Citation Nr: 21003857 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 15-13 912 DATE: January 25, 2021 ORDER Entitlement to service connection for left lower extremity neuropathy is granted. Entitlement to service connection for right lower extremity neuropathy is granted. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to a higher initial staged rating in excess of 50 percent for service-connected post-traumatic stress disorder (PTSD) and unspecified depressive disorder, prior to March 15, 2016, is denied. REMANDED Entitlement to a higher initial staged disability rating in excess of 70 percent for service-connected PTSD and unspecified depressive disorder, from March 15, 2016, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in favor of the Veteran, it is at least as likely as not that his left lower extremity neuropathy was caused by Agent Orange exposure during active duty service. 2. Resolving reasonable doubt in favor of the Veteran, it is at least as likely as not that his right lower extremity neuropathy was caused by Agent Orange exposure during active duty service. 3. The most probative evidence of record does not show that it is at least as likely as not that the Veteran’s bilateral hearing loss is etiologically related to his military service. 4. The most probative evidence of record does not show that it is at least as likely as not that the Veteran’s tinnitus is etiologically related to his military service. 5. The most probative evidence of record shows that, throughout the relevant rating period prior to March 15, 2016, the Veteran’s service-connected PTSD and unspecified depressive disorder was manifested by symptoms productive of functional impairment comparable to no worse that occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for left lower extremity neuropathy have been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326, 3.303, 3.304, 3.307, 3.309. 2. The criteria for entitlement to service connection for right lower extremity neuropathy have been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326, 3.303, 3.304, 3.307, 3.309. 3. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385. 4. The criteria for entitlement to service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 5. The criteria for entitlement to a higher initial staged rating in excess of 50 percent for service-connected PTSD and unspecified depressive disorder, prior to March 15, 2016, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1967 to September 1969. These matters come before the Board of Veterans’ Appeals (Board) on appeal from December 2013 (bilateral hearing loss, tinnitus, bilateral lower extremity neuropathy), September 2015 (PTSD), and April 2017 (TDIU) rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board last remanded the issues on appeal in April 2019. A review of the record shows substantial compliance with the Board’s remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In November 2018, the Veteran testified at a hearing before a Veterans Law Judge who is no longer employed at the Board. A transcript of the hearing is associated with the record. A September 2020 letter informed the Veteran that the judge who conducted the previous hearing is no longer employed at the Board, and provided him an opportunity to have another hearing before a different Veterans Law Judge. The letter also informed the Veteran that if he did not respond within 30 days from the date of the letter, the Board would assume that he does not want another hearing and would proceed accordingly. The Veteran has not responded to the letter or otherwise indicated that he would like another Board hearing. In addition, more than 30 days have elapsed from the date of the September 2020 letter. Therefore, the Board will proceed with appellate consideration. The Board further acknowledges that, in July 2020, the Veteran submitted additional statements relating to his service-connected PTSD. Under 38 U.S.C. § 7105(e)(1), for substantive appeals received on or after February 2, 2013, a waiver of RO review is not required for new pertinent evidence that is submitted by the appellant or representative, and the Board may proceed with adjudication and consideration of the new evidence in the first instance. The Veteran’s substantive appeal was received after February 2, 2013, in November 2017. Therefore, a waiver of RO review is not required, and the Board may consider the additional lay statements in the first instance. 38 U.S.C. § 7105(e)(1); 38 C.F.R. § 20.1304(c). Service Connection Service connection may be established on a direct incurrence basis for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1131; 38 C.F.R. § 3.303. To establish service connection on a direct incurrence basis, the Veteran must show: (1) existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Entitlement to service connection for left lower extremity neuropathy. Entitlement to service connection for right lower extremity neuropathy. The Veteran seeks service connection for bilateral lower extremity neuropathy. Specifically, the Veteran asserts that his symptoms began in-service, including burning sensation of his toes and the bottom of his feet that have continued and increased in severity to the present, and are due to Agent Orange exposure. See November 2018 Hearing Transcript. Pursuant to 38 C.F.R. § 3.309(e), veterans who have been exposed to an herbicide agent during active duty service are entitled to presumptive service connection for certain listed diseases, including early-onset peripheral neuropathy. Early-onset peripheral neuropathy must have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent. 38 C.F.R. § 3.307(a)(6)(ii). Notwithstanding the presumption, service connection for a disability claimed as due to Agent Orange may be established by showing that a disorder resulting in disability was in fact causally linked to such exposure. See Brock v. Brown, 10 Vet. App. 155, 162-64 (1997); Combee v. Brown, 34 F.3d 1039, 1044-45 (Fed. Cir. 1994); 38 C.F.R. § 3.303. The court has specifically held that the provisions of Combee are applicable in cases involving Agent Orange exposure. McCartt v. West, 12 Vet. App. 164, 167 (1999). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) the existence of a chronic disability in-service or during an applicable presumption period under 38 C.F.R. § 3.307 and present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. Under 38 C.F.R. § 3.303(b), continuity of symptomatology is an alternative route to establish service connection for specific chronic diseases, other organic diseases of the nervous system such as peripheral neuropathy, and can only be used in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also Nix v. Brown, 4 Vet. App. 462, 466 (1993) (citing WEBSTER’s MEDICAL DESK DICTIONARY 629 (1986), defining neuropathy as “an abnormal and usually degenerative state of the nervous system or nerves”). The evidence of record demonstrates the Veteran has diagnoses of left and right lower extremity neuropathy. See November 2019 VA examination. Thus, the first element of service connection, the existence of a present disability, has been met. See Shedden, 381 F.3d at 1167. With respect to the second element of service connection, in-service injury or disease, the Veteran’s military personnel records demonstrate the Veteran served in the Republic of Vietnam. Veterans who served in the Republic of Vietnam during the Vietnam era are presumed to have been exposed to herbicide agents, including Agent Orange. 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6). As such, herbicide exposure is presumed, and the second element of service connection has been met. See Shedden, 381 F.3d at 1167. As an initial matter, the evidence of record does not demonstrate that the Veteran’s bilateral lower extremity neuropathy was diagnosed and manifested to a 10 percent degree within one year of discharge from active duty. In that regard, the Veteran was afforded a VA examination in November 2019. The VA examiner noted the Veteran was diagnosed with bilateral lower extremity neuropathy in 2004. See November 2019 VA examination. The Veteran testified that he did not seek treatment for his bilateral lower extremity neuropathy within a year of discharge from active duty until approximately 2009/2010. See November 2018 Hearing Transcript. As such, presumptive service connection is not warranted. With regard to non-presumptive direct incurrence service connection, the Veteran was afforded a VA examination in November 2019. The VA examiner noted the Veteran’s complaints of symptoms related to his bilateral lower extremity neuropathy since service, and exposure to Agent Orange. See November 2019 VA examination. The VA examiner concluded that the Veteran’s bilateral lower extremity neuropathy was at least as likely as not incurred or caused by in-service exposure to Agent Orange. Id. The VA examiner noted review of the Veteran’s VA e-folder and VA treatment records and conducted an in-person examination. Id. As such, the Board finds the VA examiner’s medical opinion to be adequate and assigns it significant probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). The Veteran is competent to provide lay evidence of the existence of symptoms that are capable of lay observation and may provide sufficient support for a claim of service connection. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 470 (1994). Moreover, in appropriate situations, the Veteran can report symptoms to establish the link between an in-service incurrence and subsequent diagnosis of a disability. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The Board finds that the Veteran is competent and credible to assert that he experienced observable symptoms related to his bilateral lower extremity neuropathy since service. Despite the Veteran’s private treatment records showing the Veteran underwent back surgery in 2012 resulting in right lower extremity neuropathy, the Veteran reported lower back pain radiating down his leg to foot that has been off and on for years prior to his back surgery. See August 2012 and November 2012 private treatment records. A June 2015 VA treatment record shows the Veteran reported lower back pain that began in Vietnam and that his back surgery in 2012 helped with pain and right lower extremity radicular symptoms. A June 2017 VA treatment record notes the Veteran has a history of neuropathy that has been present since his last period in Vietnam and notes the Veteran was exposed to Agent Orange. The Veteran testified that symptoms began when he noticed problems with his feet the last three months of Vietnam in 1969, including burning in his toes and bottom of feet. See November 2018 Hearing Transcript. The Veteran further testified that he experienced shooting pains that have increased in severity and symptoms that have continued since service. Id. Finally, the November 2019 VA examiner noted the Veteran reported tingling and coldness of his toes at his separation examination, and has had pain, burning and numbness since service. See November 2019 VA examination. Thus, in applying the benefit of the doubt doctrine, the Board attributes the Veteran’s reports of symptoms since service to his current diagnosis of bilateral lower extremity neuropathy. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Therefore, the Board finds that continuity of symptomatology has been established. 38 C.F.R. § 3.303(b). In sum, after resolving all doubt in favor of the Veteran, the Board finds that the evidence of record supports a grant of service connection for right and left lower extremity neuropathy on a direct incurrence basis. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Entitlement to service connection for bilateral hearing loss. Entitlement to service connection for tinnitus. The Veteran contends that his bilateral hearing loss and tinnitus are due to military noise exposure, including from mortar fire and other ammunition fire. See November 2018 Hearing Transcript. The Veteran asserted that he began to notice hearing problems while in-service that have continued since service. Id. A hearing loss disability for VA purposes means that the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels (dB) or greater; or when the auditory thresholds for at least three of the frequencies are 26 dB or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385. The threshold for normal hearing is from 0 to 20 dB, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Sensorineural hearing loss disability and tinnitus may be presumed to have been incurred in-service if the disorder was disabling to a compensable degree within a year of a veteran’s separation from active duty. 38 C.F.R. §§ 3.307, 3.309(a). The Board must consider and assess the credibility and weight of all evidence in the claim file, including the medical and lay evidence, to determine its probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999); Barr v. Nicholson, 21 Vet. App. 303 (2007). When there is an approximate balance of positive and negative evidence regarding any material aspect of a claim, all reasonable doubt will be resolved in favor of the claimant. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. However, when the weight of the evidence is against the claim, the claim must be denied. Id. The Veteran was afforded an initial VA audiology examination in November 2013, at which time it was demonstrated that he had a bilateral hearing loss disability for VA compensations purposes. See November 2013 VA examination. Additionally, the Veteran reported recurrent tinnitus. Id. Tinnitus is readily observable by laypersons, and medical expertise is not required to establish its existence. Charles v. Principi, 16 Vet. App. 370, 374-75 (2002). Therefore, the first Shedden element of service connection for bilateral hearing loss disability and tinnitus has been established. See Shedden, 381 F.3d at 1166-77. As an initial matter, the Board first finds that, while the Veteran has bilateral hearing loss disability for VA purposes, and tinnitus, neither is shown by the evidence of record to have manifested to a compensable degree in-service or within a presumptive period after service, and continuity of symptomatology is not established. 38 C.F.R. §§ 3.307, 3.309(a). The Veteran asserted that his hearing loss and tinnitus began in-service and continued after separation. See November 2018 Hearing Transcript. However, the record does not indicate that his hearing loss and/or tinnitus began in-service or within one year after separation from service. The Veteran’s service treatment records are silent for any complaints, treatment, or diagnoses of any hearing related problems during service. The Veteran’s ears and hearing was normal upon examination at separation from service. See September 1969 separation examination. The first indication of the Veteran’s bilateral hearing loss and tinnitus is in March 2012, more than 30 years after service. While not dispositive, the passage of so many years between discharge from active service and objective documentation of a disability is a factor for consideration, and in this case, weighs against a finding of service incurrence and continuity of symptomatology. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Additionally, with regard to the Veteran’s report of onset and continuity of symptomatology, the Veteran’s statements are inconsistent which reduces the Veteran’s credibility. Specifically, at the November 2013 VA examination, the Veteran denied tinnitus during military service and the VA examiner noted that there was no significant event related to tinnitus onset. As noted, the first report of tinnitus was in March 2012 and private treatment records are silent for any complaints, treatment, or diagnoses of tinnitus. Therefore, it has not been demonstrated that the Veteran’s hearing loss and/or tinnitus were disabling to a compensable degree within a year of the Veteran’s separation from active duty. Accordingly, the presumption of in-service occurrence is not applicable. See 38 C.F.R. §§ 3.307, 3.309(a). Service connection for bilateral hearing loss and tinnitus may still be granted on a non-presumptive direct-incurrence basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s bilateral hearing and/or tinnitus and an in-service injury, event or disease. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303; Shedden, 381 F.3d at 1166-67. With respect to an in-service injury or disease, the Veteran’s military occupation specialty (MOS) was a radio relay repairman. The RO noted the Veteran’s MOS has a moderate noise exposure. See September 2013 VA treatment records. The Veteran’s military personnel records also confirm the Veteran service on active duty in combat in the Republic of Vietnam. Therefore, the Board finds that the second Shedden criteria for service connection has been met. See Shedden, 381 F.3d at 1166-67. Though the Veteran has current bilateral hearing loss disability and tinnitus, the Board finds the most probative evidence of record does not demonstrate a link between the Veteran’s disabilities and military noise exposure. The November 2013 VA examiner opined that the Veteran’s bilateral hearing loss and tinnitus were not at least as likely as not caused by or a result of military noise exposure. See November 2013 VA examination. However, the Veteran’s separation audiogram conducted in September 1969 does not list the threshold results for either ear at 3000 Hertz (Hz), and the VA examiner did not discuss the possibility that a disability might have existed. Therefore, the Board previously remanded the case for a new VA examination in April 2019. The Veteran was afforded a second VA examination in November 2019. The VA examiner opined that it is not at least as likely as not that the Veteran’s bilateral hearing loss was caused by or a result of noise exposure in-service. See November 2019 VA examination. As rationale, the VA examiner explained that the Veteran’s enlistment audiogram results appear to have been manually converted from a pre-induction audiogram a month earlier since there is minimal difference between the two after precise conversion. Id. The VA examiner stated that this assessment converted the pre-induction audiogram to the ISO-1964 standard. Id. The VA examiner stated that there is no clinically significant difference between the Veteran’s enlistment audiogram in January 1967 and the separation audiogram in September 1969 regardless of which value set was used. Id. In regard to the lack of data at 3000 Hz on the Veteran’s separation examination, the VA examiner noted the Veteran’s threshold results at 2000 Hz and 4000 Hz was a “0.” Id. The VA examiner stated that while it is possible that a significantly different threshold existed at 3000 Hz, the probability is that there is little, or no chance of that occurrence given the 0 threshold at 2000 Hz and 4000 Hz. Id. As such, the VA examiner concluded that it is less likely as not that military noise contributed significantly to the Veteran’s current bilateral hearing loss. Id. In regard to the Veteran’s tinnitus, the November 2019 VA examiner opined that it was less likely than not the Veteran’s tinnitus was caused by or a result of military noise exposure. Id. As rationale, the VA examiner noted there is no evidence to indicate noise-induced hearing loss during service. Id. The VA examiner noted the occurrence of noise-induced tinnitus in the absence of noise-induced hearing loss is not supported by medical research. Id. The VA examiner noted review of the Veteran’s VA e-folder and conducted an in-person examination. Id. As such, the Board finds the VA examiner’s medical opinion to be adequate and assigns it significant probative value. See Nieves-Rodriguez, 22 Vet. App. at 302. The Board acknowledges the Veteran’s statements contending that his bilateral hearing loss and tinnitus are related to his in-service noise exposure. Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability subject, or symptoms subject, to lay observation. See Jandreau, 492 F.3d at 1377. However, the Veteran is not competent to establish an etiological nexus between his bilateral hearing and tinnitus and his active duty service as such opinion requires medical expertise and knowledge that he has not been shown to possess. Id.; Kahana, 24 Vet. App. at 435. Moreover, the Board attaches more probative weight to the clinical findings and medical opinion who conducted the November 2019 VA examination than to the Veteran’s lay statements. As such, the Board concludes that evidence of record does not establish that the Veteran’s bilateral hearing loss and tinnitus are etiologically related to his in-service noise exposure. In light of the above, the preponderance of the evidence is against the claims and the benefit-of-the-doubt doctrine is not for application. Therefore, the claims must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. at 53. Hence, entitlement to service connection for bilateral hearing loss and tinnitus is denied. Entitlement to a higher initial staged rating in excess of 50 percent for PTSD and unspecified depressive disorder, prior to March 14, 2016. The Veteran seeks a higher initial staged rating for his service-connected PTSD and unspecified depressive disorder. The Veteran’s service-connected PTSD and unspecified depressive disorder is rated under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. The Veteran was assigned a 50 percent rating effective from May 22, 2015, the date of the Veteran’s claim for service connection. See September 2015 rating decision. As an initial matter, the Veteran submitted a claim for an increased initial rating in March 2016. New and material evidence was associated with the claims file, including a July 2016 VA examination, within one year of issuance of the September 2015 rating decision. Therefore, the Veteran’s claim remained open and the September 2015 rating decision did not become final. Subsequently, in a July 2016 rating decision, the RO granted a staged rating of 70 percent effective March 15, 2016. The Veteran perfected an appeal of that decision. The issue of entitlement to a higher staged rating in excess of 70 percent, from March 15, 2016, for service-connected PTSD and unspecified depressive disorder is discussed below. Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). The Veteran’s PTSD is rated under 38 C.F.R. § 4.130, DC 9411, of the General Rating Formula for Mental Disorders (General Rating Formula). Under the General Rating Formula, 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. Id. 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 work life 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. Id. 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 time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. Id. In rating mental disorders under the General Rating Formula, the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. 38 C.F.R. § 4.130; Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). 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). During the rating period on appeal prior to March 15, 2016, the Veteran was provided an initial VA examination in September 2015. The Veteran endorsed symptoms to include irritability, hypervigilance, depressed mood, short-term memory and concentration problems, sleep disturbance, anxiety, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. See September 2015 VA examination. The VA examiner noted the Veteran denied suicidal ideation, homicidal ideation, had casual attire, and was oriented to time, place, and situation. Id. The VA examiner concluded the Veteran’s symptoms manifested in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Id. The VA examiner noted review of the Veteran’s VA e-folder, service treatment records, private treatment records, and conducted an in-person examination. Id. As such, the Board finds the VA examiner’s medical opinion to be adequate and assigns it significant probative value. See Nieves-Rodriguez, 22 Vet. App. at 302; Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran’s VA treatment records, prior to March 15, 2016, also do not demonstrate that an initial rating in excess of 50 percent is warranted prior to March 15, 2016. The Veteran’s VA treatment records demonstrate the Veteran underwent PTSD group counseling. See June-August 2015 VA treatment records. The Veteran’s symptoms included depression, anxiety, irritability, forgetfulness, sleep problems, decreased memory and concentration, hypervigilance, and frequent nightmares. See November 2015 and February 2016 VA treatment records. The Veteran denied suicidal and homicidal ideation and not deemed an imminent threat to self or others. See August 2015 VA treatment records. Additionally, VA treatment records demonstrate the Veteran was oriented to person, place, time, and situation; had normal speech; though process generally logical and goal oriented; no hallucinations or delusions; and good general social reasoning. See November 2015 and February 2016 VA treatment records. Moreover, the Veteran nor his representative have submitted any evidence during the relevant period on appeal that demonstrates entitlement to a higher initial rating during the period prior to March 15, 2016. To the extent that the Veteran contends that his PTSD and unspecified depressive disorder was more severe prior to March 15, 2016 than reflected by his current disability rating, the Board acknowledges that the Veteran can attest to factual matters of which he has first-hand knowledge and understanding as a lay person. See Jandreau, 492 F.3d at 1377. However, he is not competent to state that his PTSD and unspecified depressive disorder is of a severity to warrant a higher rating under VA’s criteria for rating mental disorder because such an opinion requires medical expertise and knowledge that he has not been shown to possess. See Kahana, 24 Vet. App. at 435. As such, the Board attaches more weight to the September 2015 VA examination than to the Veteran’s lay statements. The Veteran’s overall symptomatology more closely approximates the criteria for a 50 percent rating. The Board has considered the extent to which there are other indications of occupational and social impairment with deficiencies in most areas prior to March 15, 2016. See Mauerhan, 16 Vet. App. at 444. In this regard, the Board has not found any further evidence that could support a finding of occupational and social impairment with reduced reliability and productivity prior to March 15, 2016. The Board finds that the record does not contain evidence of symptoms that more closely approximate the criteria set forth for a 70 percent rating such as suicidal ideation; obsessional rituals; illogical, obscure, or irrelevant speech; near-continuous panic or depression; impaired impulse control; or neglect of personal appearance and hygiene during the period prior to March 15, 2016. Though the Veteran reported irritability, VA treatment records demonstrate that his impulse control was intact, and he was not deemed an imminent threat to others prior to March 15, 2016. See February 2016 VA treatment records. Thus, the Board finds that the evidence of record for the period prior to March 15, 2016, demonstrates the Veteran’s PTSD was at worst manifest by symptoms productive of functional impairment most comparable to occupational and social impairment with reduced reliability and productivity. As such, there is no basis for a finding of increased disability so as to warrant an initial staged rating greater than 50 percent prior to March 15, 2016. As the preponderance of the evidence is against an initial disability rating greater than 50 percent, prior to March 15, 2016, there is no doubt to be resolved in the Veteran’s favor, and the provisions of 38 C.F.R. § 4.3 are not applicable. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 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). REASONS FOR REMAND Entitlement to an initial staged disability rating in excess of 70 percent for service-connected PTSD and unspecified depressive disorder, from March 15, 2016, is remanded. The Veteran was last afforded a VA examination relating to his PTSD in March 2017. In November 2018, the Veteran testified that his PTSD symptoms have worsened. Specifically, the Veteran testified that his flashbacks have become more intense and his memory has worsened. See November 2018 Hearing Transcript. The Veteran also testified that he had to quit his job because he was getting the urge to hurt and/or kill someone due to his temper and frustration. Id. The Veteran asserted that his work environment as a security guard was becoming increasingly more hostile and dangerous that was triggering his PTSD symptoms and his PTSD symptoms continue to worsen. See July 2020 Statement in Support of Claim. The Veteran has asserted additional symptoms that were not reported in his previous VA examination such as the urge to hurt and/or kill someone and has asserted that his PTSD symptoms have worsened. In light of the Veteran’s assertions, a new examination is required so that the current nature and severity of the Veteran’s service-connected PTSD may be determined. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the veteran with a thorough and contemporaneous medical examination); Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993) (VA has a duty to provide an examination when there is evidence that the disability has worsened since the previous examination). Accordingly, remand is required for a new VA examination. Entitlement to a TDIU is remanded. The Veteran’s claim to higher staged rating in excess of 70 percent for service-connected PTSD and unspecified depressive disorder impacts the claim of entitlement to a TDIU. A determination cannot be made regarding the latter without a complete understanding of the Veteran’s disability picture. Therefore, the claim for a TDIU is inextricably intertwined with the other claims and must be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected PTSD and unspecified depressive disorder. The record and a copy of this Remand must be made available to and reviewed by the examiner. The examination must include all testing deemed necessary by the examiner in conjunction with this request. The examiner should report all manifestations and functional impairment related to the Veteran’s service-connected PTSD. A complete rationale should be given for all opinions and conclusions expressed. 2. After completion of the above action, readjudicate the issues of entitlement to a higher staged rating in excess of 70 percent for service-connected PTSD and unspecified depressive disorder and the inextricably intertwined issue of entitlement to a TDIU. If the benefit sought is not granted, then the Veteran and his representative should be furnished with a Supplemental Statement of the Case and afforded an opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369, 372 (1999). M. Miller Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. P. Moore, 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.