Citation Nr: 22018591 Decision Date: 03/29/22 Archive Date: 03/29/22 DOCKET NO. 15-08 993A DATE: March 29, 2022 ORDER The August 1, 2019 Board of Veterans' Appeals (Board) decision is vacated. Entitlement to an effective date earlier than November 26, 2012, for the award of service connection for sensorineural hearing loss is denied. Entitlement to an effective date earlier than November 26, 2012, for the award of service connection for tinnitus is denied. Entitlement to an initial rating in excess of 20 percent prior to November 28, 2018, for sensorineural hearing loss is denied. Entitlement to an initial rating in excess of 10 percent for tinnitus is denied. Entitlement to a rating in excess of 50 percent prior to October 3, 2013, for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to a low back disability other than stooped posture/abnormal spine contour associated with Parkinson's disease with right upper extremity weakness is remanded. Entitlement to service connection for a sinus disability is remanded. Entitlement to a rating in excess of 40 percent for Parkinson's disease with right upper extremity weakness is remanded. Entitlement to a rating in excess of 60 percent for coronary artery disease is remanded. FINDINGS OF FACT 1. In not considering the Veteran's July 30, 2019 request that the Board wait the full 90 days from the date of a July 12, 2019 Board letter before issuing a decision, the Board denied the Veteran due process of law. 2. No communication was received from the Veteran prior to November 26, 2012, that reasonably can be interpreted as an informal or formal claim for entitlement to service connection for hearing loss. 3. No communication was received from the Veteran prior to November 26, 2012, that reasonably can be interpreted as an informal or formal claim for entitlement to service connection for tinnitus. 4. During the relevant period prior to November 28, 2018, the Veteran's sensorineural hearing loss was manifested by hearing acuity of no worse than Level IV in the right ear and no worse than Level VIII in the left ear. 5. Throughout the relevant period, the Veteran was in receipt of a rating of 10 percent for tinnitus, which is the maximum schedular rating for that disability, and all manifestations of the tinnitus were adequately considered under his schedular ratings. 6. During the relevant period prior to October 3, 2013, the severity, frequency, and duration of the Veteran's PTSD symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. Vacatur of the August 1, 2019 Board decision is warranted. 38 U.S.C. § 7104(a); 38 C.F.R. § 20.1000. 2. The criteria for entitlement to an effective date earlier than November 26, 2012, for the award of service connection for sensorineural hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5110; 38 C.F.R. §§ 3.155, 3.160 (2014); 38 C.F.R. §§ 3.102, 3.156(c), 3.159, 3.400. 3. The criteria for entitlement to an effective date earlier than November 26, 2012, for the award of service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5110; 38 C.F.R. §§ 3.155, 3.160 (2014); 38 C.F.R. §§ 3.102, 3.156(c), 3.159, 3.400. 4. The criteria for entitlement to an initial rating in excess of 20 percent prior to November 28, 2018, for sensorineural hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.85, Diagnostic Code 6100. 5. The criteria for entitlement to an initial rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.87, Diagnostic Code 6260. 6. The criteria for entitlement to a rating in excess of 50 percent for PTSD prior to October 3, 2013, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 1953 to October 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal of June 2013 and November 2013 rating decisions. The Veteran died in October 2021. The appellant is his surviving spouse and has been accepted as a substitute for purposes of continuing the appeals pending at the time of the Veteran's death. The Veteran was in receipt of schedular 100 percent ratings for PTSD from October 3, 2013, and for sensorineural hearing loss from November 28, 2018. Because a schedular 100 percent rating is the highest available benefit available for those disabilities, the Board has limited the associated issues as indicated on the first page of this decision. The appellant's representative has submitted arguments seeking an increased rating for diabetes mellitus, type II, and earlier effective dates regarding coronary artery disease, Parkinson's Disease, PTSD, and diabetes mellitus, type II. The rating decisions on appeal did not decide an issue regarding diabetes mellitus, type II. Therefore, the issues of entitlement to an earlier effective date and higher rating for diabetes mellitus, type II, are not part of this appeal. In addition, although the rating decisions on appeal did decide the Veteran's claims for increased ratings for coronary artery disease, Parkinson's Disease, and PTSD, they did not establish any sort of effective date in regard to those disabilities. Therefore, the issues of entitlement to earlier effective dates for coronary artery disease, Parkinson's Disease, and PTSD are also not part of this appeal. The Veteran submitted a timely notice of disagreement as to the effective dates assigned for the award of service connection for sensorineural hearing loss and service connection for tinnitus in the June 2013 rating decision. Following issuance of a statement of the case as to those issues in February 2015, the Veteran also submitted a timely substantive appeal as to those issues in March 2015. Therefore, those issues are on appeal before the Board at this time. Finally, a December 2019 rating decision granted entitlement to a total disability rating due to individual unemployability (TDIU) from November 8, 2010. The Veteran appealed the effective date for the award of a TDIU under the modernized review system, also known as the Appeals Modernization Act (AMA). In March 2022, the Board issued a decision on the AMA appeal remanding the issue to the agency of original jurisdiction (AOJ) for referral to the Director of Compensation Service for consideration of whether a TDIU was warranted prior to November 8, 2010, on an extraschedular basis under 38 C.F.R. § 4.16(b). The Board is cognizant that a claim for a TDIU, either expressly raised by the Veteran or reasonably raised by the record, is part of an appeal for an increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). However, in this decision the Board denies entitlement to increased ratings for sensorineural hearing loss, tinnitus, and PTSD, and the percentage requirements set forth in 38 C.F.R. § 4.16(a) remain unmet prior to November 8, 2010. Given that 38 C.F.R. § 4.16(b) requires that, in cases where the percentage requirements set forth in 38 C.F.R. § 4.16(a) are not met, the case must first be referred to the Director of Compensation Service and then adjudicated on an extraschedular basis by the AOJ in the first instance, and that such actions are currently underway, the Board does not accept jurisdiction of the remanded issue of entitlement to a TDIU prior to November 8, 2010, and will not consider the issue in this decision. Neither the appellant nor her representative has raised any issues with regard to the duty to notify or duty to assist as they pertain to the issues denied in this decision. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). The analysis in this decision focuses on the most relevant evidence and on what the evidence shows or does not show with respect to the issues denied in this decision. The Veteran should not assume that evidence that is not explicitly discussed in the decision has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000). Order to Vacate The Board issued a decision in this appeal on August 1, 2019. The Board may vacate an appellate decision at any time upon request of the appellant or his or her representative, or on its own motion, when a claimant has been denied due process of law or has been granted benefits based on false or fraudulent evidence. 38 C.F.R. § 20.904. In correspondence received by VA on July 30, 2019, prior to issuance of a decision, the Veteran's representative requested that the Board wait 90 days from the date of a July 12, 2019 Board letter before issuing a decision so that additional evidence and a brief in support of the appeal could be submitted. Although the correspondence was received on July 30, 2019, it was not associated with the record until after the Board issued the August 1, 2019 decision, and was therefore not considered by the Board prior to issuing that decision. The Board was required to consider the July 2019 request prior to issuing a decision. Because the Board did not do so, and to afford the Veteran due process of law, the August 6, 2019 Board decision is vacated. The record indicates that the appellant's representative, who was also the Veteran's representative prior to his death, presented a brief and evidence in response to the July 12, 2019 Board letter in October 2019. Therefore, the Board finds that the requested opportunity to support the appeal has been provided, and the issues on appeal may be adjudicated at this time. Effective date Issues 1. Entitlement to an effective date earlier than November 26, 2012, for the award of service connection for sensorineural hearing loss 2. Entitlement to an effective date earlier than November 26, 2012, for the award of service connection for tinnitus The appellant seeks entitlement to an effective date earlier than November 26, 2012, for the award of service connection for sensorineural hearing loss and tinnitus. Prior to his death, the Veteran did not present any arguments as to why earlier effective dates are warranted and did not suggest any other dates he believed to be more appropriate. The appellant has also not presented any particular contentions as to the issue. The effective date for an award 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 service. Otherwise, the effective date is the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a), (b); 38 C.F.R. § 3.400(b). Regulations that were in effect prior to March 24, 2015, required that an informal claim "must identify the benefit sought." See 38 C.F.R. §§ 3.155, 3.160 (2014). The regulations also provided that a claim may be either a formal or informal written communication "requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit." 38 C.F.R. § 3.1(p) (2014). The regulations in effect since March 24, 2015, require that claims be submitted on an application form prescribed by the Secretary and do not allow for informal claims not submitted on such a form. See 38 C.F.R. §§ 3.155, 3.160 (2015). The Board will apply the regulations in effect prior to March 24, 2015, to communications received during that period. Upon careful review of the record, the Board finds that the earliest communication received from the Veteran that could reasonably be construed as a request for a determination of entitlement, or that evidences a belief in entitlement, to service connection for hearing loss and tinnitus was received on November 26, 2012. The communications received prior to November 26, 2012, that may be interpreted as informal or formal claims for VA benefits do not specify hearing loss or tinnitus as a disability for which service connection or another VA benefit was sought. In particular, the Board notes that a VA Form 21-526, Veteran's Application for Compensation or Pension, received in November 2003 sought service connection benefits for "Diseases allowed by Title 38, CFR, section 3.303." In a December 2003 letter, the AOJ asked the Veteran to specify the disabilities for which he wanted to claim benefits. Later in December 2003, the Veteran indicated that he was seeking service connection for "diseases due to herbicides exposure". In a January 2004 letter, the AOJ again asked the Veteran to specify the disabilities for which he was seeking service connection, as exposure to herbicides itself is not a disability. In March 2004, the Veteran submitted a specific list of disabilities for which he was seeking service connection. That list does not include hearing loss or tinnitus. Thus, the November 2003 formal claim for service connection did not encompass hearing loss or tinnitus, and may not be considered a claim for such benefits. The earliest communication from the Veteran that suggests an intent to seek service connection for hearing loss or tinnitus is a VA Form 21-4138, Statement in Support of Claim, received on November 23, 2012, in which the Veteran describes a ringing in both ears and that he "couldn't hear a thing". In summary, an informal claim for entitlement to service connection for hearing loss and tinnitus was received on November 23, 2012. No communication was received from the Veteran prior to November 23, 2012, that reasonably can be interpreted as an informal or formal claim for entitlement to service connection for hearing loss or tinnitus. Therefore, November 23, 2012, is the appropriate effective date for the award of service connection for hearing loss and tinnitus. 38 C.F.R. § 3.400. The evidence for and against the appeal for earlier effective dates is not in approximate balance, but rather weighs against the appeal. Because there is not an approximate balance in the weight of the evidence, the doctrine of reasonable doubt is not for application, and the appeal must be denied. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Issues Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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 consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). 3. Entitlement to an initial rating in excess of 20 percent for sensorineural hearing loss prior to November 28, 2018 The appellant seeks an initial rating in excess of 20 percent for sensorineural hearing loss prior to November 28, 2018. The applicable rating period is from November 26, 2012, the effective date for the award of service connection for that disability, through November 27, 2018. See 38 C.F.R. § 3.400. Prior to his death, the Veteran did not present any particular contentions as to why a higher rating is warranted during that period. The appellant has also not presented any particular contentions as to the issue. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, Diagnostic Code 6100. To evaluate the degree of disability from bilateral service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). Turning to the evidence of record, a December 2012 VA examination reveals that the Veteran reported that he had difficulty understanding spoken words and phrases. He also reported difficulty understanding conversations through the telephone. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 40 35 45 50 42.5 72% LEFT 65 75 75 100 78.75 52% Applying the results to Table VI, the findings yield a numeric designation of Level IV in the right ear and Level VIII in the left ear. Entering the resulting bilateral numeric designation of Level IV for the right ear and Level VIII for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a rating of 20 percent under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was shown in the left ear. Applying the results for the left ear to Table VIA yields Level VII, which is less severe than the Level VIII obtained through Table VI. Thus, Table VI yields the highest rating for the left ear. Based on the evidence above, an initial rating in excess of 20 percent was not warranted for the Veteran's sensorineural hearing loss during the relevant period prior to November 28, 2018. The Board has considered the lay evidence of record when adjudicating this appeal, including the Veteran's report at the December 2012 VA examination that his sensorineural hearing loss made it difficult to understand spoken words and phrases and to communicate using a telephone. The Veteran was competent to report difficulty with his hearing; however, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran described is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran's main complaint was reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Rossy v. Shulkin, 29 Vet. App. 142, 145 (2017). The Board also acknowledges that a VA examination conducted on November 28, 2018, showed that the Veteran's sensorineural hearing loss had worsened to the point that he was entitled to a 100 percent rating and that the effective date for an increased rating depends on when a change in disability level can be ascertained and should not be assigned mechanically as of the date of an examination. See Swain v. McDonald, 27 Vet. App. 219, 224 (2015); see also 38 C.F.R. § 3.400(o). However, in this case the record does not show that the criteria for an initial rating in excess of 20 percent were met during the relevant period prior to the November 2018 VA examination. Therefore, a change in the disability level of the Veteran's sensorineural hearing loss cannot be ascertained at a date prior to the November 28, 2018 VA examination, and the 100 percent rating assigned as of that date cannot be assigned at an earlier date. Accordingly, the most probative evidence of record persuasively weighs against the claim for entitlement to an initial rating in excess of 20 percent for sensorineural hearing loss prior ot November 28, 2018. Because there is not an approximate balance in the weight of the evidence, the doctrine of reasonable doubt is not for application, and the appeal for a higher initial rating must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. 4. Entitlement to an initial rating in excess of 10 percent for tinnitus The appellant seeks an initial rating in excess of 10 percent for tinnitus. The applicable rating period is from November 26, 2012, the effective date for the award of service connection for that disability, through the date of the Veteran's death. See 38 C.F.R. § 3.400. Prior to his death, the Veteran did not present any particular contentions as to why a higher rating is warranted. The appellant has also not presented any particular contentions as to the issue. The Veteran told the December 2012 VA examiner that his tinnitus was bilateral, intermittent, and occurred six to seven times per day for a few seconds each episode. He stated that when the ringing sound is present, he would have to stop talking because he could not hear himself. He told the November 2018 VA examiner that his tinnitus was frequent, occurred almost every day, and bothered him in that he could not hear because of the ringing in his ears. In an April 2019 statement, the Veteran's daughter stated that the Veteran was "overwhelmed with his tinnitus" and "hardly hears us". The Veteran's tinnitus is rated under 38 C.F.R. § 4.87, Diagnostic Code 6260. Diagnostic Code 6260 provides a maximum schedular rating of 10 percent for tinnitus, whether the ringing is perceived as being in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note 2. Thus, the Veteran's tinnitus was assigned the maximum schedular rating available under 38 C.F.R. § 4.87, Diagnostic Code 6260, throughout the relevant rating period, and any appeal for a higher schedular rating must be denied. The Veteran did not raise, nor has the appellant or her representative raised, any other issues with regard to the rating for the service-connected tinnitus. In addition, no other such issues have been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017). The Veteran's tinnitus was manifested by a sound that the Veteran believed interfered with his hearing. Such symptoms are not exceptional or unusual for tinnitus. See Dorland's Illustrated Medical Dictionary 1930 (32nd ed. 2012) (defining tinnitus as "a noise in the ears, such as ringing, buzzing, roaring, or clicking."). He was compensated for the ringing sound through his rating for tinnitus and was compensated for difficulty hearing through his rating for sensorineural hearing loss. The Board therefore finds that the criteria for an initial rating in excess of 10 percent for tinnitus have not been met at any time during the rating period. Thus, the Board concludes that the evidence for and against the appeal is not in approximate balance, but rather weighs against the appeal. Because there is not an approximate balance in the weight of the evidence, the doctrine of reasonable doubt is not for application, and the appeal must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. 5. Entitlement to a rating in excess of 50 percent for PTSD prior to October 3, 2013 The appellant seeks a rating in excess of 50 percent for the Veteran's PTSD prior to October 3, 2013. The applicable rating period is from October 3, 2012, one year prior to receipt of the claim, through October 2, 2013. See 38 C.F.R. § 3.400(o)(2). Prior to his death, the Veteran did not present any particular contentions as to why a higher rating is warranted during that period. The appellant has also not presented any particular contentions as to the issue. For an increased rating to be awarded during the one-year period prior to the claim, the evidence must show that an increase in disability during that period was factually ascertainable. 38 C.F.R. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). For that purpose, the evidence must show that the increase in disability was sufficient to warrant a higher rating under the rating criteria. Hazan v. Gober, 10 Vet. App. 511, 519 (1992). Thus, determining the proper date for an increased rating requires (1) a determination of the date of the receipt of the claim for the increased rating and (2) a review of all the evidence of record for the one year prior to the date of the claim to determine when an increase in disability was "factually ascertainable" in terms of meeting or approximating the criteria for a higher rating. See id. at 521. In determining when an increase is "factually ascertainable", VA should look to the record as a whole, including testimonial evidence and expert medical opinions, to determine when the increase took place. VAOPGCPREC 12-98 at 5. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher. The Veteran's symptoms more closely approximated the symptoms associated with a 50 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. 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 for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. Turning to the evidence of record, at an April 2011 VA examination, the Veteran's wife reported that the Veteran had become irritable lately and had difficulty sleeping at night. The Veteran reported a good interpersonal relationship with his wife and with his two adult children. However, he mostly stayed at home due to his Parkinson's disease, and therefore his social relationships only involved his wife and their household companions. He reported spending his time mostly sitting in a chair and "reading everything from newspapers and reader's digest" and watching television. He denied a history of violence, assaultiveness, or suicide attempts. The examiner noted that although the Veteran was clean and casually dressed, he was also chronically ill looking and had psychomotor retardation and depressed mood. The Veteran performed serial 7s with two mistakes and was able to spell "America" forward but not backward. He was intact to person, place, and time; his thought process and content were unremarkable; and he was able to appropriately interpret proverbs. He reported sleep disturbance in the form of initial and early waking insomnia due to nightmares. He also reported panic attacks at least three times per week, particularly since stopping his Parkinson's disease medication. However, he denied homicidal or suicidal thoughts, and reported good impulse control. On testing, his recent and remote memory were mildly impaired, and his immediate memory was moderately impaired. He had difficulty retrieving significant data and dates about his life, was unable to recall what he ate the previous night, and he had prolonged retrieval time for his immediate recall. He reported PTSD symptoms of intrusive thoughts and recollections; avoidance of things that arouse recollections of trauma; hypervigilance; exaggerated startle response; outbursts of anger; difficulty concentrating; and being paranoid of others. The examiner opined that the Veteran's cognitive decline is age-related and not related to the service-connected PTSD. In an October 2019 statement, the Veteran's daughter reported that the Veteran "hardly expresses his love in action and never with words". She described him as not participating in the household and instead leaving parenting and chores to his wife. He rarely talked. When he did talk, his time in the Navy was his main and sole story. When he recounted in-service hardships and trauma, his stories were "so vivid like it's happening in the present". He also had erratic sleeping patterns and would wake up cold, sweaty, and restless from nightmares. He had heated argument with his wife in the 1990s. He would stay in his room and preferred to eat by himself. She stated, "I don't know of dad ever having a friend." The Veteran also rarely attended events. When he did attend events, he would soon ask to go back home and "find his peace settled for hours in his room." Although the April 2011 VA examination was conducted prior to the relevant rating period and the October 2019 statement was provided well after that period, the Board finds those items of evidence pertinent in determining whether it was factually ascertainable that there was an increase in disability occurred during the one-year period prior to the claim such that an increased rating was warranted during that period. See VAOPGCPREC 12-98 at 5. The Board finds the relevant evidence does not show that it was factually ascertainable that the Veteran's PTSD increased in severity during the one-year period prior to the October 3, 2013 claim such that a rating in excess of 50 percent was warranted during that period. The severity, frequency, and duration of the Veteran's symptoms during that period, as suggested by the April 2011 VA examination and by the October 2019 statement from the Veteran's daughter, more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. See 38 C.F.R. § 4.126. Specifically, the evidence indicates that the Veteran had sleep disturbance from nightmares, depressed mood, suspiciousness, panic attacks more than once per week but not near-continuously, disturbances in motivation and mood due to PTSD symptoms, mild memory loss, irritability without a history of violence or assaultiveness, and difficulty (but not inability) in establishing and maintaining effective relationships. Such symptoms are consistent with the criteria for a 30 percent or 50 percent rating under 38 C.F.R. § 4.130. Neither the appellant nor her representative has raised any other issues with regard to the rating for the service-connected PTSD, nor have any other such issues been reasonably raised by the record. See Yancy, 27 Vet. App. at 495; Doucette, 38 Vet. App. at 369-70. The Board therefore finds that the criteria for a rating in excess of 50 percent for PTSD prior to October 3, 2013, have not been met. The evidence for and against the claim is not in approximate balance, but rather weighs against the claim. Because there is not an approximate balance in the weight of the evidence, the doctrine of reasonable doubt is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. REASONS FOR REMAND 1. Entitlement to a low back disability other than stooped posture/abnormal spine contour associated with Parkinson's disease with right upper extremity weakness is remanded. In a March 2019 rating decision, the AOJ granted the Veteran service connection and a separate rating for stooped posture/abnormal spine contour related to his service-connected Parkinson's disease. It is unclear whether the Veteran's diagnosed degenerative disc disease of the lumbar spine may have also been secondary to his Parkinson's disease or may have been secondary to the service-connected stooped posture/abnormal spine contour. The Board cannot make a fully-informed decision on the issue because no VA examiner has opined whether such an etiological relationship exists. The issue is therefore remanded so that such an opinion may be obtained. 2. Entitlement to service connection for a sinus disability is remanded. The Veteran's service treatment records show that on a January 1966 medical examination for extension of active service, his nose was found to be abnormal for hypertrophic turbinates with boggy cyanic mucosa. It is unclear whether the Veteran's sinus problems had their onset during his active service or were otherwise related to an in-service event, injury, or disease, to include the abnormal findings noted on the January 1966 medical examination. The Board cannot make a fully-informed decision on the issue because no VA examiner has opined whether such an etiological relationship exists. The issue is therefore remanded so that such an opinion may be obtained. 3. Entitlement to a rating in excess of 40 percent for Parkinson's disease with right upper extremity weakness is remanded. 4. Entitlement to a rating in excess of 60 percent for coronary artery disease is remanded. Additional evidence, to include VA treatment records obtained by VA, has been received since the AOJ's most recent adjudication of this appeal in an April 2019 supplemental statement of the case. Some of those records are relevant to the issues of entitlement to higher ratings for the service-connected Parkinson's disease and coronary artery disease. The issues must be remanded so that the AOJ may consider the additional evidence in the first instance and issue a supplemental statement of the case. See 38 C.F.R. §§ 19.37, 20.1305(c). The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate clinician regarding whether the Veteran's diagnosed degenerative disc disease of the lumbar spine was at least as likely as not (50 percent probability or greater) proximately due to or aggravated beyond its natural progression by service-connected disability, to include the service-connected Parkinson's disease and the stooped posture/abnormal spine contour, which was determined to be associated with the service-connected Parkinson's disease. 2. Obtain an opinion from an appropriate clinician regarding whether the Veteran's claimed sinus problems at least as likely as not (50 percent probability or greater) had their onset during the Veteran's active service or were otherwise related to an in-service event, injury, or disease. The examiner must discuss the January 1966 medical examination for extension of active service in which the Veteran's nose was found to be abnormal for hypertrophic turbinates with boggy cyanic mucosa. In that regard, the examiner should address whether there is any medical reason to accept or reject the proposition that the January 1966 findings marked the onset of the Veteran's post-service sinus problems or were the cause of the post-service sinus problems. 3. Review the expanded record, including the evidence entered since the April 2019 supplemental statement of the case, and determine whether the benefits sought may be granted. If any benefit sought remains denied, furnish the appellant and her representative with a supplemental statement of the case. Allow a reasonable period for response before the appeal is returned to the Board. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. J. Anthony, 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.