Citation Nr: 19152191 Decision Date: 07/05/19 Archive Date: 07/05/19 DOCKET NO. 18-26 787 DATE: July 5, 2019 ORDER New and material evidence has not been received to reopen the claim of entitlement to service connection for metatarsalgia of the left foot. New and material evidence has not been received to reopen the claim of entitlement to service connection for metatarsalgia of the right foot. Entitlement to a 10 percent rating for painful scar, status-post left inguinal hernia repair, is granted. Entitlement to a rating in excess of 30 percent prior to March 8, 2016, and in excess of 70 percent thereafter for posttraumatic stress disorder (PTSD), is denied. Entitlement to an earlier effective date for the increased evaluation to 70 percent for PTSD is denied. REMANDED Entitlement to service connection for rhinitis is remanded. Entitlement to service connection for pneumonia is remanded. Entitlement to service connection for heart arrhythmia is remanded. Entitlement to service connection for arthritis of the hips, knees, shoulders and low back is remanded. Entitlement to total disability based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. By an April 2012 rating decision, the Veteran’s claim of entitlement to service connection for metatarsalgia of the left foot was denied. 2. Evidence received since the April 2012 RO decision, by itself, or when considered with previous evidence of record, does not relates to an unestablished fact necessary to substantiate the claim, nor does it raise a reasonable possibility of substantiating the claim. 3. By an April 2012 rating decision, the Veteran’s claim of entitlement to service connection for metatarsalgia of the right foot was denied. 4. Evidence received since the April 2012 RO decision, by itself, or when considered with previous evidence of record, does not relates to an unestablished fact necessary to substantiate the claim, nor does it raise a reasonable possibility of substantiating the claim. 5. The preponderance of the evidence establishes that the Veteran’s scar, status-post left inguinal hernia repair, is painful but stable as of January 25, 2017. 6. For the period on appeal from December 28, 2012 through March 7, 2016, the Veteran’s PTSD manifested in no more than an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 7. Throughout the entire period on appeal, the Veteran’s PTSD has not been manifested by total occupational and social impairment. 8. As the Veteran appealed the initial rating granted for service-connected PTSD, the effective date of all ratings is evaluated in association with that appeal. CONCLUSIONS OF LAW 1. The April 2012 rating decision denying service connection for metatarsalgia of the left foot is final. 38 U.S.C. §§ 7104 (2012); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103 (2017). 2. New and material evidence has not been received to reopen the claim of entitlement to service connection for metatarsalgia of the left foot. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The April 2012 rating decision denying service connection for metatarsalgia of the right foot is final. 38 U.S.C. §§ 7104 (2012); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103 (2017). 4. New and material evidence has not been received to reopen the claim of entitlement to service connection for metatarsalgia of the right foot. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 5. The criteria for entitlement to a rating of 10 percent for painful scar, status-post left inguinal hernia repair, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.118 Diagnostic Code (DC) 7804. 6. The criteria for a rating in excess of 30 percent for PTSD for the period prior to March 8, 2016 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130; DC 9411 (2017). 7. The criteria for a rating in excess of 70 percent for PTSD for the period from March 8, 2016 and thereafter, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130; DC 9411 (2017). 8. The criteria for an earlier effective date for the increased evaluation of PTSD have not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.151, 3.155, 3.400 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from March 1974 to April 1976. The issues have been recharacterized to comport with the evidence of record. The issue of entitlement to service connection for pneumonia has been recharacterized as service connection of a respiratory disorder in accordance with Clemons v. Shinseki, 23 Vet. App. 1 (2009). I. New and material Evidence The Veteran contends there is new and material evidence to warrant the reopening of the claims for entitlement to service connection for metatarsalgia of the right and left foot. For the following reasons, reopening is not warranted. A claim may be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Evidence is considered “new” if it was not previously submitted to agency decision makers. “Material” evidence is existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. “New and material evidence” can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the “credibility of the evidence is to be presumed.” Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the “credibility” of newly presented evidence is to be presumed unless the evidence is inherently incredible or beyond the competence of the witness). The language of 38 C.F.R. § 3.156(a) creates a low threshold for finding new and material evidence and views the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” Evidence “raises a reasonable possibility of substantiating the claim,” if it would trigger VA’s duty to provide an examination in adjudicating a non-final claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). In the April 2012 rating decision, the Veteran’s claims for service connection were denied based on the finding that the Veteran’s bilateral foot disorder was not caused by service. At the time of that decision the pertinent evidence of record included the Veteran’s service treatment records, the report of a VA examination dated March 2012, and VA treatment records. The evidence received since the April 2012 rating decision includes Social Security Administration (SSA) records and VA treatment records. The SSA records and additional VA treatment records while new are not material evidence. The evidence includes continuing medical treatment indicating that the Veteran currently suffers from bilateral foot disorder. This is not relevant to the issue of the nature and etiology of the bilateral foot disorder. See 38 U.S.C. § 1153 (2012). The Board notes that the Veteran has raised the theory of secondary service connection in his Form 9 dated May 10, 2018. A new theory of entitlement is not by itself enough to reopen a claim. See Boggs v. Peake, 520 F.3d 1330, 1336 (Fed. Cir. 2008) ("A new theory of causation for the same disease or injury that was subject of a previously denied claim cannot be the basis of a new claim."); Untalan v. Nicholson, 20 Vet. App. 467, 470 (2006) (holding that a new theory based on evidence of record is not new and material evidence). The Veteran provided a general statement that he is appealing his service connection claims on appeal on a direct and secondary basis. Neither the Veteran nor his representation provided any argument or evidence to support this new theory of causation. Therefore, the evidence does not raise a reasonable possibility of substantiating this claim and the petition to reopen the claims of entitlement to service connection for metatarsalgia of the right and left foot is denied. II. Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a “staged” rating is required. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). VA adjudicators must consider whether to assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than at others. The Court since has extended this practice even to established ratings, not just initial ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Scar The Veteran contends he is entitled to a compensable rating for his status-post left inguinal hernia repair scar under DC 7805. For the following reasons, the Board finds that a rating of 10 percent under DC 7804 is warranted. Scars, other than of the head, face, or neck, are evaluated under the provisions of 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7804, and 7805. Under DC 7801, a scar not of the head, face, or neck that is deep and nonlinear is rated as follows: a 10 percent rating is assigned for an area of at least 6 square inches (36 sq. cm.) but less than 12 square inches (77 sq. cm.); a 20 percent rating is assigned for an area of at least 12 square inches but less than 72 square inches (465 sq. cm.); a 30 percent rating is assigned for an area of at least 72 square inches but less than 144 square inches (929 sq. cm.); and a maximum 40 percent rating is assigned for an area of 144 square inches or greater. 38 C.F.R. § 4.118, DC 7801. A deep scar is one associated with underlying soft tissue damage. Id. at Note (1). Under DC 7802, a maximum 10 percent rating is assigned for a superficial and nonlinear scar not of the head, face, or neck if it measures 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118, DC 7802. A superficial scar is one not associated with underlying soft tissue damage. Id. at Note (1). DC 7804 assigns ratings for scars that are unstable or painful. A 10 percent rating is assigned for one or two qualifying scars, a 20 percent rating for three or four qualifying scars, and a 30 percent rating for five or more qualifying scars. Note 1 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118, Diagnostic Code 7804. Under DC 7805, other disabling effects not considered under diagnostic codes 7800-7804 are rated under an appropriate diagnostic code. 38 C.F.R. § 4.118, DC 7805. In March 2012 the Veteran attended a VA examination. The report noted a linear scar that is 11.5 centimeters in length. The scar was found to be neither painful nor unstable. The examiner concluded that the Veteran’s scar did not impact his ability to work. The Veteran attended another VA examination in January 2017 and reported numbness and intermittent sharp pains in the area of his scar. The report noted a linear scar linear that is 11 centimeters in length. The examiner found the Veteran’s scar is neither painful nor unstable and does not result in any limitations in physical or sedentary employment. When making a decision, the Board must consider all the evidence of record, to include lay statements. 38 U.S.C. § § 5107(b), 7104(a); 38 C.F.R. § 3.303(a). Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). At the January 2017 VA examination the Veteran reported intermittent sharp pains around his scar; however, the VA examiner concluded that the scar was not painful. The Board finds that the Veteran is competent to describe his symptom of pain. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, resolving all reasonable doubt in favor of the Veteran, the evidence more nearly approximates a scar which is painful; thus, a rating of 10 percent under DC 7804 is warranted. The Board has considered other diagnostic codes but finds that a separate rating is not warranted. 2. PTSD The Veteran contends he is entitled to a rating in excess of 30 percent prior to March 8, 2016 and in excess of 70 percent thereafter for PTSD. For the following reasons, the Board finds that an increased rating is not warranted. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such 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; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. The Veteran attended a VA examination in July 2014. He reported depression, reduced motivation and activity level and difficulty with sleep and nightmares. Socially, the Veteran described himself as independent but struggling with irritability. He stated that lives with his daughter and takes her to the park but rarely has contact with his friends. He also disclosed that he has a good relationship with his mother. Occupationally, the Veteran is unemployed and he indicated that he is not seeking employment due to his physical limitations. The examiner noted that the Veteran was casually dressed and groomed, well oriented and generally cooperative but vague with his descriptions of symptoms. His mood was euthymic and affect appropriate to topic with fluent speech. His thought processes were logical and his cognition appeared intact based on verbal production. The examination report listed the following symptoms: depressed mood, anxiety, chronic sleep impairment, mild memory loss and disturbance of motivation and mood. The examiner concluded that the Veteran has an occupational and social impairment with occasional decrease in work efficiency. In March 2016 the Veteran underwent another VA examination. Socially, he reported that he was still living with his daughter and has no social life. Occupationally, he was working part-time at a rescue mission since September 2015. The Veteran stated that he still suffers from nightmares, disrupted sleep, flashbacks and irritability but has no thoughts of suicide. The examination report noted the following symptoms: depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, and inability to establish and maintain effective relationships. The examiner observed that the Veteran was neatly groomed, alert, calm, coherent, cooperative and friendly. His affect was full and appropriate with spontaneous, relevant and goal-directed thought processes. There was no evidence of hallucinations or delusions or suicidal or homicidal ideations. He had no gross impairment of memory and his insight and judgment were adequate. The examiner concluded that the Veteran has an occupational and social impairment with reduced reliability and productivity. Additionally, the examiner commented that the Veteran has average intelligence and the November 2013 SSA psychological evaluation, which found borderline intellectual functioning was absurd. The Veteran attended a VA examination in January 2017. He reported that he is irritable, withdrawn, intermittently depressed, has panic attacks that occur four to five times a month, difficulty sleeping, and perceptual disturbances described as hearing voices when water is running. Socially, the Veteran stated that his still lives with his daughter but seldom leaves the house. Occupationally, he reported resigning from his position as a substance abuse counselor in September 2016 due to his inability to work as a result of disrupted sleep, difficulty concentrating, irritability, and despondence. The examiner observed that the Veteran had adequate hygiene, oriented to person, place, time and reason for referral and was cooperative. He had a depressed mood and restricted affect. He made minimal eye contact and spoke in a quiet, low tone but there was no evidence of speech or memory impairment. Thought content was absent suicidal and homicidal ideation, delusions and hallucinations. Thought processes were logical and coherent, absent evidence of a thought disruptions. Insight and judgment were fair. The following symptoms were noted: anxiety, panic attacks less than weekly, near continuous depression, speech intermittently illogical, difficulty understanding complex commands, neglect of appearance and hygiene, and intermittent inability to perform activities of daily living. The examiner concluded that the Veteran has an occupational and social impairment with reduced reliability and productivity. Review of the medical records reveal mental health treatment throughout the appeal period. In December 2012, he reported a worsening in his depression symptoms and indicated that he is more withdrawn. However, in March 2013 the Veteran’s mental status examination revealed that he was well oriented, alert, and appropriately dressed with good hygiene. His speech was coherent, goal directed and relevant with thought processes logical and clear and no evidence of cognitive deficits. His mood was euthymic and affect appropriate and spontaneous; congruent with mood. There was no evidence of hallucinations, paranoia or delusional thinking. His judgement and insight were good and he denied any suicidal and homicidal ideations. The following month, the Veteran reported nightmares, hyperventilation, appetite issues, hypervigilance, irritability, anger and lack of motivation. His mental status examination noted that he was neat and clean in appearance, pleasant and cooperative with appropriate eye contact. His attention and perception were adequate but his motor activity was restless. Thought processes were normal and he did not present as a danger to self or to others. His speech was delayed and mood was depressed, anxious and irritable with a flat affect. However, in April, the Veteran reported doing better and that he was in school to get a certificate to be a substance abuse counselor. He indicated he still struggled with motivation, nightmares and pain though. Approximately a year later, in April 2014 the Veteran reported feelings of satisfaction with his volunteer work at the rescue mission and substance abuse treatment center. In May 2015, the Veteran was enjoying mentoring and spending time with his daughter and reported no problems with depression. The Veteran reported in July that the intensity of his nightmare was mildly better, he had few residual PTSD symptoms during the day and the flashbacks had mostly subsided. The mental status examination noted that the Veteran was well-kempt with fair grooming and hygiene. His eye contact was appropriate with normal speech and linear and goal-directed thought processes. The Veteran denied any suicidal or homicidal ideations, delusions, obsessions, or auditory, visual, or tactile hallucinations. He described his mood as “pretty good” and his affect was euthymic and congruent. He was alert, oriented to person, place, time, situation, and his memory, attention, insight, and judgment was fair. At his appointment in March 2016, the Veteran was again polite and cooperative with good eye contact. He was kempt with no difficulties with articulation and logical and goal directed thought processes. He displayed no flight of ideas, no loosening of associations and no delusions, obsessions, suicidal or homicidal ideations or perceptual disturbances. While his mood was irritable, he was calm and stable at time of appointment with appropriate insight and judgment. He had no evident gross cognitive impairment. On August 2016 he reported that he was unable to remember his last flashback. Notably, at an appointment a few months later the Veteran admitted the need to engage in more social activities and indicated a willingness to engage in volunteer work. In December 2016, the Veteran disclosed that when he runs water after a minute or so he hears voices and sometimes thinks his daughter is talking to him when she is not. He reported that it had been happening for a long time (about a year and a half) but recently it has been more intense. In March 2017, the Veteran stated that he relies on his sister, youngest brother, and a female friend who is a minister in town and like a sister to him. Veteran reported contact with his mother but stated that he does not burden her with any problems as she is up there in age. The Veteran also mentioned that he does not have a social life as his time is spent taking care of his daughter. His mental status examination noted good hygiene with mildly anxious mood and no reports of auditory or visual hallucinations. In July 2017, the Veteran reported that he was trying to reestablish a social life and recently spent some time with a friend, which he enjoyed. In September, he reported continued visual hallucinations but very infrequently with an increase in flashbacks and in March 2018 he indicated that his mood and attitude had declined in the last two months. The evidence includes records from SSA. The Board notes that SSA decisions are not controlling for VA purposes. Murincsak v. Derwinski, 2 Vet. App. 363, 370 (1992). The Veteran attended an psychological evaluation in December 2012 for SSA disability benefits. The examiner noted that the Veteran’s mood was despondent, sullen and sober but he also laughed and smiled throughout the evaluation. His affect was appropriate and he was friendly and showed no problem expressing himself. His memory and fund of general information was good. The examiner specifically noted that the Veteran did not have problems with memory, concentration or completing tasks; however, he did take an unusually long time completing his information paperwork. The examiner concluded that the Veteran’s symptoms would not interfere with his ability to maintain employment. At a subsequent SSA evaluation conducted in November 2013, the examiner noted that the Veteran’s mood was generally sober and all aspects of his behavior were very slow. The Veteran was described as casually but appropriately dressed and marginally groomed. The examiner reported that his memory was poor and his fund of general information was fair and concluded that the Veteran was functioning with borderline to low average of intellectual ability. Rating in excess of 30 percent prior to March 8, 2016 The Board concludes that the Veteran’s symptoms more closely approximated the symptoms associated with a 30 percent rating for the period prior to March 8, 2016. Thus, a higher rating is not warranted. The July 2014 VA examiner found that the Veteran has an occupational and social impairment with an occasional decrease in efficiency with the Veteran exhibiting symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, and disturbance of motivation and mood. The examiner’s findings are consistent with the criteria contemplated by a 30 percent rating. These findings are also consistent with Veteran’s mental health treatment records, which frequently noted the symptoms of depressed mood with occasional irritability and anxiety. Additionally, the records also consistently reported that the Veteran was cooperative and friendly, with adequate grooming, intact memory and no suicidal or homicidal ideations. The Board notes that in December 2016 the Veteran reported that he had been hearing voices when he runs water for approximately a year and a half; however, these reports are inconsistent as the Veteran also denied auditory hallucinations at many of his appointments. As such, due to the lack of frequency and inconsistency of such; a higher rating is not warranted on that basis. The Board has also considered the evaluations conducted by the SSA examiners, specifically, the November 2013 psychological examination, which found the Veteran had borderline to below average intelligence, marginal grooming, with poor memory. The Board gives the findings of the November 2013 examiner little weight as they are inconsistent with the overall medical evidence of record. The VA examiners, as well as the December 2012 SSA examiner, found the Veteran to have average intelligence and intact cognition. Furthermore, the March 2016 VA examiner explicitly noted that the finding of borderline to below average intelligence was absurd. Conversely, the Board gives greater weight to the findings of the December 2012 SSA examiner and the July 2014 and March 2016 VA examiners. These examiners’ combined findings are probative, as they are consistent with the overall medial evidence of record. The Board finds the severity, frequency, and duration of the Veteran’s symptoms of depressed mood, anxiety, chromic sleep impairment, and irritability more closely approximated the level associated with a 30 percent rating. The Veteran was generally functioning satisfactorily. He engaged in routine behavior, cared for himself and his daughter, and participated in vocational training, part-time employment and volunteer opportunities. Thus, the evidence shows that the Veteran had an occupational and social impairment with occasional decrease in work efficiency and social deficiencies, which is consistent with a 30 percent rating. Rating in excess of 70 percent from March 8, 2016 and thereafter The Board finds the level of impairment caused by the Veteran’s symptoms does not rise to level of total occupational and social impairment. The VA examiners of record, at most, found that the Veteran has an occupational and social impairment with reduced reliability and productivity, which is consistent with the criteria contemplated by a 50 percent rating. Socially, the evidence shows that the Veteran is able to maintain some positive familial relationships, specifically with his daughter and mother. While the Veteran indicated being withdrawn and socially isolated, the record reflects that the Veteran did engage in social activities with friends or through volunteer opportunities. At the Veteran’s medical appointments and VA examinations he was consistently described as being cooperative, friendly and appropriate. Thus, the evidence suggests while the Veteran does have difficulties due to his PTSD symptoms, he is able to engage in social activities. Thus, a total social impairment is not shown. Occupationally, the Veteran is unemployed and in receipt of SSA disability benefits. As noted above, SSA decisions are not controlling on VA but the records are relevant in this case. The SSA decision found unemployment based on the Veteran’s physical limitations; however, as discussed in detail above, psychological evaluations were conducted. The December 2012 SSA examiner concluded that the Veteran’s mental health symptoms would not interfere with his ability to maintain employment, which is consistent with the findings of the VA examiners who also found the Veteran capable of employment. Therefore, the evidence is insufficient to establish a total occupational impairment. As such, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a 100 percent rating. The criteria for a 100 percent rating are not met and the appeal is denied. III. Earlier Effective Date for PTSD The general rule with respect to the effective date of an award for compensation based on an original claim or a claim for increase will be the date of the receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. A March 2016 rating decision granted the Veteran entitlement to service connection for PTSD effective December 28, 2012, the date of claim. The Veteran received an initial rating of 30 percent, which increased to 70 percent effective March 8, 2016. The Veteran contends he is entitled to an earlier effective date for his increased evaluation of PTSD. By appealing the initial rating throughout the entire claim period, the Veteran effectively asked the Board to review the appropriateness of the rating at all times throughout the period on appeal. That is to say, an evaluation of the effective date of each part of a staged rating is part and parcel of the Board's review of the claim for a higher initial rating. As such, the Board has already evaluated the effective dates of the ratings in its analysis of the claim for a higher initial rating in the section above. Furthermore, if the Veteran intended to disagree with the effective date of service connection for PTSD, the March 2016 rating decision awarded the Veteran a 30 percent rating, effective the date of the claim. For the grant of service connection, the effective date is determined by the date of the receipt of the claim. In this case, the Veteran submitted his claim on December 28, 2012. Review of the records does not reveal any claims, formal or informal, prior to the December 28, 2012. As such, an earlier effective date for the grant of service connection is also not warranted. REASONS FOR REMAND 1. Entitlement to service connection for rhinitis, pneumonia and heart arrhythmia The VA has a duty to assist, which includes providing a medical examination when necessary to make a decision on a claim. 38 C.F.R. § 3.159(c)(4)(i) (2017). The record contains sufficient evidence to trigger the VA’s duty to assist by providing a VA examination. While the Veteran underwent a general VA examination in March 2012, the nature and etiology of the Veteran’s rhinitis, respiratory disorder and heart arrhythmia was not discussed. Additionally, the Veteran raised the theory of secondary service connection. Therefore, a VA examination for an opinion to determine the etiology of the Veteran’s rhinitis, respiratory disorder and heart arrhythmia is warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for arthritis of multiple joints The Veteran’s general VA examination in March 2012 also noted arthritis of the knees, back, neck, hips and shoulders. However, the examiner did not provide a medical opinion addressing the nature and etiology of the Veteran’s arthritis. As the record contains current diagnoses and the service treatment records contain complaints of pain due to heavy lifting, the Board finds a medical opinion is necessary for adjudication. See McLendon, 20 Vet. App. 79 (2006). 3. TDIU The Veteran's entitlement to a TDIU is inextricably intertwined with the service connection claims on appeal. Therefore, the Board finds that the claim for a TDIU must be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). The matters are REMANDED for the following action: 1. Obtain updated VA and/or private treatment records. If such records are unavailable, the Veteran’s claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Schedule the Veteran for a VA examination with a medical professional with appropriate expertise to determine the nature and etiology of any diagnosed respiratory disorder, rhinitis and heart arrhythmia. The examiner should review the Veteran’s claims file. Based on a review of the record, the examiner must address the following: (a.) Is it at least as likely as not (a 50 percent or greater probability) that any diagnosed respiratory, rhinitis and/or heart arrhythmia is related to active service or is caused by or aggravated by military service? (b.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that the Veteran’s respiratory, rhinitis and/or heart arrhythmia is proximately due to or the result of any of the Veteran’s service-connected disorders? (c.) If the answer to (b) is negative, is it at least as likely as not that the respiratory, rhinitis and/or heart arrhythmia is aggravated (i.e., permanently or temporarily worsened) by any service-connected disorder? (d.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. The term “aggravation” means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms and treatment history. The examiner must consider and discuss any lay statements of record. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. Obtain a medical opinion from a medical professional with appropriate expertise to determine the nature and etiology of arthritis of the shoulder, neck, hips, knees, and low back. The examiner should review the Veteran’s claims file. Based on a review of the record, the examiner must address the following: (a.) Is it at least as likely as not (a 50 percent or greater probability) that arthritis of the shoulder, neck, hips, knees, and/or low back is related to active service or is caused by or aggravated by military service? (b.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that the Veteran’s arthritis of the shoulder, neck, hips, knees, and/or low back is proximately due to or the result of any of the Veteran’s service-connected disorders? (c.) If the answer to (b) is negative, is it at least as likely as not that arthritis of the shoulder, neck, hips, knees, and/or low back.is aggravated (i.e., permanently or temporarily worsened) by any service-connected disorder? (d.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms from in-service to the present. The examiner must consider and discuss any lay statements of record regarding his in-service injury and continuity of symptomology since service. The opinion and rationale should reflect such consideration. Additionally, the examiner should address the Veteran’s complaints of pain noted in the service treatment records. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 4. Finally, readjudicate the appeal. If the benefits sought on appeal remain denied, issue a supplemental statement of the case and return the case to the Board. G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. A. Prinsen, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.