Citation Nr: 21032551 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 14-10 597 DATE: May 27, 2021 ORDER Entitlement to an initial 70 percent rating, but no more, for a mood disorder not otherwise specified (also claimed as posttraumatic stress disorder (PTSD) and depression), prior to February 7, 2019, is granted. Entitlement to a rating in excess of 70 percent for a mood disorder not otherwise specified (also claimed as PTSD and depression) is denied. Entitlement to service connection for bilateral hearing loss is denied. REMANDED Entitlement to an initial rating in excess of 10 percent for right knee meniscal tear, status post meniscectomy, with degenerative arthritis, now rated as right knee replacement prior to November 16, 2017 and entitlement to a rating in excess of 60 percent since February 1, 2019 is remanded. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Prior to February 7, 2019, the Board finds that the Veteran's mood disorder not otherwise specified (also claimed as PTSD and depression) resulted in occupational and social deficiencies in most areas. 2. For the entire appeal period, the Board finds that the Veteran's mood disorder not otherwise specified (also claimed as PTSD and depression) has not resulted in total occupational and social impairment. 3. The Veteran does not have bilateral hearing loss for VA purposes at any time during the current appeal. CONCLUSIONS OF LAW 1. Prior to February 7, 2019, the criteria for an initial rating of 70 percent rating, but no higher, for a mood disorder not otherwise specified (also claimed as PTSD and depression), have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9435. 2. For the entire period on appeal, the criteria for a rating in excess of 70 percent for a mood disorder not otherwise specified (also claimed as PTSD and depression) have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, DC 9435. 3. The criteria for service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1978 to July 1992. The Veteran testified before the undersigned Veterans Law Judge in April 2017. A copy of the transcript is of record. This case was originally before the Board in January 2018, when the claims listed above were remanded for further development. Additional claims for entitlement to service connection for a low back disability and entitlement to service connection for a left knee disability were remanded for further development. In April 2020, the RO granted service connection for a lumbosacral strain, degenerative arthritis, and intervertebral disc syndrome and also for a left knee meniscal tear, status post meniscectomy, with degenerative arthritis. These issues are no longer in appellate status. Additional development was completed with respect to the Veteran's remaining claims. The RO issued a supplemental statement of the case in April 2020 and the appeal is once again before the Board. The Veteran indicated in a September 2020 Appellate Brief that he wanted another Board hearing. Pursuant to Quinn v. Wilkie, 31 Vet. App. 284 (2019), a veteran may have a second hearing following a Board remand. An April 2021 letter was sent to the Veteran to confirm whether he wanted an additional hearing. In a May 2021 letter, the Veteran withdrew this request for an additional hearing. Therefore, the Board may proceed with adjudication of the claims at this time without an additional hearing. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 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. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Board should consider only those factors contained in the rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating 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 also consider entitlement to staged ratings to compensate for times since filing the claims when the disabilities may have been more severe than at other times during the course of the claims on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). 1. Entitlement to an initial rating in excess of 50 percent for a mood disorder not otherwise specified (also claimed as PTSD and depression), prior to February 7, 2019. 2. Entitlement to a rating in excess of 70 percent for a mood disorder not otherwise specified (also claimed as PTSD and depression) since February 7, 2019. The Veteran's mood disorder not otherwise specified (also claimed as PTSD and depression), is currently rated as 50 percent disabling prior to February 7, 2019, and 70 percent disabling since February 7, 2019, in accordance with the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. Under Diagnostic Code 9435, a 50 percent rating is warranted when there is occupational and social impairment, but with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, 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 task); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9435. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. The maximum rating of 100 percent requires 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; and memory loss for names of close relatives, own occupation, or own name. Id. The specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Thus, the analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The classification outlined in the portion of VA's Schedule for Rating Disabilities that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-5). 38 C.F.R. § 4.130. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996). Effective August 4, 2014, the DSM-IV was superseded by a new fifth edition that significantly changed diagnostic metrics for mental illnesses. In pertinent part, the DSM-5 eliminated the GAF scores used in the DSM-IV. It was recommended that the GAF be dropped from DSM-5 for several reasons, including its lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. A review of the evidence reflects that a rating of 70 percent is warranted throughout the appeal period. At a March 2011 VA Mental Intake Assessment, it was noted that the Veteran's appearance was neat, and he was friendly and cooperative. His memory function was described as normal and his affect was appropriate. In a February 2014 addendum it was noted that the Veteran reported auditory and visual hallucinations beginning around November 2013, however no additional information as provided about these reported symptoms. An April 2011 Vet Center evaluation reflects that the Veteran experiences major and long-standing problems with sleep disturbance, nightmares, near continuous anxiety, panic attacks, severe depression, outburst of anger, impaired impulse control, social isolation, difficulty adapting to stressful circumstances, a history of cocaine abuse, intrusive thoughts and memories of combat events and maintaining effective relationships. In an August 2011 VA examination, the examiner noted that Veteran's symptoms included anxiety, suspiciousness, a chronic sleep impairment, mild memory loss, flattened effect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, and suicidal ideation. In an August 2012 VA treatment visit the Veteran denied suicidal and homicidal ideation, except for brief passing thoughts of harm to others when angered. In a January 2014 VA treatment visit the Veteran reported having suicidal ideation but denied any intent. In an April 2014 letter from the Veteran's VA treating psychiatrist it was noted that he had PTSD complicated by secondary depression and has vivid nightmares and flashbacks including auditory hallucinations of children screaming. She noted that the Veteran's antidepressant medication has been modified and augmented to address depression, and an antipsychotic had to be added for hallucinatory flashbacks. His psychosocial and occupational functioning was noted to be markedly impaired with periodic episodes of inability to report to work or even to leave his home due to exacerbation of PTSD and depressive symptoms. In a May 2014 Vet Center Treatment Summary, it was noted that the Veteran was experiencing auditory and visual hallucinations of combat events. It was noted that these symptoms, in addition to other symptoms, have been profoundly challenging to the Veteran and have been sufficiently severe that he has had to miss work on several occasions. He reported persistent suicidal ideation that constitutes a persistent danger to himself. He reported that he is no longer able to sustain gainful employment due to his service-connected disabilities and he has been counseled about his work performance by his supervisor. It was noted that it was in his professional opinion that the Veteran is not able to sustain gainful employment. In a June 2014 Private Psychological Assessment Report, it was noted that the Veteran has no social life and keeps the windows in his apartment covered. It was noted that his ability to work has been assisted by the prescription of psychotropic medications. The Veteran reported having had many jobs and being terminated from jobs. He reported that he assists in the caretaking of his six-year-old son. He reported being very depressed in the past and self-medicating with cocaine to try and snap out of his depression. He reported frequent suicidal ideation but denies that he would act on it because of his spiritual beliefs and his son. He reported that he sees things sometimes, as a possible visual hallucination. It was noted that he was anxious, and tense and his social judgment was poor. His life was noted to be severely constricted by his psychological turmoil. Under stress it was noted that he is prone to be self-critical and pessimistic and his highest score is for that measuring suicidal ideation. An April 2014 VA treatment record noted suicidal ideation and auditory hallucinations about 3-4 times a week. At the Veteran's April 2017 BVA hearing, he testified that he did not have patience and snaps. See BVA Hearing Transcript (T.) at 21. The Veteran reported a lot of anger issues. See Id. The Veteran testified that he has no friends. See BVA Hearing T. at 28. Following a review of the evidence, prior to February 7, 2019, to include the statements of the Veteran and treatment records, the Board finds that the Veteran's mood disorder not otherwise specified (also claimed as PTSD and depression), has been most consistent with a 70 percent disability rating, not the 50 percent disability rating currently assigned (prior to February 7, 2019). Although some treatment records appear to reflect milder psychiatric symptomatology, the majority of the treatment records are most consistent with a 70 percent disability rating. Accordingly, and based on these findings, the Board finds that a 70 percent rating is warranted, throughout the period on appeal, prior to February 7, 2019. Nevertheless, the Board finds that a rating in excess of 70 percent is not warranted for any period during the pendency of the claim, prior to February 7, 2019, as the Veteran's symptomatology does not manifest as total occupational and social impairment, due to such symptoms as (for example only): 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. Id. Prior to February 7, 2019, the Veteran's reported social functioning has been fairly consistent, with social isolation and some interaction. Thus, while limited, he was still able to continue relationships with some people, including some family members. VA treatment reports show that the Veteran maintains a relationship with his son and girlfriend/partner. There are also indications that the Veteran worked during this period. Additionally, although some hallucinations and suicidal ideation have been reported and a social worker indicated that they were persistent, the evidence overall does not reflect that the hallucinations and/or suicidal ideations were persistent in nature. At times, the Veteran denied experiencing suicidal and/or homicidal ideation and hallucinations. Also, the medical reports frequently show that the Veteran was oriented to time and place. The record also does not show that he was unable to perform activities of daily living. Further, the Veteran's own reports at various evaluations regarding how his mood disorder not otherwise specified (also claimed as PTSD and depression), impact him, overall, would provide additional evidence against this claim, indicating the level of symptomatology cited within the 100 percent rating have not been met at any point during the period on appeal. A rating of 100 percent is only warranted for both total social and total occupational impairment due to his mood disorder not otherwise specified (also claimed as PTSD and depression). The Board concludes the criteria for a 100 percent rating for mood disorder not otherwise specified (also claimed as PTSD and depression) have not been met at any point during the period on appeal. 38 C.F.R. § 4.130, DC 9435. The Veteran most recently underwent a VA examination in February 2019. The VA examiner characterized his mental disorder as resulting in occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking and/or mood. His symptoms were noted to include depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, impaired judgment, disturbances of motivation and mood, circumstantial circumlocutory or stereotyped speech, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a work like setting, inability to establish and maintain effective relationships, suicidal ideation, obsessional rituals which interfere with routine activities, impaired impulse control and intermittent inability to perform activities of daily living. Again, although the evidence reflects some symptomatology found in the 100 percent criteria; for example, a single notation of the inability to perform activities of daily living, most recently noted in the February 2019 VA examination, the evidence as a whole is not consistent with total occupational and social impairment. As noted, although some auditory and visual hallucinations are noted sporadically in the record, the medical reports do not support a finding that they are persistent in nature. In fact, in the February 2019 VA examination report, symptoms of persistent hallucinations and suicidal ideation, gross impairment in thought processes or communication, persistent danger of hurting self or others, and disorientation to time or place were not noted. Further, regarding an inability to perform activities of daily living, the examiner explained that the activities of daily living were intact, but the Veteran experienced severe difficulties with joining community activities, walking long distances, interacting with others he doesn't know, talking care of household activities, and maintaining friendships. Also, while the Veteran indicated that he has had an estranged relationship with his son and a volatile relationship with his girlfriend, the record shows that he has maintained some relationships, to include a granddaughter whom he tries to maintain a relationship with. While the Veteran has been significantly socially limited by his service-connected mood disorder not otherwise specified (also claimed as PTSD and depression), the evidence fails to show that his impairment was "total" so as to warrant a 100 percent rating, at any point during the period on appeal. Based on the foregoing discussion, the Board finds that Veteran's mood disorder not otherwise specified (also claimed as PTSD and depression), more nearly approximates the rating criteria for a 70 percent for the entire period on appeal. As such, a rating of 70 percent is granted prior to February 7, 2019, but a rating in excess of 70 percent is not warranted at any time during the period on appeal. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden elements is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Finally, 38 U.S.C. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Specifically, "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 3. Entitlement to service connection for bilateral hearing loss. To establish the presence of hearing loss for VA compensation purposes, the Veteran has to show his hearing loss constitutes a disability by proffering evidence that the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 40 decibels or greater; or at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels or greater; or when speech recognition scores are less than 94 percent (Maryland CNC Test). 38 C.F.R. § 3.385. The Board points out that the absence of in-service evidence of hearing loss is not fatal to a claim for service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability (i.e., one meeting the requirements of 38 C.F.R. § 3.385) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). To establish service connection, the Veteran is not obliged to show that his hearing loss was present during active military service. However, if there is insufficient evidence to establish that a claimed chronic disability was present during service, the evidence must establish a nexus between his current disability and his in-service exposure to loud noise. Godfrey v. Derwinski, 2 Vet. App. 352 (1992). At the outset, the Board concedes in-service noise exposure. The Veteran has already been granted service connection for tinnitus. At a March 2015 VA examination, objective findings revealed that the Veteran's pure tone thresholds, in decibels, for the right ear were 25, 20, 20, 10 and 25, measured at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Speech recognition ability was 100 percent in the right ear. Objective findings revealed that the Veteran's pure tone thresholds, in decibels, for the left ear were 25, 25, 20, 25 and 30, measured at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Speech recognition ability was 96 percent in the left ear. A June 2017 VA audiological clinic note reflects what appears to be elevated hearing thresholds and complaints by the Veteran of difficulty hearing in some situations. However, it is unclear if the Maryland CNC Test was used to determine speech recognition scores, as required by 38 C.F.R. § 4.85(a), and little probative value is accorded to these June 2017 findings. Nevertheless, the Veteran was afforded a subsequent February 2019 VA examination. Objective findings revealed that the Veteran's pure tone thresholds, in decibels, for the right ear were 20, 15, 15, 15, and 25, measured at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Speech recognition ability was 94 percent in the right ear. Objective findings revealed that the Veteran's pure tone thresholds, in decibels, for the left ear were 15, 15, 15, 25 and 25, measured at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Speech recognition ability was 94 percent in the left ear. In order to warrant service connection, the threshold requirement is competent medical evidence of the existence of the claimed disability at some point during a veteran's appeal. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that the requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim... even though the disability resolves prior to the Secretary's adjudication of the claim"); Degmetich v. Brown, 104 F.3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). While the Board recognizes the Veteran's sincere belief in his bilateral hearing loss claim and description of his symptoms, the most competent medical evidence of record does not show that the Veteran has a bilateral hearing loss disability for VA compensation purposes during any period of his appeal. Indeed, as noted above, according to the objective evidence of record, the pure tone thresholds do not demonstrate sensorineural hearing loss in either ear as defined by VA regulations at any point during the appeal period. Here, the VA examination findings for either ear do not demonstrate disability, as the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is not 40 decibels or greater; the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are not 26 decibels or greater; and speech recognition scores using the Maryland CNC Test are not less than 94 percent. 38 C.F.R. § 3.385. In this case, the question of whether there is an actual hearing loss disability is answered by audiometric testing, and not by lay diagnosis, or even the diagnosis of the examiner administering the testing. By regulation, VA defines what constitutes hearing loss, and does so by reference to audiometric findings and speech recognition scores. The fact that diagnostic testing is required to establish the requisite level of impairment to legally constitute hearing loss renders lay opinions concerning the presence of hearing loss incompetent. In other words, the Veteran is not competent to diagnose himself with hearing loss. Consequently, in light of the findings of the VA examinations showing that the Veteran does not have a current bilateral hearing loss disability for VA compensation purposes, the Board concludes that the Veteran's statements and opinions as to diagnosis and etiology are of no probative value. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). As there is no competent evidence of a bilateral hearing loss disability, the Board concludes that the preponderance of the evidence is against granting service connection. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim for entitlement to service connection for bilateral hearing loss must be denied. See 38 U.S.C. § 5107(b); see generally Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). REASONS FOR REMAND Further evidentiary development is required prior to reviewing the issues remaining on appeal. 1. Entitlement to an initial rating in excess of 10 percent for right knee meniscal tear, status post meniscectomy, with degenerative arthritis, now rated as right knee replacement prior to November 16, 2017 and entitlement to a rating in excess of 60 percent since February 1, 2019. The Veteran's increased rating claim for his right knee disability was most recently remanded in January 2018 by the Board so that the Veteran could be afforded another VA examination. The Veteran was most recently provided a VA examination for his right knee in February and March 2019. Treatment records also associated with the claims file on remand reflect that the Veteran was scheduled to undergo an additional surgery on his right knee in May 2020, following his most recent VA examination. A December 2019 VA treatment record noted the Veteran's complaints of right knee pain and that he had loose prosthetics of the right knee. The treating practitioner noted that the Veteran was scheduled for right knee surgery in the near future and needed to have a cardiac clearance done. The Veteran reported a pain level of 10 out of 10 in severity and that it worsened with movement. A January 2020 VA treatment records reflected that the Veteran had right knee pain with a pending knee replacement in May 2020. If completed, this surgery may in some way have changed the nature of the disability. Thus, a new examination should be afforded to the Veteran. Recent medical reports, to include reports generated from this surgery, should also be obtained. 2. Entitlement to a TDIU. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a TDIU claim is part of an increased rating claim when such claim is reasonably raised by the record. The Board finds that the issue of entitlement to a TDIU has been reasonably raised by the record (see May 2014 Vet Center Treatment Summary) and is properly before the Board by virtue of the Veteran's increased rating claims pursuant to Rice. Veterans Claims Assistance Act of 2000 (VCAA) notice should be provided to the Veteran. The record is unclear as to the employment status of the Veteran. Although, VA treatment records reflect the Veteran may be employed it is not certain this is the case. Further development is necessary prior to adjudication of this claim and it is therefore remanded. The matters are REMANDED for the following actions: 1. Provide the Veteran with notice in compliance with the VCAA that notifies him of what evidence he must show to support a claim for a TDIU. Also, ask the Veteran to complete and return a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. 2. Obtain all relevant outstanding VA treatment reports and associate them with the claims file. 3. Schedule the Veteran for VA examination to determine the nature and severity of his service-connected right knee disability. The Veteran's claims file must be provided to the examiner, who must obtain a detailed clinical history from the Veteran and must note all pertinent pathology found on examination in the reports of evaluation. Any testing deemed necessary should be performed. The examiner must provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's service-connected right knee disability under the applicable rating criteria. The examiner must comment on the functional effects of the disability evaluated. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. M. Clark, 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.