Citation Nr: 21003550 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 17-54 645 DATE: January 21, 2021 ORDER Service connection for cancer of the bladder is granted. The appeal for service connection for gastroesophageal reflux disease (GERD) is denied. The appeal for service connection for a heart disorder (claimed as ischemic heart disease), is denied. The appeal for an initial rating for posttraumatic stress disorder (PTSD) greater than 70 percent, is denied. REMANDED The appeal for a compensable initial rating for bilateral hearing loss is remanded. The appeal for a total disability rating due to individual unemployability (TDIU) is remanded. The appeal for Dependents’ Educational Assistance (DEA) is remanded. FINDINGS OF FACT 1. The evidence demonstrates that the Veteran served near the South Korean demilitarized zone (DMZ) during the qualifying time period, and is deemed to have been exposed to herbicide agents. 2. The Veteran has been diagnosed with cancer of the bladder; this disability is subject to presumptive service connection as a result of exposure to herbicide agents. 3. The preponderance of the evidence is against a finding that the Veteran’s GERD had its onset in service or is otherwise related to service. 4. The preponderance of the evidence indicates that the most accurate diagnosis of the Veteran’s heart disorder is atrial fibrillation; the preponderance of the evidence is against a finding of a diagnosis of ischemic heart disease. 5. The preponderance of the evidence is against a finding that the Veteran’s atrial fibrillation had its onset in service or is otherwise related to service. 6. For the entire period on appeal, the Veteran’s PTSD was manifested, at its worst, by occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for cancer of the bladder, are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2020). 2. The criteria for service connection for GERD are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2020). 3. The criteria for service connection for a heart disorder (claimed as ischemic heart disease), are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2020). 4. The criteria for an initial rating for PTSD greater than 70 percent, are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1969 to October 1970. In a May 2019 decision, the Board denied the Veteran’s claim for entitlement to an initial compensable rating for bilateral hearing loss. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a May 2020 Order, the Court set aside the Board’s May 2019 decision in part, granted the parties’ Joint Motion for Remand (“Joint Motion”), and remanded the case to the Board. Thereafter, the Board remanded the appeal in August 2020 in compliance with the Joint Motion. The remaining issues on appeal were remanded by the Board in May 2019. The Board also notes that it remanded a claim for service connection for hypertension in May 2019 which was granted in full while on remand. See September 2020 rating decision. The Board acknowledges that additional VA treatment records were added to the record following the issuance of the September 2020 supplemental statement of the case. However, these records were cumulative or duplicative of evidence already of record. Therefore, the Board may proceed without returning the entire appeal to the AOJ for readjudication. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C. § 1112; 38 C.F.R. § 3.304. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Additionally, for Veterans who served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including hearing loss and tinnitus, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). The use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Additionally, a veteran who served in the Republic of Vietnam between January 9, 1962, and May 7, 1975, or in certain areas near the Demilitarized Zone in the Republic of Korea from September 1, 1967 to August 31, 1971 is presumed to have been exposed to certain designated herbicide agents (e.g., Agent Orange) during such service, absent affirmative evidence to the contrary. 38 U.S.C. §§ 1116(f), 1116B; 38 C.F.R. § 3.307(a)(6)(iii). In the case of such a veteran, service connection based on herbicide agent exposure will be presumed for certain specified diseases including ischemic heart disease and cancer of the bladder, that become manifest to a compensable degree. 38 U.S.C. § 1116(a)(2); 38 C.F.R. §§ 3.307(a)(6), 3.309(e). Of note, the disease of cancer of the bladder was recently added to the list of diseases subject to presumptive service connection, via the National Defense Authorization Act for Fiscal Year 2021, effective January 1, 2021. The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C. § 7104(a) (2012); Baldwin v. West, 13 Vet. App. 1 (1999); see 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for cancer of the bladder. There is no dispute that the Veteran had a diagnosis of bladder cancer during the pendency of the claim. See October 2019 VA examination report. Additionally, in the May 2019 Remand, the Board conceded herbicide agent exposure during the Veteran’s service in Korea. At that time, the Board explained that the Veteran’s military personnel record noted that the Veteran served with a battalion that has been recognized as by the Department of Defense (DOD) as operating in the Korean DMZ during the qualifying time period (which under recently amended statute, is from September 1, 1967 to August 31, 1971). See 38 U.S.C. § 1116B. As discussed above, the disease of cancer of the bladder was also recently added to the list of diseases subject to presumptive service connection under 38 U.S.C. § 1116(a)(2) (January 1, 2021). Moreover, in the present case, the Board finds that the Veteran’s bladder cancer became manifest to a compensable degree under 38 C.F.R. § 4.115A, as he has associated voiding dysfunction. See October 2019 VA examination report. Based on the above, the Board finds that service connection for bladder cancer may be presumed. The benefit sought on appeal is granted. 2. Entitlement to service connection for GERD. There is no dispute that the Veteran has a current diagnosis of GERD. The Veteran asserts that his GERD is related to service. However, for the reasons explained below, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s GERD began during service. Service treatment records are silent as to any treatment for, or complaints of GERD symptoms. Nevertheless, the Board acknowledges that the Veteran is competent to report any symptoms that came to him through his senses, such as heartburn or reflux. A private medical opinion indicates that the Veteran reported that GERD began during service and that he experienced symptoms since service. See December 2016 private examination report. Based upon this statement alone, the private diagnostic consultant opined that the Veteran’s current GERD began during service. In May 2019, the Board determined that the December 2016 private opinion was not supported by an adequate rationale, and remanded the claim for a VA opinion. In December 2019, the Veteran was provided with a VA examination to address GERD. The examiner diagnosed GERD and Barrett’s esophagus, explaining that the GERD led to the Barrett’s esophagus. The examiner offered a negative nexus opinion based in part on a lack of in-service symptoms or treatment, and observation that the Veteran’s separation examination did not identify any symptoms of disability. While the examiner did not specifically address the December 2016 private opinion, the examiner affirmatively indicated that the Veteran’s electronic file had been reviewed. Moreover, specific discussion of the lay statements by the examiner was not necessary in this case as the Board is finding the Veteran’s statements of continuity of symptoms since service to be not credible in light of prior inconsistent statements to the contrary. In this regard, when the Veteran sought treatment for GERD symptoms in June 2001, he reported that his symptoms began approximately 7 years prior. The Board notes that an onset date in approximately 1994 was more than 20 years following service separation. He also reported that he was in good health, without mention of any reflux symptomatology at the time of his September 1970 examination upon separation. The Board places greater weight of probative value on the history the Veteran presented to medical professionals for treatment purposes (i.e., during active service and years thereafter) than it does on his recent statements to VA in connection with his claim for monetary benefits. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the veteran). In addition, the Veteran’s history of prior inconsistent statements weighs against his credibility. See Caluza v. Brown, 7 Vet. App. 498 (1995) (in determining whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of a veteran). Because the December 2016 private opinion linking the Veteran’s GERD to service was based on the Veteran’s report of onset in service, with continuous symptoms since service—which the Board has found to be not credible—the Board accordingly affords the opinion no probative value. The December 2019 examiner reviewed the record, to include the Veteran’s service records, and provided a clear and concise rationale in support of the negative nexus opinion that is consistent with the Veteran’s prior medical history. The Veteran has not otherwise asserted that GERD is related to a particular in-service injury. Based on the above, the Board finds that a preponderance of the lay and medical evidence of record weighs against the claim for service connection for GERD, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for a heart disorder (claimed as ischemic heart disease). The Veteran asserts that he has ischemic heart disease that is presumptively associated with his in-service herbicide agent exposure. There was some dispute as to whether the Veteran ever had ischemic heart disease. For the reasons explained below, the Board finds that at no point during the pendency of the appeal did the Veteran have ischemic heart disease. The Veteran provided a private diagnostic consultant’s opinion which noted that the Veteran had ischemic heart disease due to herbicide exposure. See December 2016 private opinion. The private consultant explained that the diagnosis was based upon VA treatment records which referenced ischemic heart disease. The Board has reviewed the VA treatment records and notes that the only records which reference ischemic heart disease are nursing notes dated in September 2015. Specifically, they are instructions regarding goals for managing angina and note that the Veteran understands the etiology of ischemic heart disease. VA provided the Veteran with a VA examination in March 2017. The examiner reviewed the VA treatment records, including a stress echocardiogram report, and explained that the Veteran did not have ischemic heart disease but rather had an arrythmia, paroxysmal atrial fibrillation. The examiner based the determination in part on an EKG conducted in September 2015 which revealed that there was no evidence of ischemia. In May 2019, the Board sought another VA opinion, in part because the March 2017 VA examiner did not offer a nexus opinion with respect to whether the Veteran’s atrial fibrillation was due to service. As a result, a VA opinion was obtained in December 2019. The December 2019 VA examiner also noted that the correct diagnosis was atrial fibrillation. The examiner opined that it was less likely than not that the Veteran’s atrial fibrillation was related to service. The examiner explained that atrial fibrillation is a type of arrythmia, and that it is closely tied to age. The examiner also listed other risk factors including obesity and alcohol consumption. The examiner also explained that medical literature did not support a relationship between atrial fibrillation and Agent Orange exposure. As an initial matter, the Board places a higher probative value on the VA examiners’ diagnosis of atrial fibrillation than the private consultant’s diagnosis of ischemic heart disease as the VA examiners’ determination was based upon review of the Veteran’s entire claims file, including diagnostic reports and medical history. Although the private diagnostic consultant cited VA treatment records, he did not indicate review of the file and did not review the VA diagnostic tests which resulted in finding of atrial fibrillation and specifically indicated that there was no evidence of ischemia. Thus, the remaining question is whether the Veteran’s atrial fibrillation is related to service. For the reasons explained below, the Board finds that it is not. The Board places a high probative value on the December 2019 VA examiner’s opinion as it was based on review of the entire file and medical literature pertinent to the claim. Moreover, the examiner cited other pertinent nonservice-related risk factors for the Veteran’s atrial fibrillation. The Board places only a limited probative value on the December 2016 private opinion as it was based upon a finding that the Veteran had ischemic heart disease, which was subsequently found to not be the correct diagnosis upon testing. The Veteran had an opportunity to supply another private opinion in favor of the claim but did not. The Board has considered the Veteran’s statements that he has a heart disorder that is related to service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, diagnosis and etiology of a heart disorder, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Based on the above, the Board finds that a preponderance of the evidence weighs against the claim for service connection for heart disorder, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating Entitlement to an initial rating greater than 70 percent for PTSD. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). As in the instant case, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. Id. at 126. Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). PTSD is evaluated under VA’s General Rating Formula for Mental Disorders. Under the formula, a 70 percent rating 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; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. A 100 percent rating is warranted when 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), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). In Vasquez-Claudio v. Shinseki, F.3d 112, 117 (Fed. Cir. 2013), the Court also held that a Veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. The Court further held that, in assessing whether a particular disability rating is warranted requires a two-part analysis, including (1) an initial assessment of the symptoms displayed by the Veteran and, if they are of the kind enumerated in the regulation and (2) an assessment of whether those symptoms result in the occupational and social impairment contemplated by that particular rating. See id. at 118. Indeed, considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a). In this case, the Veteran’s PTSD has been rated 70 percent disabling since the effective date of service connection. The present appeal arises from her disagreement with the assigned initial rating. The Board has reviewed the evidence of record and finds that an initial rating greater than 70 percent is not warranted. Throughout the pendency of the claim, the Veteran was afforded VA-contracted examinations in March 2017, December 2017, and October 2019. The Veteran also provided a private disability benefits questionnaire dated in December 2016, authored by Dr. R.O. In December 2016, the Veteran reported that he was only able to sleep for about two hours nightly. He related his insomnia to back pain and night terrors. He reported that he needed to have his back to the wall in public environments, avoided crowds, and reacted to loud noises. He reported performing repeated perimeter checks around his residence when disturbed by unfamiliar sounds. He reported suspiciousness of others, low tolerance for frustration, and easy irritability resulted in him preferring an insular and reclusive lifestyle. Dr. R.O. noted that the Veteran’s symptoms of hyperarousal and hypervigilance remained descriptive of his overall psychological functioning. Dr. R.O. noted that the Veteran had poor ability to establish and maintain effective social relationships. Dr. R.O. also found that the Veteran exhibited depressive features with loss of motivation and meaningfulness. Dr. R.O. also indicated that the Veteran had dependency and abuse of alcohol. Dr. R.O. attributed the following symptoms to the Veteran’s PTSD: depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationship, and suicidal ideation. During the March 2017 VA-contracted examination, the Veteran reported experiencing flashbacks and nightmares about the war. The Veteran also reported being divorced twice. He reported that he did not have patience for his spouses. He also reported waking up upset, sweating and experiencing nightmares. He reported avoiding talking about the war. He reported having worked on a railroad for seven years operating a bridge and running trains. He reported that he worked alone in that job and did not have to report to anyone. He reported that he lived by himself but saw his grandchildren almost every day. He also reported that he had worked in construction for 42 years. He reported that his jobs were mostly independent and did not require him to interact with others. He reported that he had always experienced depression, anxiety since service. Regarding behavioral issues, he reported being arrested for driving under the influence on one occasion and having to spend a night in jail as a result. He also reported difficulty keeping a job long term and explained that if someone aggravated him, he would find a new job the next day. He reported that at the drop of a hat, he would fight. Regarding behavioral observations, the March 2017 VA-contracted examiner noted that the Veteran was oriented to person, place, time, and situation. The examiner noted that rapport was eventually established. The examiner noted that the Veteran’s mood was stable and dysphoric with blunted affect, his speech was clear, coherent and pessimistic. The examiner noted the Veteran’s report of waking up in cold sweats and difficulties feeling calm. The examiner noted the Veteran’s report that symptoms occurred three to four days per week and that the Veteran felt the symptoms impaired his daily activities at a moderate to severe level. Following review of the file and interview with the Veteran, the March 2017 VA-contracted examiner identified the following symptoms related to the Veteran’s PTSD: depressed mood, anxiety, suspiciousness, panic attacks weekly or less often, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, flattened affect, circumstantial, circumlocutory, or stereotyped speech, difficulty in understanding complex commands, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, neglect of personal appearance and hygiene. The examiner did not believe that the Veteran should be considered a current imminent or increased risk. During the December 2017 VA-contracted examination the Veteran denied any significant changes in family relationship since the prior examination. Regarding work, the Veteran reported working sporadic stints of helping a friend run a loader/heavy machinery. He reported doing this to help his friend four or five times per month. He reported significant feelings of depression and anxiety and denied any suicide attempts or psychiatric hospitalizations. He denied taking any medication for depression or anxiety. He denied any legal or behavioral issues. He reported a history of smoking marijuana and drinking heavily in the 1990’s. Following review of the file and interview with the Veteran, the December 2017 examiner noted the following symptoms related to the Veteran’s PTSD: depressed mood, anxiety, suspiciousness, and chronic sleep impairment. The examiner noted that the Veteran presented as social, open, and participative in the interview process. The examiner noted that the Veteran’s affect was positive, the Veteran had good eye contact, and rapport was easily established. The examiner noted that the Veteran was easily engaged in the interview and responded openly to all requests for information. In the June 2018 Substantive Appeal Form 9, the Veteran reported memory loss of names close relatives and friends, no self-confidence, difficulty making decisions, frequent anxiety, inability to concentrate, disorientation when waking up, occasional depression, occasional mood swings, and that he was unable to maintain social relationships. In October 2019, the VA-contracted examiner noted the Veteran’s report that he takes care of his personal hygiene every day, showers every day, and at times gets “a little shabby” and needs a haircut and a beard trim. The Veteran denied any suicide attempts in the prior two years. The Veteran reported that he had not received any mental health treatment, medication or counseling in the prior two years and that he had not been hospitalized for mental health reasons. The Veteran also reported that his mood was disturbed by PTSD symptoms. He reported that his marriages had not lasted and that he had only been able to maintain one friend. He also reported he was able to maintain relationship with his daughters, son-in-law, and grandchildren. He reported that he mostly stayed at his home and kept to himself. He reported that at home, he had difficulty in his thinking and became anxious and worried. He reported that he spent a great deal of time “talking” himself down. He also reported being irritable and angry. The examiner noted that the Veteran’s judgment was impaired per Mental Status Exam. The October 2019 VA examiner noted the Veteran’s report that he had difficulty working before being retired. He reported being retired at the time of the examination but that prior to retirement, he had worked independently for the most part in construction as a heavy equipment operator. He indicated that he had a history of having conflicts with others at work and that he would quit jobs upon having conflicts with others. He reported a history of fighting and that he would fight “at the drop of a hat.” He also reported that in the two years prior to the examination, he worked in a limited capacity for two men for whom he had previously worked. In accordance with the May 2019 remand directives, the October 2019 VA psychiatric examiner clarified whether the Veteran had an alcohol use disorder and found that he did not. Moreover, the October 2019 VA examiner found that although the Veteran had multiple psychiatric diagnoses, it was not possible to differentiate which symptoms were attributable to PTSD alone. Following review of the claims file and interview with the Veteran, the October 2019 VA examiner indicated that the Veteran had the following symptoms: depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships. The examiner noted that during the examination, the Veteran was cooperative and appeared to answer questions as best as he could. The examiner confirmed that symptom exaggeration was not suspected. VA treatment records indicate no worse findings than those described in the examination reports. Based on the findings of the December 2016 private examiner, as well as review of the Veteran’s treatment records, the AOJ granted service connection for the Veteran’s PTSD and assigned a 70 percent disability rating. See April 2017 rating decision. The Board agrees with the AOJ that the Veteran’s suicidal ideation, depressed mood, irritability, anxiety, difficulty adapting to stressful situations and problems with working cooperatively with others, are of the type, severity, and frequency to support the currently-assigned 70 percent disability rating, but no higher. In this regard, the Board finds that the evidence does not support a finding of PTSD symptoms that are of the type, frequency, or severity to result in total occupational and social impairment. The lay and medical evidence of record simply does not demonstrate that the Veteran’s psychiatric disability manifests in total occupational and social impairment, warranting the assignment of a 100 percent rating. Importantly, at the time of the Veteran’s October 2019 VA examination, although the Veteran considered himself retired, he was still working independently for two men he had previously worked for, as a heavy equipment operator. While it is clear the Veteran has significant trouble working with others, the assessments of record have not suggested his PTSD prevented him from performing certain occupational tasks independently. Thus, total occupational impairment is not shown. Moreover, the October 2019 VA examiner found the Veteran’s thinking and judgment to be good and thoughts to be clear and logical. VA treatment records also indicate normal findings with respect to thought process and content. See e.g. June 2017 VA treatment record. Thus, the Board finds that gross impairment of thought processes is not shown. Additionally, the Veteran has not reported experiencing persistent delusions or hallucinations. See e.g. June 2017 VA treatment record. The October 2019 VA examiner noted that there were no signs of delusions or hallucinations. The Veteran has consistently denied any homicidal ideation and there is no indication that he poses a threat to himself or others. See VA-contracted examination reports and VA treatment records. None of the VA treatment records or examination reports indicate any grossly inappropriate behavior, intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, or memory loss for names of closes relatives, own occupation, or own name. The Board also notes that no examiner during the period under review has selected the box indicating that the Veteran’s psychiatric disorder manifests in total occupational and social impairment when provided the opportunity to do so at each examination. Indeed, each examiner assessed the Veteran as having less than total impairment, which the Board finds probative, as each examiner is medically trained to perform these assessments and draw conclusions as to the overall level of disability based on a review of medical history, interview and examination. Their assessments are not at odds with the other evidence of record. Based on the above, the Board finds that the Veteran’s symptoms more nearly approximate the currently assigned 70 percent disability rating, and the next-higher 100 percent rating, is not warranted. In reaching this conclusion, the Board has considered the Veteran’s June 2018 Substantive Appeal Form 9 in which he reported memory loss of names close relatives and friends, no self-confidence, difficulty making decisions, frequent anxiety, inability to concentrate, disorientation when waking up, occasional depression, occasional mood swings, and was unable to maintain social relationships. However, Moreover, many of the symptoms reported in the June 2018 statement support a 70 percent rating but no higher. The only symptoms reported during the pendency of the appeal that would support a 100 percent rating is the report of memory loss of names close relatives and friends and neglect of personal hygiene. With respect to memory loss, the Board places a higher probative value on the finding by the October 2019 VA examiner who examined the Veteran after the Veteran’s June 2018 statement and did not find memory loss to the same degree. Rather, the October 2019 VA-contracted examiner found only mild memory loss. Similarly, although neglect of personal hygiene was noted by the March 2017 VA examiner, since then, the Veteran reported the Veteran’s report that he takes care of his personal hygiene every day, showers every day, and knows when he needs a haircut and a beard trim. See October 2019 VA-contracted examination report. For these reasons, the Board finds that any memory loss for names of close relatives and friends, or neglect of personal hygiene, was not of the severity intended by the 100 percent disability rating. The Board emphasizes that, in analyzing this claim, the symptoms identified in the Rating Formula have been considered not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant a higher rating for PTSD. As indicated above, here, the collective evidence supports a finding that, since the effective date of the award of service connection, the Veteran’s PTSD, at its worst, has been characterized by symptomatology which results in no more than occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, consistent with a 70 percent rating. As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt provision is not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). REASONS FOR REMAND 1. Entitlement to a compensable initial rating for bilateral hearing loss. The Veteran was provided with a VA examination in March 2017 to address the severity of his hearing loss. Since that time, he submitted a private audiogram dated in June 2020 which indicates that the Veteran’s hearing loss may have worsened since the March 2017 VA examination. In this regard, pure tone thresholds appeared to be higher in the right ear at frequencies 500 through 4000 and higher in in the left ear at frequencies 500 through 3000. Unfortunately, the private audiogram is not an adequate report upon which to base the rating evaluation as the Maryland CNC word recognition test was not applied. For these reasons, the Veteran should be provided a more contemporaneous VA examination to ensure that the record includes sufficient medical evidence to properly evaluate the disability under consideration. See 38 C.F.R. § 5103A; 38 C.F.R. § 3.159; Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). See also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide a veteran with a thorough and contemporaneous medical examination). 2. Entitlement to a TDIU. 3. Entitlement to DEA. The development ordered for the Veteran’s hearing loss claim, and the effectuation of the Board’s award of service connection for bladder cancer may impact the outcome of the Veteran’s TDIU and DEA claims. As such, a decision on these matters is deferred. The matters are REMANDED for the following action: Afford the Veteran a VA examination to determine the current severity of his service-connected bilateral hearing loss. The entire record must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. Following a review of the record, to include the Veteran’s statements, the examiner should describe all symptoms and functional effects associated with his bilateral hearing loss, including any impact that his bilateral hearing loss has on his activities of daily living. (Continued on Next Page) 2. Readjudicate the issues on appeal, to include entitlement to a TDIU and DEA. If the benefits sought remain denied, send the Veteran a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Donna D. Ebaugh, 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.