Citation Nr: 21029785 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 17-02 930 DATE: May 17, 2021 ORDER The previously denied claim for service connection for hearing loss is reopened. The previously denied claim for service connection for tinnitus is reopened. Service connection for dental condition as secondary to tonsillar head and neck cancer (claimed as respiratory cancer) is denied. An effective date prior to August 22, 2011, for the award of service connection for coronary artery disease is denied. An effective date prior to January 4, 2013, for the award of service connection for posttraumatic stress disorder (PTSD) is denied. An initial disability rating for PTSD with major depressive disorder (also claimed as anxiety disorder) higher than 30 percent prior to December 15, 2015, and higher than 50 percent thereafter is denied. REMANDED Service connection for bilateral hearing loss is remanded. Service connection for tinnitus is remanded. Service connection for a skin condition is remanded. Service connection for residuals of stroke as secondary to the service-connected disability of coronary artery disease is remanded. An initial disability rating higher than 60 percent for coronary artery disease is remanded. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. In an unappealed rating decision dated in September 2006, the RO denied service connection for hearing loss and tinnitus on the basis of no current diagnosis and no evidence of either disorder in service. 2. Additional evidence received since September 2006 is not cumulative or redundant of the evidence of record at the time of that rating decision; it relates to an unestablished fact necessary to substantiate the claim for service connection for hearing loss and tinnitus; and it raises a reasonable possibility of substantiating the claim. 3. The claimed dental condition (described by the Veteran as deteriorating teeth and bleeding gums following radiation treatment) is not secondary to a service-connected disability; dental caries is not a disability for which VA compensation benefits are payable; and a bleeding gums condition did not manifest during and is not now related to service. 4. There is no prior unadjudicated claim for service connection for coronary artery disease before August 22, 2011. 5. There is no prior unadjudicated claim for service connection for PTSD before January 4, 2013. 6. The Veteran's service-connected PTSD with major depressive disorder was productive of at most mild symptoms prior to December 15, 2015; and it has been manifested by at most occupational and social impairment with reduced reliability and productivity since then. CONCLUSIONS OF LAW 1. The September 2006 rating decision denying service connection for hearing loss and tinnitus is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence having been received, the criteria for reopening the previously denied claim of service connection for hearing loss have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. New and material evidence having been received, the criteria for reopening the previously denied claim of service connection for tinnitus have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. The criteria for service connection for a dental condition manifested by deteriorating teeth and bleeding gums have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310, 3.381, 4.150. 5. The criteria for an effective date prior to August 22, 2011 for the grant of service connection for coronary artery disease have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400. 6. The criteria for an effective date prior to January 4, 2013 for the grant of service connection for PTSD have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400. 7. The criteria for an initial disability rating for PTSD with major depressive disorder higher than 30 percent prior to December 15, 2015, and higher than 50 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from May 1967 to February 1970, including in the Republic of Vietnam from April 1968 to March 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision issued by a VA Regional Office (RO). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). 1. Reopening of a claim of service connection for hearing loss 2. Reopening of a claim of service connection for tinnitus The Veteran contends that his hearing loss and tinnitus began during service. In a rating decision dated in September 2006, the RO denied the claims on the grounds that there was no evidence of a current disorder, and no record of either disorder during service. No new evidence or notice of disagreement was received by VA within one year of the issuance of the September 2006 rating decision. Thus, it became final. A claimant may reopen a finally adjudicated legacy claim by submitting new and material evidence. New evidence is evidence not previously part of the actual record before agency adjudicators. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110 (2010). In correspondence dated in January 2013, the Veteran requested to reopen his claim of service connection for hearing loss and tinnitus and, in a rating decision dated in September 2013, the RO denied the claims on the basis of no new and material evidence. Regardless of what the RO did, the Board has the jurisdictional responsibility to consider whether it was proper to reopen the claim. The Board will therefore determine whether new and material evidence has been received and, if so, consider entitlement to service connection on the merits. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). At the time of the September 2006 rating decision, the record included service treatment records, service personnel records, Social Security Administration (SSA) records, and VA treatment records dating from February to June 2006. There was no mention of hearing loss or tinnitus in the SSA or VA treatment records, although the STRs did reflect a decrease in hearing thresholds, including an ISO test finding of 40 decibels at 4000 Hertz in August 1967 [which converts, per ANSI, to 45 decibels]. The evidence also included a June 2006 statement from the Veteran, in which he stated: "I contribute my bilateral hearing loss and tinnitus to the constant exposure to noise from artillery fire, small arms fire, enemy mortar and rocket fire (attacks) and noise from the Huey helicopters during daily missions." The evidence also included the Veteran's report, in a June 2006 PTSD stressor statement, that he "experienced" constant out-going artillery fire (155 and 175 mm guns); countless incoming mortar and rocket attacks; Viet-Cong ground attacks, and "the ensuing fire-fights defending the base camp." On review of the record the Board finds that new and material evidence has been submitted since the RO's September 2006 denial of these claims. In October 2016, the RO acknowledged that the Veteran had excessive noise exposure during service, stating "the Veteran's MOS was an Air Traffic Tower Operator which is a high probability of noise exposure." The Veteran was then afforded a VA hearing loss and tinnitus examination, which returned a diagnosis of left and right ear sensorineural hearing loss, and tinnitus. Based on the foregoing, the Board finds that new and material evidence has been added to the record since the September 2006 decision. That decision found that there was no currently diagnosed disability. Medical evidence added to the record provides the requisite diagnoses, and the RO asserts that the Veteran's military work had a high probability of noise exposure. The Board finds that this additional evidence relates to unestablished facts necessary to substantiate the Veteran's claim for service connection. Accordingly, new and material evidence has been received and the claims are reopened, and they are addressed in the remand section of this decision. 3. Service connection for dental condition as secondary to tonsillar head and neck cancer The Veteran is requesting service connection for dental condition secondary to tonsillar head and neck cancer (claimed as respiratory cancer). During a March 2013 VBMS Agent Orange review he described the disorder as bleeding gums and deteriorating teeth caused by radiation treatment for his tonsillar/head- neck cancer. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. "To establish a right to compensation for a present disability, a veteran must show: "(1) the 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"the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310. The dental and oral conditions which may be service connected for VA compensation purposes are delineated at 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Compensation is available for loss of teeth but only if such loss is due to loss of substance of body of maxilla or mandible due to trauma or due to disease such as osteomyelitis, but not due to the loss of the alveolar process as a result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Code 9913, Note. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not considered disabling conditions and may be considered service connected solely for establishing eligibility for outpatient dental treatment. 38 C.F.R. § 3.381(b). VA has a duty to address all arguments put forth by a claimant and/or theories under which entitlement to benefits sought may be awarded. See generally Schroeder v. West, 212 F.3d 1265 (Fed. Cir. 2000). 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 Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Preliminarily, the Board notes that that the Veteran's claim is for compensation purposes, so the issue of service connection for dental treatment purposes is not presently before the Board. However, this decision does not preclude the Veteran from pursuing a claim of service connection for dental treatment purposes if he is ever inclined to do so in the future. Applying the legal criteria set forth above to the facts in this case, the Board finds that service connection for a dental condition for VA compensation purposes is not warranted. The Veteran is not service-connected for his tonsillar/head-neck cancer, so service connection for his claimed dental disorder under his propounded (secondary) theory of entitlement is not possible. As for service connection on a direct basis, the Board notes that the Veteran received treatment for carious teeth during service; however, treatable carious teeth are not considered disabling conditions for VA compensation purposes. See 38 C.F.R. § 3.381. Moreover, the Veteran was not diagnosed with a bleeding gums disorder during service. On the contrary, service treatment providers expressly noted that there was no unusual bleeding. The Board accordingly finds that the preponderance of the evidence is against the claim under applicable theories of entitlement. Service connection for dental condition manifested by bleeding gums and deteriorating teeth is thus not warranted and the appeal is denied. In this regard, the Board notes that the Veteran has not been afforded a VA examination regarding this claim but finds that such is not needed as the Veteran is not service-connected for the primary disorder; VA regulations prohibit service connection for carious teeth; and there is no record of a bleeding gum condition during service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board thus finds that a VA examination is not necessary to decide the claim. 38 C.F.R. § 3.159(c)(4). Effective Date Unless specifically provided otherwise, the effective date of an evaluation and grant of pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. The effective date for a grant of service connection is the day following the date of separation from active service or the date entitlement arose, if the claim is received within one year after separation from active service; otherwise, it is the date of receipt of claim, or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i). Prior to March 24, 2015, a "claim" was either a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. See 38 C.F.R. § 3.1(p). "Date of receipt" of a claim, information, or evidence means the date on which a claim, information, or evidence was received by VA. See 38 C.F.R. § 3.1(r). Any documented communication from, or action by, a veteran indicating intent to apply for a benefit under laws administered by VA may be considered an informal claim. See 38 C.F.R. § 3.155(b). To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). Effective March 24, 2015, all claims must be submitted on a form prescribed by the Secretary of VA. See 38 C.F.R. § 3.3155. 4. An effective date prior to August 22, 2011 for service connection for coronary artery disease In a rating decision dated in September 2013, the RO granted service connection for coronary artery disease with a rating of 60 percent effective August 22, 2011. In September 2013, the Veteran submitted a Notice of Disagreement, in which he requested an earlier effective date. On review of the record the Board finds no basis to award an earlier effective date. The Veteran originally filed a claim for ischemic heart disease (hereinafter coronary artery disease) that was received by VA on August 22, 2011, and the claim was granted with an effective date of August 22, 2011. In September 2013, the Veteran submitted a Notice of Disagreement to the "effective date of award." However, neither the Veteran nor his representative has ever elaborated on why the Veteran thinks that the assigned effective date is incorrect. The Board has thoroughly reviewed the evidence of record to determine if there was some prior communication from the Veteran that would suffice as a claim for service connection for coronary artery disease before August 2011. To that end, the Board notes the Veteran did file a claim in February 2006 for other disabilities in 2006, to include tinnitus and bilateral hearing loss, but no statement prior to August 22, 2011, raised or reasonably raised a claim for service connection for coronary artery disease. Indeed, the fact that the Veteran filed claims for other disabilities prior to 2011 shows he was aware of how to file for service connection and chose not to do so prior to August 22, 2011. VA regulations expressly provide that the effective date for an award of service connection can be no earlier than the date of receipt of claim or the date entitlement arose, whichever is later. This means that the effective date of service connection will never be earlier than the date of claim (unless the claim is received within the year after the Veteran's separation from service). In this case the claim was received on August 22, 2011; more than one year after his separation from service. And there is no prior formal or informal unadjudicated claim for coronary artery disease before that date. An effective date prior to August 22, 2011, for the grant of service connection for coronary artery disease is thus not warranted and the appeal is denied. 5. An effective date prior to January 4, 2013, for the award of service connection for posttraumatic stress disorder (PTSD) is denied. In a rating decision dated in September 2013, the RO granted service connection for PTSD with a rating of 30 percent effective January 4, 2013. In September 2013, the Veteran submitted a Notice of Disagreement, in which he requested an earlier effective date. On review of the record the Board finds no basis to award an earlier effective date. The Veteran originally filed a claim (VA Form 21-526) for PTSD in February 2006, which the RO denied in a September 2006 rating decision. The Veteran was notified of the decision by letter in October 2006, which was mailed to the then current mailing address of record. The Veteran did not appeal this decision and it became final. Nothing further regarding the matter was received until correspondence received by VA on January 4, 2013, when the Veteran requested (via a VA Form 21-4138 Statement in Support of Claim) that his claim for service connection for PTSD be reopened. In a September 2013 rating decision, the RO granted service connection for PTSD with a rating of 30 percent effective January 4, 2013, and in September 2013, the Veteran submitted a Notice of Disagreement, in which he requested an earlier effective date. Neither the Veteran or his representative has ever elaborated on why the Veteran thinks that the assigned effective date is incorrect or what he thinks it should be. On review of the record the Board finds no basis to award an earlier effective date. VA regulations provide that the effective date for reopened claims shall be the date of receipt of the claim to reopen or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(r). The Board has thoroughly reviewed the evidence of record to determine if, after the September 2006 rating decision, VA received another claim for PTSD prior to January 2013. However, there is no formal claim for PTSD, or any correspondence that can be construed as an informal claim for compensation for PTSD before the Veteran's January 4, 2013 informal request to reopen his claim. Although the Veteran did indeed first file for service connection for PTSD in February 2006, that claim was denied by rating decision dated in September 2006; and there is no subsequent communication from the Veteran regarding his PTSD until the January 2013 informal claim to reopen. To the extent that the Veteran suggests that an earlier effective date is warranted because there is medical evidence of a psychiatric disorder/PTSD prior to January 4, 2013, the mere presence of medical evidence does not establish an intent to seek service connection. See Brannon v. West, 12 Vet. App. 32, 34-35 (1998) (holding that the mere receipt of medical records could not be construed as an informal claim); see also Criswell v. Nicholson, 20 Vet. App. 501, 503 (2006) ("[W]here there can be found no intent to apply for VA benefits, a claim for entitlement to such benefits has not been reasonably raised."). Thus, any medical records tending to show the existence of PTSD prior to the current effective date do not result in the assignment of an earlier date because they do not meet the definition of an informal claim. Additionally, and to the extent that the Veteran contends that he suffered from a mental disorder/PTSD prior to January 4, 2013, and so is entitled to an earlier effective date, VA regulations clearly provide that the effective date of service connection shall be the date of claim or the date entitlement arose, whichever is later. As previously explained, no document can be construed, after the September 2006 denial, as a claim of service connection for PTSD specifically, or a psychiatric disorder more broadly, prior to January 4, 2013. Therefore, the effective date can be no earlier than the January 4, 2013 date of the informal claim to reopen the issue of service connection for PTSD. The sole remaining avenue for obtaining an earlier effective date is via a finding of clear and unmistakable error in the September 2006 rating decision, which the Veteran has not alleged. In sum, as the Veteran did not appeal the September 2006 denial of service connection, that decision became final, and the effective date for the current award of service connection can be no earlier than the date of the claim to reopen, which is January 4, 2013. This is the later date between the date entitlement arose and date of the reopened claim. 38 C.F.R. § 3.400(r). An effective date prior to November 3, 2016, for the grant of service connection for PTSD is thus not warranted and the appeal is denied. Increased Rating Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Even if a rating is increased during the pendency of an appeal, a veteran is presumed to be seeking the highest possible rating, unless he expressly indicates otherwise. AB v. Brown, 6 Vet. App. 35, 39 (1993). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 6. An initial disability rating higher than 30 percent prior to December 15, 2015, and higher than 50 thereafter for PTSD with major depressive disorder In a rating decision dated in September 2013, the RO granted service connection for PTSD with a rating of 30 percent effective January 4, 2013. The Veteran has appealed for a higher initial rating and is specifically requesting a 100 percent rating for his PTSD. See Veteran's September 2013 Notice of Disagreement. In a rating decision dated in October 2016, the RO increased the rating to 50 percent effective December 15, 2015. The issue in this appeal is whether the Veteran's PTSD and associated symptoms caused the level of impairment required for an initial disability rating greater than 30 percent prior to December 15, 2015, and greater than 50 percent thereafter. The Veteran asserts that he suffers from nightmares, flashbacks, survivor's guilt, irritability, and memory loss, and is requesting a 100 percent rating for his symptoms. For the reasons that follow the Board concludes that the Veteran's symptoms did not cause the level of impairment required for an initial disability rating higher than 30 percent prior to December 15, 2015, and higher than 50 thereafter. 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 Veteran's PTSD is rated under the provisions at 38 C.F.R. § 4.130 (Diagnostic Code 9411), which provide for a 30 percent rating where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. The symptoms associated with the psychiatric rating criteria are not intended to constitute exhaustive lists, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Thus, the Board will consider whether "the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code," and, if so, the "equivalent rating will be assigned." Id. In Vazquez-Claudio v. Shinseki, the Federal Circuit held that a Veteran may only qualify for a given disability rating "by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." 713 F.3d 112, 117 (Fed. Cir. 2013) ("Reading [38 C.F.R. §§ 4.126 and 4.130] together, it is evident that the 'frequency, severity, and duration' of a Veteran's symptoms must play an important role in determining his disability level."). The Board notes that this appeal was first certified to the Board after the August 4, 2014, adoption of the DSM-5, so the DSM-IV is inapplicable, and the Board will not consider any GAF scores. See 80 Fed. Reg. 14308 (March 19, 2015). See also Golden v. Shulkin, 29 Vet. App. 221, 225 (2018) (holding that the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies). The evidence in this case for the relevant appellate timeframe (since the effective date of service connection) includes VA primary care records, which document the Veteran as denying feeling depressed or anxious. They also document the Veteran as denying thoughts of suicide or homicide. The evidence also includes the reports of two VA PTSD examinations; the first in August 2013, and the second in December 2015. During the August 2013 examination, the Veteran reported that he was married with children and grandchildren. He also reported that he had a good relationship with his sister and wife's side of the family, and also had "one good close friend." He stated that he read a lot, watched television with his wife, occasionally used the Internet, and regularly attended church. He also reported that he had seen a counselor at a VA Community Clinic in 1998 because he was always getting into arguments and fighting a lot with people. He added that he only saw the counselor about 3-4 times and has not seen anybody since then. Mental status examination found the Veteran to be fully alert and oriented to time, place, and person, although there was some anxiousness and the Veteran rarely laughed. Mood was depressed and affect was slightly in the constricted range. Speech was fluent and goal-directed, though often circumstantial. The Veteran's concentration, general knowledge, and abstraction skills were good, as was immediate, short-term, and long-term memory. There were no suicidal or homicidal thoughts, and no delusions or hallucinations. The diagnosis was PTSD, which the examiner categorized as mild. The examiner added "symptoms are not severe enough either to interfere with occupational or social functioning or to require continuous medication." In December 2015, the Veteran was afforded another VA PTSD examination, during which he reported that he that he was married and very active in his church. He also reported that he had not worked since his last PTSD evaluation in 2013. The examiner observed that the Veteran was "clearly depressed, and his depression is more dominant than a diagnosis of PTSD alone would indicate," and added that the Veteran "was frequently tearful as we talked." The examiner added that the Veteran's church involvement keeps him from becoming completely isolated; and reiterated that the Veteran "seems more depressed than he was at the time of his first PTSD examination two years ago." Clinical symptoms were identified as depressed mood; chronic sleep impairment; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner concluded that the Veteran's PTSD disability was productive of 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. Based on the totality of the evidence, the Board finds the Veteran's disability picture more closely approximated the criteria for a 30 percent rating prior to December 15, 2015; and has more closely approximately the criteria for a 50 percent rating since then. Prior to December 2015, there was depressed mood, anxiousness, and some anger issues, but overall impairment from the service-connected psychiatric disability was described as mild. Indeed, by the Veteran's own report he was married and engaged with his family and in his church, had at least one close friend, and was independent in his activities of daily living. This level of functioning comports at most with a rating of 30 percent under Diagnostic Code 9411. While the Veteran did experience some symptoms contemplated by a 50 percent rating, such as flattened affect and circumstantial speech, the evidence overall does not demonstrate the level of impairment associated with a 50 percent rating. Additionally, although not diagnosed by the 2013 examiner, even conceding the Veteran's subjective complaint of memory loss, the symptoms still do not support a higher rating, as memory loss is one of the symptoms within the 30 percentile criteria. Accordingly, the Board finds the Veteran's symptoms prior to December 15, 2015 more closely approximated the symptoms contemplated by a 30 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 50 percent rating. See 38 C.F.R. § 4.126. As for a rating higher than 50 percent since December 15, 2015, although the Veteran's symptoms in 2015 were pretty much the same as they were in 2013, the Board is mindful of the 2015 examiner's assertion that the Veteran's depression had noticeably worsened since his last examination; thus justifying the increase in rating to 50 percent. However, a rating higher than 50 percent is not warranted. There specifically is no evidence of the kinds of symptoms that would warrant an increase to the next higher rating of 70 percent, such as 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; spatial disorientation; neglect of personal appearance and hygiene; or inability to establish and maintain effective relationships. In this regard, the Board notes that quite a few of the Veteran's symptoms, i.e., anxiousness, chronic sleep impairment, depressed mood, and memory loss, are actually components of the 30 percentile rating criteria, but given the increase in severity of the depression component of the disability since the 2013 examination, finds that the increase in rating to 50 percent is not unreasonable. See 38 C.F.R. § 4.7. As for the Veteran's specific request for a 100 percent rating for his PTSD, the evidence does not show that the Veteran's PTSD has been productive of total psychiatric impairment at any time. On the contrary, the Veteran has been fully oriented and involved with his family, church, and friends, and independent in his activities of daily living, within the home and about, throughout the appeal period. There is no evidence of gross impairment in thought processes or communication; persistent hallucinations or grossly inappropriate behavior; disorientation to time or place; or memory loss for names of close relatives, own occupation or own name at any time during the appeal period. The Veteran's level of functioning is not reflective of total psychiatric impairment. The criteria for a maximum disability rating of 100 percent are therefore not met at any time during the appeal period. The Board accordingly finds that the Veteran's overall PTSD disability picture does not comport with the criteria for an initial rating higher than 30 percent prior to December 15, 2015 (during which time the Veteran's symptoms were regarded as mild); or higher than 50 percent since that time, as the nature and severity of the Veteran's PTSD symptoms has not resulted in occupational and social impairment with deficiencies in most areas. Although there clearly is functional impairment caused by the Veteran's PTSD, the Board finds that the preponderance of the evidence does not show the kinds of symptoms contemplated by a rating other than as presently assigned. The criteria for an initial disability rating for PTSD higher than 30 percent prior to December 15, 2015, and higher than 50 percent thereafter are thus not met and the appeal is denied. REASONS FOR REMAND 1. Service connection for bilateral hearing loss is remanded. 2. Service connection for tinnitus is remanded. The Veteran is requesting service connection for hearing loss and tinnitus (ringing in his ears), which he attributes to "the constant exposure to noise from artillery fire, small arms fire, enemy mortar and rocket fire (attacks) and noise from the Huey helicopters during daily missions" while in Vietnam. He maintains that he went to VA for treatment for his hearing loss and ringing in his ears shortly after his separation from service in 1970, but left before seeing a clinician and was not examined. He adds, "I have had a hearing loss and ringing in my head (ears?) since rotating back to the U.S. in 1969." Military records confirm that the Veteran served in Vietnam during the Vietnam war, and that he participated in two campaigns while in Vietnam. Additionally, in October 2016 the RO stated : "the Veteran's MOS was an Air Traffic Tower Operator which is a high probability of noise exposure." Whereupon, in November 2016 the Veteran was afforded a VA audiology examination. The diagnosis was left and right ear sensorineural hearing loss, which the examiner averred was less likely related to service "based on the objective evidence (enlistment and separation audiograms)." According to the examiner, "When comparing enlistment/induction testing in 1967 with separation testing in 1970, there are no significant changes/decreases in thresholds during active duty." Unfortunately, the examiner did not mention the other audiology testing conducted during service, such as the August 1967 audiology examination (which found right ear threshold of 40 decibels at 4000 Hertz). See Caffrey, 6 Vet. App. 377, 381 (holding that the examiner "must consider the records of prior medical examinations and treatment in order to assure a fully informed examination"). Additionally, and regarding the claim for tinnitus, the examiner said that the Veteran's tinnitus is less likely than not caused by or a result of military noise exposure because "there is no evidence of noise injury." However, the Veteran maintains, and the RO has acknowledged, that the Veteran had noise injury during service. The November 2016 examination is thus inadequate, and the Veteran should be afforded a new VA examination. 3. Service connection for a skin condition is remanded. The Veteran is also requesting service connection for skin rash, which he suggests may be due to Agent Orange exposure. During a March 2013 Agent Orange Review Consult he recalled having developed a rash to his arms and torso about 8 months after his return from Vietnam. STRs reveal that the Veteran had an outbreak of skin rash on his forearms and legs while in service. This was prior to the Veteran's departure for Vietnam. Additionally, the Veteran has a current rash disorder involving the scalp, arms, legs, trunk. However, the Veteran has not been afforded a VA examination. In addition to the foregoing, relevant treatment records have been associated with the claims file since the RO's February 2017 certification of the case to the Board, and on reviewing this evidence it appears that there may be extant private medical records. See VA medical records dated in January 2020, in which the provider noted that private dermatology records needed to be requested. After extant medical records have been obtained, the Veteran should be afforded a VA examination. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 4. Service connection for residuals of stroke as secondary to the service-connected disability of coronary artery disease is remanded. The Veteran is requesting service connection for stroke, which he maintains is secondary to his service-connected coronary artery disease. Treatment records confirm that he has had a stroke. On VA examination in September 2013, the examiner stated that the Veteran's stroke was not caused by his coronary artery disease. The examiner added that the Veteran's atrial fibrillation caused the stroke, and averred that the Veteran's coronary artery disease did not cause or aggravate his atrial fibrillation. However, the examiner did not advise as to whether the Veteran's stroke disorder is aggravated by his service-connected coronary artery disease. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013) (holding that assertions of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under § 3.310(b)). Remand for an addendum opinion is warranted. 5. An initial disability rating higher than 60 percent for coronary artery disease is remanded. In a rating decision dated in September 2013, the RO granted service connection for coronary artery disease with a rating of 60 percent effective August 22, 2011. The Veteran has appealed for a higher initial rating. He was last afforded a VA heart examination in July 2016. In February 2017 the case was certified to the Board. However, relevant medical records have been associated with the claims file since that time. Based on this additional evidence the Board finds that further development is warranted. In December 2019, the Veteran's treating VA cardiologist (Dr. C.J.P.) completed an Ischemic Heart Disease DBQ, in which he asserted that the Veteran has chronic congestive heart failure and an ejection fraction of < 20 percent. Dr. C.J.P. referred to an August 20, 2019 echocardiogram. However, the only such record in the claims file is an August 20, 2019 narrative echocardiogram report which actually pertains to a different person. The December 2019 Ischemic Heart Disease DBQ is consequently not sufficient for rating purposes. However, the record also contains other evidence which indicates that there may have been a material change in the Veteran's coronary artery disability since the July 2016 VA examination. Medical records dated in September 2019 indicate that the Veteran has undergone heart surgery since his 2016 VA examination. Additionally, treatment records dated before the July 2016 VA examination indicate that the Veteran had a history of congestive heart failure. See January 2016 VA Cardiology Consult report. In order to clarify the symptomatology and severity of the Veteran's coronary artery disease, a new examination is needed. See 38 C.F.R. § 3.327(a). 6. Entitlement to a TDIU is remanded. The Veteran also has a pending appeal for TDIU. The RO should re-adjudicate this matter after deciding the other remanded claims as this issue is inextricably intertwined with the resolution of the other issues being remanded here. The matters are REMANDED for the following action: 1. Schedule the Veteran for a new VA examination regarding the claim for service connection for hearing loss and tinnitus. The examiner must review the claims file and note that the claims file review took place. The examiner is asked to provide a response to the following: (a.) Whether the Veteran's bilateral hearing loss and/or tinnitus at least as likely as not (probability of 50 percent or greater) i. began during active service, ii. manifested within one year after discharge from service, or iii. is related to some incident of his active service, to include conceded loud noise exposure during service. The examiner should consider the Veteran's lay description of in-service noise exposure and focus specifically on whether the noise exposure in service caused the Veteran's hearing loss, or the Veteran's tinnitus. Facts and medical principles relied upon to arrive at an opinion should be set forth, and the examiner must discuss all audiology reports of record, including the August 1967 audiology examination results. In considering lay statements of record, the examiner should note that the Veteran is competent to attest to matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the clinician should provide a reasoned explanation. The examiner should consider all medical and lay evidence of record and offer a complete rationale for each opinion expressed. If the examiner concludes that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so should be provided. 2. Regarding the outstanding dermatology records discussed by VA treatment providers in January 2020, associate the Veteran's records from Forefront Dermatology with the claims file, to the extent they exist. Document all efforts to obtain these records. 3. After completion of step 2, schedule the Veteran for a VA examination regarding the issue of service connection for skin rash. The examiner must review the claims file. The examination should be done during a period of outbreak, if possible. The examiner is asked to provide a response to the following: (a.) Describe the area(s) of outbreak and characteristics of each current/recurrent skin condition and provide the diagnosis for each skin condition. (b.) Opine, for each current/recurrent skin condition, as to whether it is at least as likely as not (50/50 probability) that that the disorder i. began during active duty service. ii. is related to some incident of active duty service, including the Veteran's exposure to Agent Orange during service or his in-service treatment for rash outbreaks. In formulating this opinion, the examiner must discuss the skin rash that manifested and was treated during active duty service. See STRs dated in July 1967. In considering the Veteran's lay assertions, the examiner should note that the Veteran is competent to attest to matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a reasoned explanation. A discussion of the facts and the medical principles involved will be of considerable assistance to the Board. Any conclusions or opinions offered must be accompanied by a complete medical rationale, citing to established medical principles and relevant medical evidence, such as examination findings, service records, VA and private treatment records, or other pertinent evidence in the record to support the conclusions reached. If the examiner concludes that the requested opinion cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so should be provided. 4. Submit the issue of service connection for stroke for an addendum opinion. The examiner must review the claims file. The need for additional examination is left to the discretion of the examiner. The examiner is asked to provide a response to the following: Whether it is at least as likely as not (50/50 probability) that the Veteran's stroke condition is aggravated (worsened beyond natural progression) by the Veteran's service-connected coronary artery disability. A discussion of the facts and the medical principles involved will be of considerable assistance to the Board. Any conclusions or opinions offered must be accompanied by a complete medical rationale, citing to established medical principles and relevant medical evidence, such as examination findings, service records, VA and private treatment records, or other pertinent evidence in the record to support the conclusions reached. If the examiner concludes that the requested opinion cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so should be provided. 5. Schedule the Veteran for a new examination by an appropriate clinician to determine the current severity of his service-connected coronary artery disease. The examiner must report all signs and symptoms necessary for evaluating the Veteran's coronary artery disease under the rating criteria. 6. After completion of the above directives and any other necessary action, re-adjudicate all of the claims, including the pending appeal for TDIU. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Childers, 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.