernia was not seen or diagnosed in the VA treatment records. IBS was not diagnosed. The Veteran denied any existence of the bowel condition caused by medications for PTSD. The VA examiner elaborated that the transitional one time stomach/bowel upset with Metformin was resolved. The VA examiner also noted that the Veteran was still taking medications without further intestinal problems. The February 2015 Board remand found the July 2014 remand lacking insofar as it failed to address whether the Veteran's claimed gastrointestinal disability may be either caused or aggravated by medications prescribed for service-connected disabilities (i.e., PTSD and diabetes mellitus), and ordered a supplemental medical opinion addressing that question. A December 31, 2015 VA treatment record shows that the Veteran had what he thought was a stomach virus. He noted some stomach cramping especially at night, and no diarrhea, nausea, or vomiting. Symptoms were abating. Otherwise the Veteran had no particular medical issues to discuss. A February 18, 2016 VA treatment record shows that the Veteran reported having upset stomach if he does not take Harvoni on a full stomach. The VA treatment record shows that he was nevertheless tolerating it well. A March 22, 2016 VA addendum medical opinion located in Virtual VA shows that the VA examiner found that the Veteran's gastrointestinal disorder was less likely than not (less than 50 percent probability of aggravation) permanently aggravated beyond natural progression by a service connected disability or by medications, specifically, Mirtazapine, Trazodone, Metformin, and Glyburide. The VA examiner also opined that the claimed GI condition was less likely than proximately due to or the result of the Veteran's service connected condition or medications proscribed for any of the Veteran's service connected conditions. The March 22, 2016 VA examiner further reasoned that his GI symptomatology was caused by his habits. The VA examiner highlighted that in 2006, the Veteran was diagnosed with hepatitis C and diabetes. The VA examiner noted that of the medications in question, the Veteran switched to medications that he could tolerate. Metformin was listed under the Veteran's allergies. The GI issues were also noted at the time when he did not control his diabetes. Regarding prescription medication, the VA examiner opined that just because the symptoms were listed does not necessarily mean that the Veteran would experience them. An April 13, 2016 VA treatment record shows that the Veteran underwent a CT scan of the abdomen. Upon clinical examination, the stomach was decompressed and poorly evaluated. The Veteran had normal caliber small bowel and colon, normal appendix, and mild diffuse colonic wall thickening, likely secondary to underdistention. He had minimal colonic diverticulosis. The August 2016 Board remand found that the March 2016 addendum opinion (by the same examiner) was somewhat unclear, in that it simply concluded that the Veteran's unspecified gastrointestinal condition was not permanently aggravated by any of his medications. The remand requested in part a more detailed discussion by the VA examiner. A January 25, 2017 VA primary care note shows that the Veteran had no abdominal pain, nausea, vomiting, or bowel changes. The Veteran was afforded February 2017 VA examinations. The VA examiner reviewed the STRs and highlighted that there was no evidence of GERD until 2007. The VA examiner reviewed the entire claims file. The VA examiner noted that the Veteran was released from active duty in 1968. The VA examiner opined that it is less likely as not that GERD is related to service. The VA examiner noted that Veteran was on Saxagliptin and Glipizide for his diabetes. The VA examiner opined that neither of these medications were listed in medical literature as causing colon polyps. The Veteran denied IBS. The VA examiner also opined that the claimed conditions, including GERD and IBS, were less likely than not incurred in or caused by the claimed in-service injury, event or illness. The VA examiner noted that there was no diagnosis of IBS. The VA examiner opined that therefore it was less likely as not that IBS is service connected. Regarding a gastrointestinal disability to include GERD, the VA examiner found that it was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Overall, the VA examiner noted that it is less likely as not that colon polyps, or GERD, were worsened beyond their natural progression by any medications. The VA examiner also opined that it is less likely than not that PTSD was aggravated by any medications. The VA examiner noted that the Veteran took diabetic medications Saxagliptin and Glipizide. The VA examiner explained that the medical literature does not show any evidence that these medications cause either colon polyps or GERD. The VA examiner also opined that colon polyps and GERD were not proximately due to or the result of the Veteran's service connected condition. A March 29, 2017 statement from the Veteran and his representative dated March 7, 2017 asserted that the VA examiner did not identify all medications prescribed, past or present, for PTSD and diabetes. On March 29, 2017, VA received an article from the Peoples Pharmacy showing possible side effects and complications from taking Metformin. It listed possible side effects, including gas, stomach ache, and diarrhea. It also noted that "After several weeks, however, the digestive symptoms often fade away." It further notes, "These side effects may seem daunting, but most people tolerate this medication well." VA treatment records show that a list of medications was associated with the claims file on April 7, 2017. In part, they show that he was prescribed Trazodone as needed for mood and sleep. This is listed under "antidepressants, other." An April 12, 2017 VA examination in Virtual VA shows that the VA examiner reviewed the Veteran's medications and their side effects, including Trazodone. The physician opined that the Veteran's gastrointestinal disability, to include GERD and colon polyps, was less likely than not proximately due to or the result of the Veteran's service connected condition. The physician reasoned that there was no evidence that any of the medications (Saxagliptin, Glipizide, Trazodone, Metformin) prescribed to the Veteran for diabetes and PTSD caused GERD and colon polyps. The physician concluded that it is less likely as not that any of these medications caused GERD or colon polyps. Again on April 19, 2017, a VA medical opinion was obtained. It shows that same physician reviewed the claims file, and the side effects of the Veteran's medications. The physician opined that it was less likely as not that any of these medications aggravated GERD or colon polyps. Ongoing VA treatment records show the Veteran takes Omeprazole to lower stomach acid. Additional VA treatment records are substantially the same. Prior to the April VA examinations, the Veteran and his representative asserted that the AOJ should have provided a VA examination performed by a physician, and all medications past and present should be considered by the VA examiner for both PTSD and diabetes. B. Analysis The Veteran is competent to report pain in his stomach. He is competent to report experiencing this shortly after taking Metformin, and other medications. He is competent to report what he has been told by his doctor. The Board finds these reports credible. The service treatment records show that the Veteran was clinically normal upon separation for the genitourinary system, and abdomen and viscera. He denied frequent indigestion, stomach, liver, or intestinal trouble. The Veteran did not begin to receive ongoing related treatment until July 2006, many decades removed from discharge. At the time, aggravating factors were cited including alcohol and illegal drug use. Later VA treatment records show episodes of stomach upset around the time when he was starting Metformin, which was promptly discontinued. They also show reports of upset stomach due to a virus. The VA treatment records show that specific symptoms were often acute, transitory, and resolved. The February 2017 VA examiner reviewed the claims file, and opined that the Veteran's gastrointestinal disabilities were less likely than not related to service. The examiner reasoned that there was no evidence of GERD until 2007, although he was separated from active duty in 1968. Given the VA examiner's review of the claims file, and discussion of the rationale of the opinion, the Board finds the VA examiner's opinion is highly probative evidence against the claims. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) ("It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion."). The April 12, 2017 VA examining physician also reviewed the claims file, including medication lists, and opined that the Veteran's gastrointestinal disability, to include GERD and colon polyps, was less likely than not proximately due to or the result of the Veteran's service connected condition. The VA examiner reasoned that there was no evidence that any of the medications (Saxagliptin, Glipizide, Trazodone, Metformin) prescribed to the Veteran for diabetes and PTSD caused GERD and colon polyps. The related April 19, 2017 medical opinion by the physician shows that it was less likely than not that the Veteran's claimed condition was aggravated beyond its natural progression by his service connected condition. The VA examiner reviewed the latest complete list of medications for both PTSD and diabetes, and opined that none of these medications aggravated GERD or colon polyps. The physician in April 2017 also reviewed the potential side effects of the listed medications, including those for PTSD, in rendering his opinions. The Board finds these VA medical opinions to be highly probative. See Nieves, supra. In addition, although various shortcomings have been noted, the Board notes that these findings are consistent with the impressions from previous VA examiners. There is no probative evidence to the contrary. Here, a gastrointestinal disability was not noted or manifest during service. In addition, he did not have characteristic manifestations sufficient to identify the disease process during that time frame. The most probative evidence establishes a remote onset of transitory gastrointestinal disability, and the Veteran's own opinion warrants less probative value (regarding etiology) when compared with the objective evidence of record. In addition, the competent and probative evidence shows that a gastrointestinal disability is not proximately due to, the result of, or aggravated service connected disease or injury. The most probative evidence also shows that the Veteran's medications did not aggravate GERD or colon polpys. In arriving at this finding, the Board reiterates that it is basing its decision on the probative, competent, medical evidence of record. Consequently, service connection for a gastrointestinal disability is not warranted. IV. TDIU A. Law and Regulations Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by non service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2006); Van Hoose v. Brown, 4 Vet. App. 361 (1993). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities: Provided That, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). It is the established policy of the Department of Veterans Affairs that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Therefore, rating boards should submit to the Director, Compensation Service, for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in paragraph (a) of this section. The rating board will include a full statement as to the Veteran's service-connected disabilities, employment history, educational and vocational attainment and all other factors having a bearing on the issue. 38 C.F.R. § 4.16 (b). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, a uniform evaluation is warranted. The term "unemployability," as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. The issue is whether the Veteran's service-connected disabilities preclude him from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a "living wage"). See Moore v. Derwinski, 1 Vet. App. 356 (1991). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). B. Analysis - TDIU At the July 2012 VA psychiatric examination, the VA examiner opined that the Veteran's time appears to be primarily focused on working on his farm and then spending time with his family, especially with his grandson who plays baseball. The Veteran reported being a farmer/rancher. The Veteran shared that he was having problems mostly because of the weather and the cost of hay. The Veteran shared that he was having some problems because of being exhausted due to his diabetes. The Veteran shared that he had to sit down repeatedly when his blood sugar was depleted. The Veteran reported that he runs water for the cows, and then feeds them corn. He walks about a 1/4 of a mile to 3/4 of a mile every day. He had to keep his eye on the calves. He reported that it gets hot, and he has to know how many calves he has at all times. He watches for buzzards. The Veteran reported that he was going to "the boat" to gamble, but both of his cousins who he used to go with died. The Veteran also used to play pool, but after those two cousins died, he stopped going to the tournaments. The August 2014 VA psychiatric examination showed that the Veteran's most recent job has been in farming, and he has been doing this since 1987 on his land. He stated that he worked all year round. He also helped his neighbors at times too. He could not work if it is too hot, and he would pace himself. He stated he would work in the early morning and later in the evening. One of his neighbors worked with him and helped him out. His church pastor's son came out and helped as well. His neighbor looked out for him and would suggest that he take a break if he looked too flushed. In June, July, and August, he worked in the fields so that his cows can have something to eat in the winter. In the winters he did his own snow removal and also fed the cows. The Veteran reported that he had no crops. Regarding his education, the Veteran reported at the VA examination that he had earned his GED. When he first got out of the military, he worked for the highway department and had some job training as part of that job. He went to a motorcycle mechanic school, and he earned a certificate in 1975. He had no other coursework or training. Regarding family, the Veteran reported that his sons lived in the area. He went out to eat with his sons, and they also came over and help him with tasks at his house. He had one grandson, and he was close to him. The Veteran drove to see him play baseball. The grandson drove to the Veteran's place and fished at the pond near his property. The Veteran also has a brother who lives in the Kansas City area, whom he visits when he is in the area. They have a good relationship and they talk on the phone every day. He does not have any other brothers and sisters. Regarding friends, the Veteran stated that every morning he went to a restaurant and touched base with his friends who are Veterans. They had a "liars table," and they chatted on a daily basis. The Veteran had also met fellow Veterans at auctions, and he met a few who were also in Vietnam. He reported that they were friends to some extent. At the February 2017 VA psychiatric examination, the Veteran reported that he had a female friend who called when she gets stressed. They then talk. She also would call when she wanted to go see a show or go out to eat. Sometimes they went together to help with both feeling sad. The Veteran also continued to report that he went to a restaurant every morning for coffee and he met his friends there. The Veteran reported enjoying spending time with them, "We watch football games together sometimes too...I'm going to one of their houses this weekend to watch the Superbowl." Regarding occupational activities, the Veteran reported that he still lived and worked on a farm to earn money. He reported doing this since 1987. He took care of farm chores and other related responsibilities in his free time. He had six new calves. The Veteran stated that he hires a few people to help him, but otherwise he does the rest on his own in taking care of the livestock. He had one cat and he took care of it and the other animals on the farm. He sold his livestock when he could. In the March 29, 2017 Remarks to Supplemental Statement of the Case, the Veteran and his representative asserted that his PTSD and lack of coping skills entitle him to a TDIU. The Veteran argues that given the combined impact of his service-connected medical impairments, he is unable to secure or maintain any substantially gainful employment, and therefore should be awarded individual unemployability benefits. In the present case, service connection has been granted for PTSD at 50 percent from August 23, 2010. It has also been granted for diabetes mellitus, type II, at 20 percent from October 2, 2006. The Veteran's combined rating is 20 percent from October 2, 2006 and 60 percent from August 23, 2010. The Veteran and his representative assert that the Veteran's PTSD symptomatology, including lack of coping skills, entitles to him a TDIU. As here, where the scheduler rating is less than total, a total disability rating for compensation may be assigned when Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. See 38 C.F.R. § 4.16 (a). The Veteran's rating did not meet the objective criteria for entitlement to a TDIU. The Board will still consider whether referral to VBA's Director of Compensation & Pension Services is warranted pursuant to 38 C.F.R. § 4.16 (b). Here, the weight of the competent and probative evidence does not support a finding that the Veteran's service-connected disabilities render him unable to secure and follow a substantially gainful occupation. An August 2014 VA psychiatric examination indicates that the Veteran has been living and working as a farmer/rancher since 1987. As of the recent February 2017 VA examination, the Veteran was still working on his farm and had six calves. He went to a show or out to eat with a female friend. He was isolative in terms of his daily work, but was able to earn a living on his own land with his current occupation. He hired help when he needed it, and helped others. He met at a restaurant to socialize daily, and also had plans to watch the Superbowl. He talked to friends and family on the phone. He was able to ambulate. He knew to pace himself. The Veteran was also able to go to auctions, and met friends regularly. The VA examinations indicated that although he does not work well with other people regularly, he is able to work with them when needed. He had a GED and previously earned a motorcycle certificate. While the Veteran indicated he believes that his symptoms associated with PTSD entitle him to a total disability rating based on individual unemployability, there is no probative evidence to indicate that he is unable to maintain substantially gainful employment. The Veteran was also asked to submit additional documentation to help develop his claim, and has not done so. While the Veteran and his representative may contend that his current occupation is in a protected environment because he has been working at home on a farm, the Board finds that his farm business is not a protected environment, and the Veteran still interacts with others both socially and occupationally. As a farmer, his work with the animals would also likely be relatively solitary in terms of sociability, and that would not perpetuate the symptoms of his PTSD related difficulty with coping skills. He has earned a living in this manner since 1987. In addition, the Board finds that this is not marginal employment. In short, he has demonstrated the longstanding capacity for employment in his current occupation, albeit with the noted limitations. Similarly, none of the results of the VA examinations suggest that the Veteran's service connected disabilities, PTSD and diabetes mellitus, type II, are of sufficient severity as to prevent leaving the home, driving an automobile, or accomplishing the mobility and physical skills necessary to pursue his ranching business. Consequently, the Board finds that entitlement to a TDIU is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching this conclusion, the Board finds that the preponderance of the evidence is against this claim. As such, the benefit of the doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial rating in excess of 50 percent for PTSD is denied. Entitlement to service connection for a gastrointestinal condition, claimed as acid reflux, hiatal hernia, and irritable bowel syndrome, as secondary to service connected disease or injury, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. ____________________________________________ BISWAJIT CHATTERJEE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs