Citation Nr: 21031168 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 19-25 076 DATE: May 20, 2021 ORDER Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for diabetes mellitus type II is remanded. Entitlement to service connection for diabetic retinopathy is remanded. FINDING OF FACT The evidence of record does not show that the Veteran's PTSD symptoms result in occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for an initial evaluation in excess of 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1965 to November 1967. This case is before the Board of Veterans' Appeals (Board) on appeal from a July 2018 rating decision by a Department of Veterans Affairs (VA) Regional Office. The Veteran's scheduled virtual hearing in April 2021 was cancelled. Subsequently, the Veteran submitted a written request to withdraw his previous hearing request. See April 26, 2021 Correspondence. Now the matters are before the Board. The Veteran is seeking for a higher initial evaluation for his service-connected PTSD. He is currently evaluated at 30 percent disabling for PTSD. A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). See generally 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practicably be determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. See 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2019). Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.27 (2019). VA has a duty to acknowledge and to consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. See Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). Where there is a question as to which of two ratings to apply, VA will assign the higher rating if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7 (2019). Otherwise, it will assign the lower rating. Id. PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. In pertinent part, a 50 percent is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; 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); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted 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; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2020). The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). On May 2018 VA examination, the examiner noted the Veteran's current diagnosis of PTSD under DSM-V criteria. The examiner provided that the Veteran's PTSD symptoms include anxiety, suspiciousness, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. The examiner observed that the Veteran's speech was within normal limits for rate and articulation, his affect was broad and appropriate, and his thought processes were clear, coherent, and goal-directed. The examiner noted that the Veteran denied auditory and visual hallucinations, and suicidal and homicidal ideations. The Veteran endorsed intense episodes of anxiety with palpitations, but denied experiencing full-blown panic attacks. The Veteran also denied any problems with post-military employment. The examiner reported that the Veteran teared up when talking about his PTSD symptoms and described his mood as being angry only to himself. The examiner concluded that the Veteran's PTSD results in occupational and social impairment due to mild or transient symptoms which decreases work efficiency and ability to perform occupational tasks only during periods significant stress, or symptoms controlled by medication. The Veteran's wife submitted a statement in May 2018. She provided that the Veteran is antisocial, does not trust anyone, and has mood shifts where he is very loving and kind, but then becomes very angry and picky for no good reason. Based on above, the Board finds that the evidence of record does not show that the Veteran's PTSD symptoms result in occupational and social impairment with reduced reliability and productivity, and his initial evaluation of 30 percent for his PTSD is appropriate. Although the May 2018 VA examiner noted the Veteran's difficulty in establishing and maintaining effective work and social relationships, the Board finds that the Veteran's current PTSD symptoms are predominantly reflected in the 30 percent evaluation criteria. Consequently, the Veteran's entitlement to an evaluation in excess of 30 percent for PTSD is not warranted. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2020). REASONS FOR REMAND The Veteran is also seeking service connections for diabetes mellitus type II and diabetic retinopathy. However, the Board finds that more development is necessary prior to final adjudication. The Veteran underwent a VA examination in May 2018 for diabetes mellitus; however, the examiner found that the Veteran does not have current diagnosis of diabetes. In this regard, the examiner provided that the Veteran most likely has impaired glucose tolerance per review of data from his private physician and the most recent blood test. However, the examiner failed to adequately explain why a diagnosis of diabetes was not warranted. The Board is unable to understand the examiner's basis for not finding a diabetes diagnosis since the examiner simply mentioned the glucose levels shown in the Veteran's bloodwork. Obtaining an adequate explanation for the current finding is particularly important in this case because the record contains a diabetes mellitus type II diagnosis provided by the Veteran's private medical provider. See March 2018 Diabetes Mellitus Disability Benefits Questionnaire (DBQ). As such, the Board finds that an addendum opinion to clarify the Veteran's current diabetes mellitus type II diagnosis must be obtained in order to make a fully informed decision. Further, because a decision on the remanded issue of service connection for diabetes mellitus type II could significantly impact a decision on the issue of service connection for diabetic retinopathy, the issues are inextricably intertwined. Thus, a remand of the service connection claim for diabetic retinopathy is also required. Accordingly, the matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) must obtain an addendum opinion from the May 2018 VA examiner regarding the Veteran's service connection claim for diabetes mellitus type II. If the May 2018 VA examiner is not available, the requested opinion with rationale should be rendered by another appropriate medical professional. If the examiner determines that a new examination is necessary, the AOJ should schedule one for the Veteran. The examiner should review the Veteran's claims file and a copy of this REMAND order before rendering the requested addendum opinion. (a.) The examiner is asked to clarify whether the Veteran has a current diagnosis of diabetes. The examiner should also address the diabetes mellitus type II diagnosis provided in the March 2018 diabetes mellitus DBQ report completed by the Veteran's private medical provider. (b.) The examiner must provide a complete written explanation/rationale for any findings or opinions offered. 2. After completing the above actions and any other necessary development, the issues on appeal must be readjudicated. If the claims remain denied, a Supplemental Statement of the Case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. E. Kim, 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.