Citation Nr: 21010784 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 15-12 859 DATE: February 25, 2021 ORDER Entitlement to an initial, compensable rating for bilateral hearing loss is denied. Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. FINDINGS OF FACT 1. The Veteran’s bilateral hearing has been manifested by hearing acuity of no worse than Level I in both ears during the appeal period. 2. The severity, frequency, and duration of the Veteran’s PTSD symptoms did not more closely approximate total occupational and social impairment during the appeal period. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. 2. The criteria for a disability rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1967 to July 1970. These matters are before the Board of Veterans’ Appeals (Board) on appeal from May 2011 and July 2012 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). These matters have been before the Board on several occasions. The Board most recently remanded the above-listed issues for further development in August 2018. The Board’s remand directives have been substantially completed. See Stegall v. West, 11 Vet. App. 268 (1998). In February 2017, the Veteran and a witness (R.A.) testified before a Veterans Law Judge (VLJ) who has since retired from the Board. A transcript of the hearing is associated with the claims file. A January 2021 letter notified the Veteran that the VLJ who conducted his hearing is no longer at the Board, and he was asked to respond within 30 days indicating whether he would like a new hearing. VA has received no response to date. Therefore, the Board finds that there is no hearing request pending at this time. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, found in 38 C.F.R. Part 4. 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. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to an initial, compensable rating for bilateral hearing loss is denied. The Veteran contends that he is entitled to an initial compensable rating for his bilateral hearing loss. See April 2017 Form 9. Service connection for hearing loss was granted in a July 2012 rating decision. An initial noncompensable rating was granted, effective January 30, 2012 pursuant to 38 C.F.R. § 4.85, Diagnostic Code 6100. The Veteran appealed from this rating decision. The appeal period before the Board begins on January 30, 2012, the effective date of service connection. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, Diagnostic Code 6100. To evaluate the degree of disability from bilateral service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). A January 2012 VA examination reveals that the Veteran reported he “can’t hear a thing unless things are loud.” 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran’s Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: January 30, 2012 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 20 25 35 45 31 96 LEFT 25 20 35 40 30 96 Applying the results to Table VI, the findings yield a numeric designation of Level I in both ears. Entering the resulting bilateral numeric designation of Level I to 38 C.F.R. § 4.85, Table VII, equates to a 0 percent disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. During the February 2017 Board hearing, the Veteran reported his hearing has gotten worse since the last VA examination in January 2012. He stated his family gets annoyed when he watches his TV with loud volume, and that he has difficulty communicating with his wife. He also stated that he is unable to hear anything on the phone. In October 2018, the Veteran submitted a private audiological evaluation. The evaluation was performed by a state-licensed audiologist. The Veteran’s pure tone thresholds, in decibels, were as follows: October 15, 2018 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 55 65 70 65 64 - LEFT 55 65 65 70 64 - The evaluation noted that the Veteran’s “speech discrimination scores were 75%.” However, there was no indication that Maryland CNC was used. The evaluation was not adequate for rating purposes under § 4.85(a) as the speech recognition scores were not based on Maryland CNC test. Pursuant to the August 2018 Board remand, VA requested VA examination for evaluation of the Veteran’s bilateral hearing loss and PTSD on June 5, 2019. On June 20, 2019, a Congressional personnel in the Veteran’s district sent an email to the VARO’s Congressional liaison, inquiring about a recent VA examination request the Veteran received. It noted the Veteran was told, “no examination will be scheduled in the future for your permanent and total disabilities.” It noted that the Veteran felt he was being hurried into something that he has not approved or was not given enough warning about. On June 27, 2019, the Veteran submitted a letter which noted he could not attend the scheduled appointments as he had already planned to be out-of-state during that time. He also expressed confusion as to why additional exams were scheduled as he had submitted required evidence in October 2018, and that a January 2015 letter from the VARO noted that no examination will be scheduled in the future for his permanent and total disabilities. A June 27, 2019 VA Form 21-0820 noted that Veteran and his authorized third party requested rescheduling of the VA contract exam scheduled on July 1, 2019 as the Veteran was having a medical procedure on that day for spinal stenosis. It noted they were uncertain when the Veteran will be able to attend a future exam. On July 2, 2019, VA scheduled examinations for evaluation of the Veteran’s bilateral hearing loss and PTSD. A July 5, 2019 VA record noted that the exams were cancelled by the Veteran. On July 5, 2019, the Veteran submitted a letter which included an excerpt from a January 2015 VARO letter that noted the following: “We granted entitlement to the Individual Unemployability 100% rate effective January 1, 2007, because you are unable to work due to your service connected disabilities. . . No examination will be scheduled in the future for your permanent and total disabilities.” The Veteran inquired why VA was pursing repeat examinations for his bilateral hearing loss and PTSD when the above statement was made. A July 9, 2019 VA Form 21-0820 noted that VA called the Veteran in an attempt to reschedule exams for bilateral hearing loss and PTSD. The Veteran stated that the phone conversation on June 27, 2019 was a request to put the exams on hold. He did not want to take examinations because a January 2015 VARO notification stated that no examination will be scheduled for permanent and total disabilities. He stated he will not take them until he hears an answer from the Congressional personnel who made inquiries about the examinations on June 20, 2019. It further noted the Veteran had a pending medical appointment on July 15 for another cervical treatment. A July 17, 2019 email from VARO to the Congressional personnel explained that, “While the Veteran was notified in 2015 he was P&T [permanent and total], the conditions in which the Veteran had on appeal were still in contention. If there are issues in contention, you are subject to VA Examination no matter if they are P&T or not.” It further noted that the attached copy of the August 2018 Board remand was sent to the Veteran and has informed him that VA exams would be needed for his two conditions on appeal. On May 19, 2020, VA requested VA examinations for bilateral hearing loss and PTSD. A May 22, 2020, VA record noted that the exams were cancelled at the Veteran’s request. Another May 22, 2020 VA scheduling record noted, “The Veteran stated he is rated at 100% and this is not required.” VA and private treatment records during the appeal period generally note an active problem of hearing loss. The records did not show any audiometric evaluations. Based on the evidence above, a compensable rating for the Veteran’s bilateral hearing loss is not warranted. Pursuant to 38 C.F.R. § 3.655, when entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination, and a claimant, without good cause, fails to report for such examination or reexamination, scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. The records indicate that the Veteran’s cancellations of June and July 2019 VA examinations were based on good cause as he was out of town and/or had overlapping medical appointments. However, the records show otherwise for the May 2020 exam. The VA Regional Office had explained to the Veteran’s Congressional personnel that the Veteran is still subject to VA examination for permanent and total disabilities even if he was granted 100 percent for his unemployability claim. The Veteran was also provided a copy of the August 2018 Board decision that he would be subject to VA examinations to determine the current severity of the disabilities on appeal. Thus, the Board finds that good cause has not been shown for cancellation of the May 2020 VA examination. As such, the claim will be rated based on the evidence of record. The January 2012 VA audiological evaluation shows that the Veteran’s bilateral hearing has been manifested by hearing acuity of no worse than Level I in both ears. While the Veteran submitted a private evaluation in October 2018, the evaluation is not valid as there is no indication that Maryland CNC was used for the word discrimination test. 38 C.F.R. § 4.85(a). There is no other audiometric evaluation of record during the appeal period. Accordingly, the Veteran’s bilateral hearing loss does not approximate the criteria more nearly corresponding to a compensable rating. The Board expressly acknowledges its consideration of the lay evidence of record when adjudicating this claim, including the statements made during the February 2017 Board hearing. The Veteran is competent to report difficulty with his hearing; however, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran describes, is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran’s main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Rossy v. Shulkin, 29 Vet. App. 142, 145 (2017). In short, the preponderance of the most probative evidence is against the claim of entitlement to an initial, compensable rating for the Veteran’s bilateral hearing loss. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to an initial rating in excess of 70 percent for PTSD is denied. The Veteran contends that he is entitled to a rating in excess of 70 percent for his PTSD. See May 2013 correspondence; see also April 2017 Form 9. Service connection for PTSD was granted in a May 2011 rating decision. An initial 50 percent rating was granted, effective September 6, 2005 pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran appealed from this rating decision. A rating decision in August 2012 increased the rating to 70 percent effective September 6, 2005. The appeal period before the Board begins on September 6, 2005, the effective date of service connection. 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). The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 100 percent. The Board concludes that the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 100 percent. The Veteran’s symptoms more closely approximated the symptoms associated with a 70 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. 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 for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. A September 2005 VA treatment record noted the Veteran had a positive screening for PTSD. A July 2009 VA mental health record noted complaint of PTSD. The Veteran reported he always knew he had PTSD, but had always refrained from talking about it as he felt no one would understand. He reported that over the years, his family got used to staying away from him when he isolated himself or as a result of his severe irritability. He reported he used to be a mason contractor. He reported he is not employed due to economy and his physical disability. The clinician noted the Veteran was oriented to time, place, and personal information. He was neat and well groomed. His speech was quiet, clear, and coherent. His mood was sad, and affect was blunted. His thoughts were logical and goal-directed with no psychosis. He denied suicidal or homicidal ideation. His insight and judgment were intact. The clinician noted the Veteran has had ongoing symptoms of PTSD for 40 years, and that he had a severe exacerbation of symptoms including short dissociations in the context of no work, physical problems, loss of a relationship, and son’s illness. An August 2009 VA PTSD consultation noted the following PTSD symptoms: nightmares; intrusive thoughts; difficulty connecting with other people; having few friends; trouble sleeping; getting easily irritated and startled; trouble concentrating; being on guard all the time; and having thoughts over the past 3 months such as “maybe I should just get over with” or “life doesn’t mean much to me,” but without any concrete plan to kill himself. The Veteran stated he would not kill himself because of the pain it would cause to his family and because of his religious beliefs. The Veteran has been married to his wife for 32 years and they have 4 sons. He is a mason contractor, although he has not worked much lately. The mental status examination noted the Veteran was a casually dressed, groomed man. He was pleasant and cooperative. His eye contact was poor, and mood was dysthymic with intermittent tearfulness. His speech was normal for rate, volume, and production, and was logical and goal-directed. He acknowledged fleeting thoughts of suicide without plan or intention to act on the thoughts. There was no evidence of homicidal intent or psychosis. Cognition was grossly intact to interview, and insight and judgment were good. The Veteran underwent a private evaluation by Dr. E.K. in January 2010. He reported that about 5-7 years ago, he began having frequent intrusive recollections of his experiences in Vietnam, including seeing bodies stacked alongside the road; seeing bodies carried away on bamboo poles; and seeing his friend who lost his legs and one who was shot by Viet Cong. He reported the following symptoms: sleep disturbances; nightmares; startle; avoidance of crowds, loused noises, and TV shows about Vietnam; avoidance of men of his age who remind him of war; irritability; and numbness. The Veteran reported he lives with his wife of 32 years who he described as his best friend. They have 4 sons, 3 of whom attend college. The 2 youngest live at home with him. The Veteran stated his PTSD symptoms have affected his relationship with his wife over the years, and the wife verified that he is at times intensely irritable and unapproachable. The mental status exam revealed the Veteran displayed good hygiene, normal alertness, good eye contact, normal motor, and appropriate and intense affect. His mood was angry, depressed, and dysphoric. His speech was normal. His associations were logical, and his stream of thought was unremarkable. His thought content was depressive, and had guilt. He had no plans or intent to hurt others or self. His perception was normal. He was oriented. He had good concentration, and memory was intact. His fund of knowledge, insight, and judgment were good. He refrained from buying a firearm recognizing it may raise the risk of impulsively using it when drinking alcohol. For assessment, Dr. E.K. noted that the Veteran experienced nightmares, flashbacks, intrusive recollections, numbing, startle, and avoidance symptoms, which all worsened when he consumed alcohol, which was daily in varying amounts. His mood symptoms, to include depressed mood, insomnia, poor energy, concentration, anhedonia, and thoughts of suicide, have also worsened in the last month since he stopped taking his antidepressant medications prescribed at the VA. In a February 2010 VA mental health note, the Veteran reported increased depression and fleeting thoughts of suicidal ideation. The mental status exam revealed he was oriented x3, fair groomed, and had good eye contact. His speech was normal, coherent, logical, and goal directed. There was no looseness of associations, flight of ideas, delusions, paranoid ideation, or hallucinations. He had suicidal ideation, but without plan or intent. There was no homicidal ideation. Judgment was intact for treatment purposes. The clinician noted the Veteran has history of PTSD, has been married for more than 30 years, and that he is self-employed but is with reduced work now due to economy. She noted there was no evidence of psychosis or manic episodes. In a July 2010 VA mental health record, the Veteran expressed that he is tired of living this way. He reported increase in stress, isolation, and irritability. He reported he is stressful because his buddies frequently talk about Vietnam. The Veteran underwent a VA examination in September 2010. The following PTSD symptoms were noted: sleep disturbance; nightmares about once every 2 months; occasional intrusive thoughts; verbal anger and irritability; avoidance behavior; and significant hypervigilant behavior. The Veteran reported that on a typical day he is at home, and watches television and grows some plants. He will occasionally go to Bible study. His social activity outside the immediate family is limited. He displays verbal anger and irritability. The Veteran has been married to his wife for 32 years. There have been several separations in the past, but none since 2002. It noted both the Veteran and his spouse are committed to the relationship. The mental status exam revealed the Veteran’s immediate, recent, and remote memories were intact. He was oriented in all spheres. His speech was normal as to rate and volume, and emotional in tone. Thought process production was spontaneous and abundant. He was goal directed when frequently refocused by the examiner. Continuity of thought contained some rambling as well as some tangential responding. Thought content contained no suicidal or homicidal ideation. There were no delusions, ideas of reference, or feelings of unreality. His abstract ability and concentration were intact. His mood had elements of anxiety and depression. His range of affect throughout the examination was broad. He was alert, responsive, and cooperative. His judgment was intact, and his insight was fair. The Veteran managed his own personal hygiene and grooming. His appearance at the examination was neat, clean, and casual. The examiner noted his mental health condition would not preclude participation in routine activities of daily living. The Veteran underwent a VA examination for PTSD in July 2012. The Veteran reported he has been married to his wife for 32 years, but they do not live together. He reported his wife is in Phoenix, and he is in Wickenburg. He reported they have had this arrangement off/on in the past two years due to his anger problem. He reported his relationship with his sons is not good. He reported he generally cannot deal with people and gets easily angry at them. He reported he enjoys attending church, but that relationships are kept to a minimum. He reported he has no social support outside of his family, and that support within family is strained. The Veteran reported he has maintained his masonry license and has had sporadic work with subcontractors over the last two years. He reported problems at work due to losing temper, and that he has been in about 4 fistfights with employees or other subcontractors over the last two years. He reported having some passive suicide thought about a month ago but denied any current suicidal intent or plan. He denied any suicide attempts. The examiner noted the following symptoms: depressed mood; anxiety; suspiciousness; panic attacks more than once a week; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; flattened affect; disturbances of motivation and mood; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; and impaired impulse control, such as unprovoked irritability with periods of violence. The examiner summarized the Veteran’s level of occupational and social impairment as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. In a July 2013 letter, the Veteran asserted that he feels like he has no motivation to do anything anymore. He stated he has trouble concentrating which makes it difficult to get anything done, especially with mechanical tasks which he used to be able to do with ease. He stated problems with memory, decision making, and judgment. He stated these all create anxiety which carries over to the nighttime, which is the worst time for him. He stated he cannot be around people much due to having a short fuse. He stated he prefers to be by himself. He stated a recent reunion with his buddies from Vietnam was good in some respects, but also negative as the past trauma and flashbacks reoccurred. A July 2013 letter from the Veteran’s son wrote that his father has been a masonry contractor in the past, but is now visibly having difficulty with any work. He reported the Veteran is very irritable and unpredictable, quick to get frustrated with others as well as himself. He stated the Veteran gets very angry with slightest provocation. He stated the Veteran keeps distance and prefers to be by himself. A July 2013 letter from his wife noted that the Veteran has struggled with PTSD symptoms since 1970. She noted that they have not done things together which many families do. She noted the Veteran avoids crowds, so there were no sports games, or kids’ events, shows, or concerts. She noted the Veteran dislikes family gatherings, especially if large. She noted he attends church with her, but chooses to sit in the very back row. She noted the Veteran gets very agitated at times. She noted it is very difficult for him with the VA paperwork process as he needs to repeat his Vietnam traumas. In an October 2013 VA mental health note, the Veteran complained of increasing anxiety and amotivation. He also reported being hypervigilant and short with temper. The mental status exam noted that the Veteran was appropriately dressed, well-groomed, had good eye contact, and was polite and cooperative. His speech was normal, mood was anxious and mildly dysphoric, and affect was congruent and mildly constricted. He was oriented x3. His thought process was logical and coherent. He denied any suicidal or homicidal ideations. He denied auditory or visual hallucinations or paranoia. A November 2014 VA treatment record noted the Veteran reported continued nightmares and anxiety, but denied current suicidal or homicidal ideation. A January 2015 VA treatment noted the Veteran reported anxiety and depression, but denied any suicidal or homicidal ideation. In a February 2015 VA mental health record, the Veteran reported feeling more depressed and anxious over the last few months with symptoms of anhedonia, irritability, and low energy levels. He reported anger problems. He stated he remains isolated because he does not want to be around others. The clinician noted the Veteran is a patient with symptoms of anxiety and irritability that affected his daily living. The clinician noted there were no signs or symptoms of mania, obsessive-compulsive disorder, psychosis, or suicidal ideation. The mental status examination noted his appearance was adequately groomed. He was cooperative and had good eye contact. His speech was normal and spontaneous. Mood was depressed, and affect was constricted. His thought process was linear/organized. He denied suicidal or homicidal ideation, or auditory or visual hallucinations. He was poor with concentration. His insight was fair, and he was oriented x4. The Veteran’s private treatment records from Sahara Behavioral Health for the period from March 2016 to February 2017 were received in February 2017. The records generally noted that the Veteran was oriented to person, place, time, and situation; behaviors was anxious and cooperative; speech was unremarkable; mood was depressed, anxious, and fearful; affect was sad; thought process was appropriate, logic, intact; thought content was without delusions, paranoia, or hallucinations. Other than a March 2016 record that noted intermittent suicidal ideation, the records noted no suicidal or homicidal ideation or plan. During the February 2017 Board hearing, the Veteran and his wife also stated that the Veteran’s PTSD symptoms have worsened since the last VA examination in July 2012. They also reported an incident where the Veteran left town and stayed in a hotel room for two days, and thought about committing suicide. In a February 2017 letter, the Veteran’s son wrote that he has worked with his father for many years which has always been difficult, but is impossible now. He noted that the Veteran refuses to listen to what others have say, cannot focus to complete a task, gets angry very quickly, is extremely irritable, acts confused and disoriented regularly, and acts out in violence. He noted the Veteran has intense mood swings that come on quickly and last for long periods of time. He stated he has heard the Veteran speak of suicide. In a February 2017 letter, the Veteran’s wife noted that she has known the Veteran for the last 47 years, 39 of those as his wife. She noted it took thirty years to realize how to not arouse his anger. She noted the Veteran’s nightmares and fitful sleeping awakes her. She noted the Veteran never liked being in crowds, and wants to sit in the back or at least in the aisle of anywhere they go. She reported the Veteran is becoming more forgetful and disoriented at times, and is very irritable and short tempered. She noted he developed compulsive behaviors where in one instance he spent an entire day polishing his 3 pairs of boots. She stated that in December 2016, the Veteran became exceedingly upset of an insignificant statement she made, and he left home to go stay in a motel in another town, talking about taking his life. She stated he was feeling extremely remorseful over the Vietnam buddies who died, wondering why he was still alive. She noted the Veteran thankfully did not attempt to hurt himself though he had a weapon. She noted she loves the Veteran, and is committed to her husband and their marriage. A March 2017 letter from Dr. S.P. at Sahara Behavioral Health noted that the Veteran has been treated at Sahara Behavioral Health since January 2017. He noted the Veteran has nightmares that wake him up in terror, and that he is unable to fall back asleep. Dr. S.P. noted that the symptoms the Veteran experiences at times are so frightening that the Veteran has to leave town to be alone and regain his composure. Dr. S.P. noted that due to flashbacks, the Veteran suffers from severe depression, anxiety, anger, and mood swings. Dr. S.P. noted that the Veteran attends all appointments and is compliant with medication, but he still has severe breakthrough symptoms of PTSD. In an April 2018 VA treatment record, the Veteran reported he still thinks of killing himself every day. The Veteran denied any plans for killing himself at this time, but stated he has in the past. The Veteran denied any suicide attempts. On mental status examination, his attitude was agitated/frustrated. His speech was normal, and affect was flat. His thought process was tangential/circumstantial. He was oriented x3. An October 2018 letter from Dr. K.N.at Sahara Behavioral Health noted that she has been providing psychiatric care for the Veteran since December 2015. She noted the Veteran had ongoing issues with sleep, nightmares of combat experiences, and suicidal thoughts. She noted the Veteran suffers from anxiety and depression which have significantly affected his life, particularly his interpersonal relationships. Pursuant to the August 2018 Board remand, the RO scheduled VA examinations for the Veteran’s PTSD in June and July of 2019, and in May 2020. For the same reasons previously noted for his bilateral hearing loss, the Veteran cancelled the examinations. Private treatment records from Dr. S.P. received in May 2020 noted prescriptions for his PTSD from September 2018 to March 2020. The Veteran generally denied hallucinations, paranoia, or homicidal intent. Other than March 2019 and September 2018 records that noted fleeting thoughts of suicidal intent, the Veteran generally denied suicidal intent or plan. On mental status examination, the Veteran was alert and oriented x4; his attention, judgment, and impulse control were good; and his appearance was well-groomed and well-nourished. After careful review of the evidentiary records, the Board finds the severity, frequency, and duration of the Veteran’s PTSD symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. See 38 C.F.R. § 4.126. The Board initially notes that the Veteran had cancelled the July 2019 and May 2020 VA examinations without good cause shown. Thus, the claim will be rated based on the evidence of record. 38 C.F.R. § 3.655. During the appeal period, the Veteran displayed symptoms of depressed mood, anxiety, hypervigilance, suspiciousness, sleep disturbances, flattened affect, near-continuous panic or depression, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, irritability, impaired impulse control, and suicidal ideation. These symptoms span from 30 percent to 70 percent rating criteria under Diagnostic Code 9411. Further, the July 2012 examiner summarized the Veteran’s level of occupational and social impairment as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. This clinical determination is commensurate with a 70 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. Moreover, while the records show the Veteran has been granted a total disability rating based on individual unemployability from January 1, 2007, the Veteran was not totally socially impaired. The Veteran reported he enjoys attending church, and he attends Bible study group at times. Despite off/on arrangements to stay at separate places, the Veteran and his wife still continue to hold on to their 30 plus years of marriage. Indeed, the wife stated in February 2017 that she loves her husband, and is still committed to their marriage. The July 2012 VA examiner also did not find total occupational and social impairment due to his PTSD. The Veteran did report suicidal ideations intermittently, but he consistently denied an actual plan or an attempt, or any homicidal ideation. Notably, the record during the entire appeal period does not contain any evidence of symptoms such as gross impairment in thought processes; persistent delusions or hallucinations; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); grossly inappropriate behavior; or memory loss for names of close relatives, own occupation, or own name, as is considered for a 100 percent disability rating for PTSD. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s PTSD symptoms resulted in the level of impairment required for a 100 percent rating during the appeal period. Thus, the criteria for a 100 percent or higher rating are not met and the appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Jake Choi, 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.