Citation Nr: 18152985 Decision Date: 11/27/18 Archive Date: 11/26/18 DOCKET NO. 16-31 782 DATE: November 27, 2018 ORDER Entitlement to an increased rating in excess of 10 percent for left lower extremity sciatica is denied. Entitlement to a separate rating of 40 percent, but no higher, for traumatic brain injury (TBI) from January 19, 2012 is granted. Entitlement to a separate rating of 50 percent, but no higher, for posttraumatic stress disorder (PTSD) from January 19, 2012 is granted. Entitlement to a total disability rating due to individual unemployability (TDIU) is granted. REMANDED Entitlement to an increased rating in excess of 10 percent for low back strain is remanded. Entitlement to an increased rating in excess of 10 percent for left knee derangement is remanded. Entitlement to an increased rating in excess of 10 percent for right knee derangement is remanded. FINDINGS OF FACT 1. The Veteran’s left lower extremity condition manifested by no worse than mild incomplete paralysis of the sciatic nerve, reflected by intermittent pain, numbness, and tingling. 2. The Veteran’s TBI manifested by no worse than level “2” neurobehavioral effects and no worse than level “1” mild memory loss, social interaction, and language comprehension. 3. The Veteran’s PTSD manifested by symptoms including depression, anxiety, suspiciousness, hypervigilance, sleep impairment, weekly panic attacks, impaired impulse control, disturbances of mood and motivation, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances; these symptoms caused occupational and social impairment with reduced reliability and productivity. 4. The evidence of record is in relative equipoise as to whether the Veteran is unable to secure and follow a substantially gainful occupation due to service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an increased evaluation in excess of 10 percent for left lower extremity sciatica are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.10, 4.120, 4.124a, Diagnostic Code 8520 (2017). 2. The criteria are met for a separate disability rating of 40 percent, but no higher, for TBI from January 19, 2012. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1-4.10, 4.124a, Diagnostic Codes 8045, 8100 (2017). 3. The criteria are met for a separate disability rating of 50 percent, but no higher, for PTSD from January 19, 2012. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1-4.10, 4.130, Diagnostic Code 9411 (2017). 4. Resolving all reasonable doubt in the Veteran’s favor, the criteria for entitlement to a TDIU are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.15, 4.16, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from May 2001 to September 2001; May 2004 to August 2005; and December 2007 to January 2009. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from October 2011 and January 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The Veteran submitted notices of disagreement (NODs) in February 2012 and December 2014. A statement of the case (SOC) was issued in June 2016. The Veteran perfected a timely substantive appeal via VA Form 9 later in June 2016. The Veteran submitted additional evidence since the issuance of the June 2016 SOC. However, as the Form 9 addressing the issues on appeal was received after February 2, 2013, a waiver of review of the evidence by the Agency of Original Jurisdiction is not required. See 38 U.S.C. § 7105 (2012). The Veteran reported receiving private psychological treatment from Dr. W. in 2011. Multiple attempts were made by VA via mail and telephone to obtain these records. No response was received. The Veteran was advised of the lack of response from Dr. W. While multiple private mental health and vocational evaluations have been received from the Veteran, Dr. W.’s records have not been provided. The Board finds that VA has adequately discharged its duty to locate records and afforded the Veteran notice and opportunity to submit any identified records that may be in his possession. The Veteran has not identified any outstanding records that have not been requested or obtained. Accordingly, appellate consideration may proceed. Increased Ratings The Board has reviewed the evidence in the Veteran’s claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every item of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). The Board will summarize the relevant evidence as appropriate and focus specifically on what the evidence shows or fails to show as to the claims. General Rating Principles 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. A veteran’s entire history is to be considered when making disability evaluations. See 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board must consider entitlement to “staged” ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the appeal. See Hart v. Mansfield, 21 Vet. App. 505 (2007). However, assigning separate ratings for combination may not be permitted to result in pyramiding under 38 C.F.R. § 4.14, which prohibits “[t]he evaluation of the same disability under various diagnoses.” See Brady v. Brown, 4 Vet. App. 203, 206 (1993); see also Esteban v. Brown, 6 Vet. App. 259, 262 (1994) (the critical element is if symptoms of one condition are duplicative of or overlapping of another). The Board attempts to determine the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Notwithstanding the duty to assist, it remains a claimant’s responsibility to submit evidence to support his or her claim. See 38 U.S.C. § 5107(a); see also Skoczen v. Shinseki, 564 F.3d 1319, 1328 (Fed.Cir.2009). When there is an approximate balance of evidence regarding an issue material to the determination of a matter, the benefit of the doubt in resolving the issue shall be given to the Veteran. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to an increased rating in excess of 10 percent for left lower extremity sciatica. The Veteran contends that the service-connected left lower extremity sciatica is more severe than contemplated by the currently assigned 10 percent rating. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. 38 C.F.R. § 4.123 (2017). Diagnostic Code 8520 provides the rating criteria for paralysis of the sciatic nerve. A 10 percent evaluation is warranted for incomplete paralysis of the sciatic nerve that is mild. A 20 percent evaluation is warranted for incomplete paralysis of the sciatic nerve that is moderate. A 40 percent evaluation is warranted for incomplete paralysis of the sciatic nerve that is moderately severe. A 60 percent evaluation is warranted for incomplete paralysis of the sciatic nerve that is severe, with marked muscular atrophy. An 80 percent evaluation is warranted for complete paralysis; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. The Board notes that the terms “mild,” “moderate,” “moderately severe,” and “severe” are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Although a medical examiner’s use of descriptive terminology such as “mild” is an element of evidence to be considered by the Board, it is not dispositive of an issue. The Board must evaluate all evidence in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Turning to the evidence of record, the Veteran underwent a VA spine examination in October 2011. The examiner found no muscle atrophy. Reflexes and sensory examination returned normal results. No radiculopathy was reported by the Veteran. In August 2013, the Veteran underwent further VA spine examination. The examiner found no muscle atrophy. Reflexes and sensory examination returned normal results. No radiculopathy was reported by the Veteran. Another VA spine examination was conducted in May 2016. The Veteran reported ongoing intermittent radicular pain into the left thigh down to the knee with tingling and numbness. No weakness was noted in the left lower extremity. No bladder or bowel issues were reported. The Veteran described mild to moderate impact on his daily activities of living due to his back and associated sciatica disabilities. After review of the claims file and physical examination of the Veteran, the examiner noted involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve). The Veteran denied constant pain, but endorsed moderate intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness in the left lower extremities. Muscle atrophy was not present. A sensory exam revealed normal sensation. The examination report indicated that incomplete paralysis of the left sciatic nerve was of mild severity. After thorough consideration of the evidence of record, the Board finds that the preponderance of the evidence warrants the assignment of no more than 10 percent disability ratings for left lower extremity sciatica. In this case, the findings most closely reflect mild incomplete paralysis, thus warranting a 10 percent rating for the disability. While the Veteran has reported pain, numbness, and tingling at times, these symptoms were intermittent. The intermittent nature of the symptoms supports the Board’s finding that the level of incomplete paralysis was no more than mild. The Veteran is competent to describe his symptoms related to the left side sciatica. See Layno v. Brown, 6 Vet. App. 465 (1994). However, outside of the examinations, he has provided little information regarding his symptomatology or its effect on his life. He has simply asserted that a higher rating is warranted. While he is credible to the extent that he sincerely believes he is entitled to a higher rating, he is not competent to identify a specific level of disability according to the appropriate Diagnostic Code, as this is a complex medical determination outside the realm of common knowledge of a lay person. See e.g. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Without some problems associated with the Veteran’s left lower extremity sciatica, there would be no basis for a compensable disability rating. The 10 percent rating is an acknowledgement that the Veteran’s ability to engage in employment and activities of daily life is impaired and that this impairment is significant enough to warrant a compensable rating. Based upon the competent and probative lay and medical evidence of record, the Board finds that the pain, numbness, and other symptoms have been intermittent with minimal or mild occupational effect. Given the objective evidence of record, moderate, moderately severe, or severe incomplete paralysis warranting an evaluation of 20 percent or higher is not warranted; likewise, complete paralysis warranting an 80 percent rating is not shown by the lay or medical evidence. In summary, the Veteran’s service-connected left lower extremity sciatica manifested through intermittent pain, numbness, and tingling. Such symptomatology is entirely contemplated by the 10 percent disability rating assigned; the criteria for a higher rating are not met. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53. The Veteran has not raised any other issues with respect to the increased rating claim for his left lower extremity sciatica, nor have any other assertions been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). 2. Entitlement to an increased rating for TBI in excess of 40 percent from January 19, 2012. As an initial matter, the Board notes that the appellate period for this issue relates back to the claim for increased disability benefits received by VA on January 19, 2012, which begins the period of appellate review now before the Board (plus consideration of the one-year look back period prior to the filing of that claim). See Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010). Rating Criteria The Veteran’s TBI is evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8045. Effective October 23, 2008, Diagnostic Code 8045 states that there are three main areas of dysfunction that may result from a TBI and have profound effects on functioning: cognitive (which is common in varying degrees after a traumatic brain injury), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. VA is to evaluate cognitive impairment under the table titled “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified.” Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, should be evaluated under the subjective symptoms facet in the table titled “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified.” However, VA is to separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere’s disease, even if that diagnosis is based on subjective symptoms, rather than under the “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified” table. VA is to evaluate emotional/behavioral dysfunction under 38 C.F.R. § 4.130 (Schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled “Evaluation of Cognitive Impairment and Other Residuals of Traumatic Brain Injury Not Otherwise Classified.” VA is to evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of a TBI. For residuals not listed in 38 C.F.R. § 4.124a, Diagnostic Code 8045 that are reported on an examination, VA is to evaluate under the most appropriate diagnostic code. Each condition is to be evaluated separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under 38 C.F.R. § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified” table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Diagnostic Code 8045 instructs that VA should consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. The table titled “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified” contains 10 important facets of a traumatic brain injury related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled “total.” However, not every facet has every level of severity. The consciousness facet, for example, does not provide for an impairment level other than “total,” since any level of impaired consciousness would be totally disabling. A 100 percent evaluation is assigned if “total” is the level of evaluation for one or more facets. If no facet is evaluated as “total,” the overall percentage evaluation is assigned based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, a 70 percent evaluation is assigned if 3 is the highest level of evaluation for any facet. Diagnostic Code 8045 contains the following notes: Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled “Evaluation Of Cognitive Impairment And Other Residuals Of a Traumatic Brain Injury Not Otherwise Classified” with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): “Instrumental activities of daily living” refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one’s own medications, and using a telephone. These activities are distinguished from “Activities of daily living,” which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms “mild,” “moderate,” and “severe” traumatic brain injury, which may appear in medical records, refer to a classification of a traumatic brain injury made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. Factual Background Turning to the evidence of record, VA treatment records reflect that the Veteran was referred to Speech Pathology for reported memory problems in early 2012. Upon testing, the Veteran was rated as a 1 out of 4, indicating a poor memory. He was referred for further therapy. The Veteran underwent VA examination in conjunction with his PTSD claim in June 2012. The diagnoses documented were PTSD and alcohol abuse. TBI was also noted. His symptoms were depressed mood, anxiety, suspiciousness, panic attacks weekly or less often, chronic sleep impairment, mild memory loss, disturbances of mood and motivation, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The examiner stated that she was unable to differentiate because concentration and memory issues could be due to both PTSD and TBI. The mental diagnoses were reported to cause occupational and social impairment with reduced reliability and productivity. The examiner noted that this was due to PTSD and pain problems. Further VA examination was completed in August 2013. A TBI evaluation revealed complaints of mild memory loss, attention, concentration, or executive functions, but without objective evidence on testing. Judgment was normal, although social interactions were occasionally inappropriate. He was always oriented to person, time, place, and situation. Motor activity and visual spatial orientation were normal. There were no subjective symptoms. The examiner indicated that there were one or more neurobehavioral effects that occasionally or frequently interfered with workplace interaction, social interaction, or both, but did not preclude them. Comprehension or expression of communications were occasionally impaired. Consciousness was normal. No other symptoms or residuals were noted. The examiner stated that none of the present TBI residuals impacted the Veteran’s ability to work. In January 2014, an addendum VA opinion noted that the TBI caused neurobehavioral effects on the Veteran’s ability to work in that he could not work with a group or in a crowded environment. The Veteran underwent further VA examination in April 2016. The examiner noted that the Veteran’s TBI had remained essentially stable since the previous examination in 2013. Evaluation revealed complaints of mild memory loss, attention, concentration, or executive functions, but without objective evidence on testing. The examiner documented the Veteran’s reports of difficulty with immediate and short-term memory and decreased attention and concentration. Judgment was normal, although social interactions were occasionally inappropriate. He was always oriented to person, time, place, and situation. Motor activity and visual spatial orientation were normal. There were no subjective symptoms. The examiner indicated that there were one or more neurobehavioral effects that occasionally or frequently interfered with workplace interaction, social interaction, or both, but did not preclude them. The Veteran was able to communicate and comprehend spoken and written language. Consciousness was normal. No other symptoms or residuals were noted. The examiner reported that the Veteran was able to use a map or GPS if lost without significant difficulty. He indicated that the Veteran’s inappropriate social interactions were primarily due to anxiety issues. He stressed that the TBI remained essentially stable, although the Veteran reported that it impacted his ability to work. Analysis Initially, the Veteran sought to increase his rating for service-connected PTSD, which was rated separately from the service-connected TBI. By way of a January 2014 rating decision, the RO merged the evaluations for PTSD and TBI and assigned a combined 70 percent rating effective January 19, 2012 for PTSD with TBI, based upon the June 2012 VA examiner’s statement that the symptoms could not be differentiated between the conditions. The Veteran now contends that an increased rating is warranted for his service-connected TBI. Additionally, he asserts that a separate rating is warranted for the disability throughout the period on appeal. After review of the evidence, the Board resolves all reasonable doubt in favor of the Veteran to find that separate ratings for TBI and PTSD are warranted. While the June 2012 examiner was unable to distinguish symptoms, other examiners have provided evidence of the separate symptomatology for the TBI and PTSD conditions. By way of this decision, a separate 40 percent rating for TBI is assigned effective January 19, 2012. However, a higher evaluation of 70 or 100 percent is not supported by the lay or medical evidence of record. The medical evidence reflects essentially normal functioning in regard to motor activity, orientation, communication, consciousness, and other evaluated facets of TBI. While the Veteran has consistently reported memory impairment and VA examinations reveal some neurobehavioral effects, such symptoms are consistent with the assigned 40 percent rating for evaluating brain disease due to trauma pursuant to Diagnostic Code 8045. Pursuant to the revised criteria for evaluating residuals of TBI, there was a complaint of mild memory loss, attention, concentration, or executive functions, with a “1” is assigned for the level of impairment. Social interaction was occasionally inappropriate. For this facet of cognitive impairment, a “1” is assigned for the level of impairment. Communication or expression in either written or spoken form was occasionally impaired. For this facet of cognitive impairment, a “1” is assigned for the level of impairment. Judgment, motor activity, visual spatial orientation and consciousness were all normal. He was always oriented to person, time, place and situation. For each of these facets of cognitive impairment a “0” is assigned for the level of impairment. For the facet of subjective symptoms, a “0” is assigned. No additional subjective factors were noted upon examination. Although the examiners noted anxiety, this symptom is considered in conjunction with the Veteran’s PTSD evaluation. The August 2013 VA examiner reported one or more neurobehavioral effects that occasionally or frequently interfere with workplace or social interaction, but do not preclude them. For this facet of cognitive impairment, a “2” is assigned for the level of impairment. In summary, several facets are assigned a “1” level and one facet is assigned a “2” level, thus, the assigned 40 percent evaluation contemplates the highest severity level of “2” under Diagnostic Code 8045. A rating in excess of 40 percent is not warranted at any time as the Veteran did not have any findings that would warrant any facet being evaluated as level “3” during any time of the period on appeal. The Veteran is competent to provide evidence about his disability; for example, he is competent to describe symptoms related to his TBI. See Layno, 6 Vet. App. at 465. He also sincerely believes he is entitled to a higher rating. However, he is not competent to identify a specific level of disability according to the appropriate Diagnostic Code. While lay persons are competent to provide opinions on some medical issues, determining the severity of a complex condition falls outside the realm of common knowledge of a lay person. See Kahana, 24 Vet. App. at 435. Competent evidence concerning the nature and extent of the Veteran’s TBI was provided by the VA examiners who interviewed and evaluated him during the relevant period on appeal. The medical findings as provided in the examination reports directly address the criteria under which this disability is evaluated. Thus, the competent lay evidence is outweighed by the competent medical evidence that evaluates the true extent of the disability. The Board has considered whether any additional Diagnostic Codes would yield an increased rating; however, Diagnostic Code 8045 is the most appropriate in light of the TBI diagnosis and the Veteran’s symptoms. The Veteran has not raised any other issues with respect to the increased rating claim for his TBI, nor have any other assertions been reasonably raised by the record. See Doucette, 28 Vet. App. at 369-70. 3. Entitlement to an increased rating in excess of 50 percent for PTSD from January 19, 2012. As noted above, the appellate period for this issue relates back to the claim for increased disability benefits received by VA on January 19, 2012, which begins the period of appellate review now before the Board (plus consideration of the one-year look back period). See Gaston, 605 F.3d at 984. Rating Criteria The Veteran’s service-connected PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula For Mental Disorders, to include PTSD, a 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where 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; intermittently illogical, obscure, or irrelevant speech; 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); and inability to establish and maintain effective relationships. A 100 percent evaluation is assignable where there is 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran’s capacity for adjustment during periods of remission. An evaluation shall be assigned 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. See 38 C.F.R. § 4.126 (2017). Furthermore, when evaluating the level of disability arising 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. Id. It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. The symptoms associated with the psychiatric rating criteria are not intended to constitute exhaustive lists, but rather 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, 443 (2002). Thus, the Board will consider whether “the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code,” and, if so, the “equivalent rating will be assigned.” Id. The Federal Circuit held previously that a Veteran may only qualify for a given disability rating “by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (“Reading [38 C.F.R. §§ 4.126 and 4.130] together, it is evident that the ‘frequency, severity, and duration’ of a Veteran’s symptoms must play an important role in determining his disability level.”). Prior to August 4, 2014, VA’s Rating Schedule that addresses service connected psychiatric disabilities was based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as “DSM-IV”). 38 C.F.R. § 4.130. As in this case, diagnoses many times included an Axis V diagnosis, or a Global Assessment of Functioning (“GAF”) score. The DSM was recently updated with a 5th Edition (“DSM-V”), and VA issued an interim final rule amending certain provisions in the regulations to reflect this update, including the Schedule for Rating Disabilities. 70 Fed. Reg. 45093 (Aug. 4, 2014). This updated medical text recommends that GAF scores be dropped due to their “conceptual lack of clarity.” See DSM-V, at 16. As the Veteran’s PTSD claim was certified to the Board after August 4, 2014, DSM-5 applies and GAF scores are no longer used in evaluation of a psychiatric disorder. Factual background Turning to the evidence of record, an April 2011 VA treatment note reflects that the Veteran was seen for mental health care. The provider noted that he was being evaluated for headaches. The Veteran reported being separated from his wife due to frequent arguments. He was still experiencing issues with temper and irritability. He reported fragmented sleep and intrusive thoughts about combat. He denied suicidal or homicidal thoughts. The Veteran underwent VA examination in conjunction with his PTSD claim in June 2012. The diagnoses documented were PTSD and alcohol abuse. TBI was also noted. His symptoms were depressed mood, anxiety, suspiciousness, panic attacks weekly or less often, chronic sleep impairment, mild memory loss, disturbances of mood and motivation, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The examiner stated that she was unable to differentiate because concentration and memory issues could be due to both PTSD and TBI. The mental diagnoses were reported to cause occupational and social impairment with reduced reliability and productivity. The examiner noted that this was due to PTSD and pain problems. In November 2013, VA treatment records reflect further mental health treatment. The Veteran reported panic attacks two to three times a week for over a year. He also reported significant hyper-startle reflex and feeling isolated. His sleep was disrupted, with nightmares and trouble falling asleep. He endorsed mild depressive symptoms, panic symptoms, and PTSD-type symptoms. In December 2013, he was seen again. He reported individual counseling from an outside therapist, which ended when he could no longer afford it. The Veteran reported feelings of depression, anxiety, and irritability, rated as a 7 out of 10. He reported mood swings in the form of anger outbursts and panic attacks twice a week. He stated that he experienced paranoid ideations and hypervigilance. Sleep impairment and low motivation were also present. He denied hallucinations, delusions, and suicidal or homicidal ideations. In January 2014, the Veteran was seen again at VA for mental health treatment. He reported that medication was improving his mood symptoms. His anxiety and irritability were better. He indicated that feelings of depression, anxiety, irritability had decreased in severity to 5 out of 10. Panic attacks had decreased to once a week. No symptoms of psychosis were present. He denied hallucinations, delusions and suicidal or homicidal ideations. In April 2014, he reported that the severity of his psychiatric symptoms decreased to a 4 out of 10. He enrolled in an online history class and was receiving an “A” grade. A private psychological assessment was completed in October 2015. The evaluator concluded that the Veteran could not sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his PTSD. He struggled with anxiety, hypervigilance, and disturbances of mood and motivation. She noted that his difficultly maintaining effective relationships indicates that he struggles with a severe impairment. The Veteran underwent further VA examination in May 2016. The examiner noted diagnoses of PTSD, TBI, tinnitus, migraines, and back and knee problems. He stated that the symptoms of PTSD and TBI were distinguishable, with memory problems and headaches dues to TBI and the remaining symptoms due to PTSD. His symptoms were depressed mood, anxiety, panic attacks weekly or less often, chronic sleep impairment, mild memory loss, disturbances of mood and motivation, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and impaired impulse control. He reported treatment at the local VA facility through April 2014 for PTSD, but he stopped attending because he did not like the medication. He received no other treatment outside of occasionally speaking with his pastor. Per the examiner, the mental diagnosis caused occupational and social impairment with reduced reliability and productivity. The examiner noted that this was mainly due to PTSD. A private vocational evaluation completed in August 2017 noted a combination of psychological and emotional conditions. The evaluator concluded that the Veteran is totally and permanently precluded from performing work at a substantial gainful level due to the severity of his service-connected PTSD, TBI, knees, tinnitus, and back with sciatica. Analysis Based upon review of the above lay and medical evidence, the Board concludes that the Veteran’s PTSD meets the criteria under 38 C.F.R. § 4.130 for increased evaluation of 50 percent, but no higher, effective January 19, 2012. Collectively, the lay and medical evidence reflects that the Veteran’s PTSD was manifested predominantly by the following symptoms during the relevant period: depression, anxiety, suspiciousness, hypervigilance, sleep impairment, weekly panic attacks, impaired impulse control, disturbances of mood and motivation, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. While the Veteran was noted to have difficulty in adapting to stressful circumstances, the examiners ultimately found that the resultant functional impairment was occupational and social impairment with reduced reliability and productivity, which is consistent with the currently assigned rating. The medical evidence of record demonstrates that the Veteran’s mood can be anxious and depressed, but he is cooperative and competent. He does not experience hallucinations or delusions, and good judgment and insight have been noted throughout his evaluations. Suicidal or homicidal ideation has consistently been denied. While the evidence reflects bouts of anxiety, depression, and isolation, there is no evidence of obsessive ritualistic behavior; intermittently illogical, obscure, or irrelevant speech; spatial disorientation; neglect of personal appearance and hygiene; or near-continuous panic or depression which interfered with routine ability to function. The Veteran was appropriately dressed at appointments, and able to perform all activities of daily living. The Veteran has alleged disturbances of motivation and mood, and difficulty in establishing and maintaining effective relationships. In this regard, he is competent to report on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, in determining the actual degree of disability, an objective examination is more probative of the degree of the Veteran’s impairment. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the Board as adjudicator. Guerrieri v. Brown, 4 Vet. App. 467 (1993). In this case, the Board finds that the VA examination reports and other probative evidence of record have consistently indicated that the Veteran’s service-connected PTSD has resulted in no more than occupational and social impairment with reduced reliability and productivity. When the Veteran’s disability picture is considered as a whole, the Board finds that a rating in excess of 50 percent is not warranted for PTSD. 38 C.F.R. § 4.130, Diagnostic Code 9411. The evidence does not support a finding that the Veteran’s psychiatric symptoms are best approximated by a 70 percent or higher rating. While he has separated from his wife and is unemployed, he attends church and has a good relationship with his children. Although it is difficult for him to engage in work relationships, his overall disability picture shows that he has the ability to maintain functioning relationships with family and he interacts in a cooperative manner with medical staff. The evidence does not persuasively show that the PTSD disability was manifested by social and occupational impairment so severe as to warrant a 70 percent or higher rating during this period. The Veteran is competent to provide evidence about his disability; for example, he is competent to describe symptoms related to his PTSD. See Layno, 6 Vet. at 465. He is also credible to the extent that he sincerely believes he is entitled to a higher rating. However, he is not competent to identify a specific level of disability according to the appropriate Diagnostic Code. While lay persons are competent to provide opinions on some medical issues, determining the severity of a complex condition such as a psychiatric condition falls outside the realm of common knowledge of a lay person. See Kahana, 24 Vet. App. at 435. Competent evidence concerning the nature and extent of the Veteran’s PTSD was provided by the VA examiners who interviewed and evaluated him during the relevant period on appeal. The medical findings as provided in the examination reports directly address the criteria under which this disability is evaluated. Private evaluations were also considered. Thus, the competent lay evidence is outweighed by the competent medical evidence that evaluates the true extent of the disability. The Board realizes that the symptoms noted in the rating criteria are not intended to be an exhaustive list, but are examples of the types and severity of symptoms that indicate a certain level of disability. Thus, although the Veteran has endorsed some symptoms indicative of higher disability ratings, the Board believes that based on the overall record, including the Veteran’s lay statements, treatment records, and the VA and private examination reports, the frequency, duration, and severity of his PTSD are most consistent with a 50 percent disability rating. The Board has considered whether any other potentially relevant Diagnostic Codes would yield higher ratings for the Veteran’s PTSD. However, when a condition is specifically listed in the Rating Schedule, it may not be rated by analogy. See Copeland v. McDonald, 27 Vet. App. 333, 338 (2015) (pes planus is specifically rated under Diagnostic Code 5276; hence an analogous rating under Diagnostic Code 5284 was not permitted). Thus, Diagnostic Code 9411 is the most appropriate in light of the PTSD diagnosis and symptoms. The Veteran has not raised any other issues with respect to the increased rating claim for his PTSD, nor have any other assertions been reasonably raised by the record. See Doucette, 28 Vet. App. at 369-70 (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). Total Disability Rating Due to Individual Unemployability 4. Entitlement to a TDIU A total disability rating based upon individual unemployability due to service-connected disabilities is assigned when service-connected disabilities result in such impairment of mind or body that the average person would be precluded from following a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. If there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be at least 70 percent. 38 C.F.R. § 4.16(a). A claim for a total compensation rating based upon individual unemployability, “presupposes that the rating for the [service-connected] condition is less than 100%, and only asks for TDIU because of ‘subjective’ factors that the ‘objective’ rating does not consider.” Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In evaluating a veteran’s employability, consideration may be given to his or her level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran in this case is service connected for PTSD at 50 percent; TBI at 40 percent, and lumbar strain, left and right knees, left lower extremity sciatica, and tinnitus, all at 10 percent. His combined rating was 80 percent as of January 12, 2009. Thus, he meets the requirements for a schedular TDIU evaluation. After thorough review, the Board finds that the claims file contains lay and medical evidence weighing for and against entitlement to a TDIU. The Veteran contends that he left his last job in March 2010 because of back pain and the inability to get along with co-workers. He is in receipt of Social Security disability benefits in conjunction with his mental health condition. In a July 2013 statement, his prior employer indicated that the Veteran left of his own volition without any time lost due to disability during the 12 months prior to leaving. VA examiners noted that the back and knee conditions did not affect his ability to work, although the neurobehavioral effects of his TBI prohibited working in a group or a crowded location. The Veteran submitted a January 2017 mental health status evaluation. The evaluator noted some processing inefficiencies with mildly impaired attentional abilities. His remote memory was low normal and mental flexibility, psychomotor speed, and judgment were mildly impaired. His emotional status was basically unremarkable. The evaluator documented a number of signs and symptoms consistent with PTSD and some mild cognitive issues consistent with cognitive disorder. She stated that the Veteran had the ability to do some complex, detailed, and simple repetitive types of tasks. The Veteran also submitted an August 2017 vocational evaluation. The evaluator noted a combination of psychological and emotional conditions. She ultimately concluded that the Veteran is totally and permanently precluded from performing work at a substantial gainful level due to the severity of his service-connected PTSD, TBI, knees, tinnitus, and back with sciatica. After careful consideration and resolving all doubt in favor of the Veteran, the Board finds that the above evidence establishes that the Veteran’s service-connected disabilities preclude him from following a substantially gainful occupation. 38 C.F.R. §§ 3.102, 4.3. Accordingly, entitlement to a TDIU is granted. REASONS FOR REMAND 1. Entitlement to increased ratings in excess of 10 percent each for low back strain and the left and right knees is remanded. While the record contains contemporaneous VA examinations regarding the Veteran’s lumbar spine and bilateral knee disabilities, the examinations do not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158, 168 (2016). The examinations do not contain passive range of motion measurements or pain on weight-bearing testing. Additionally, the examinations do not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). Accordingly, remand for new examinations is warranted. The matters are REMANDED for the following action: 1. Schedule the Veteran for examinations to determine the current severity of his lumbar sprain and left and right knee disabilities. (a.) The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. (b.) The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. Pursuant to Sharp v. Shulkin, 29 Vet. App. 26 (2017), if the Veteran is not currently experiencing a flare-up, based on relevant information elicited from the Veteran, review of the file, and the current examination results regarding the frequency, duration, characteristics, severity, and functional loss regarding his flares, the examiner is requested to provide an estimate of the Veteran’s functional loss due to flares expressed in terms of the degree of additional range of motion lost, or explain why the examiner cannot do so. [The Board recognizes the difficulty in making such determinations but requests that the examiner provide his or her best estimate based on the examination findings and statements of the Veteran.] TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jamison, Elizabeth G.