Citation Nr: 1436838 Decision Date: 08/18/14 Archive Date: 08/27/14 DOCKET NO. 11-20 228 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Fort Harrison, Montana THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for disability exhibited by insomnia, to include as secondary to PTSD. 3. Entitlement to service connection for disability exhibited by acid reflux, to include as secondary to PTSD. 4. Entitlement to a higher initial rating for posttraumatic stress disorder (PTSD), currently rated as 70 percent disabling. 5. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant, C.B. ATTORNEY FOR THE BOARD C. D. Simpson, Counsel INTRODUCTION The Veteran had active duty service from August 1968 to August 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2010 and January 2011 rating decisions by the Regional Office (RO) of the Department of Veterans Affairs (VA) in Fort Harrison, Montana. These decisions assigned an initial rating of 50 percent for PTSD and denied service connection for insomnia, hypertension, erectile dysfunction, and irritable bowel syndrome. The Veteran timely appealed. The Veteran had a September 2011 RO hearing before a Decision Review Officer (DRO). The hearing transcript is of record. In October 2012, the RO awarded service connection for erectile dysfunction. As this rating action results in a complete grant of the benefit sought, this issue is no longer on appeal. In May 2013, the RO awarded an initial 70 percent disability rating for PTSD and granted service connection for irritable bowel syndrome. Although the appealed rating decisions do not reflect a separate TDIU claim, the issue is part of the initial PTSD disability rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran's actions show a clear desire to pursue the claim despite withdrawing an appeal for a higher initial rating for PTSD. It remains on appeal. Also for clarification, the Veteran has repeatedly characterized his sleep disorder as insomnia and it was developed as such. See July 2011, September 2012, and January 2012 Veteran statements. During the course of the appeal, he was also diagnosed with sleep apnea. His statements during the pendency of the appeal raise the matter of service connection for sleep apnea. This matter has not been considered by the RO and consequently, the Board does not have jurisdiction over it. It is REFERRED to the RO for appropriate action. The Veteran was afforded a June 2013 hearing before the undersigned. The hearing transcript found within the Virtual VA electronic folder (efolder). Review of the Virtual VA efolder also shows updated VA treatment records. No pertinent evidence is found within the Veterans Benefits Management System (VBMS) efolder at this time. The issue of entitlement to TDIU is REMANDED to the Agency of Original Jurisdiction (AOJ) and addressed the REMAND section below. VA will notify the appellant if further action is required. FINDINGS OF FACT 1. Hypertension did not have its clinical onset in service and is not otherwise related to active duty or a service-connected disability; hypertension was not exhibited within the first post service year. 2. The Veteran is service connected for PTSD; the persuasive evidence does not show disability exhibited by insomnia apart from chronic sleep impairment contemplated in the currently assigned rating for PTSD. 3. On June 24, 2013, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that a withdrawal of the appeals for service connection for acid reflux and higher initial rating for PTSD is requested. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension are not met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 4.104, Diagnostic Code 7101 (2013). 2. The criteria for service connection for disability exhibited by insomnia are not met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310, 4.14, 4.130, Diagnostic Code 9411 (2013). 3. The criteria for withdrawal of an appeal by the appellant for service connection for disability exhibited by acid reflux have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2013). 4. The criteria for withdrawal of an appeal by the appellant for a higher initial rating for PTSD have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawal of appeals The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2013). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the appellant has withdrawn the appeals for service connection for disability exhibited by acid reflux and a higher initial rating for PTSD and, hence, there remain no allegations of errors of fact or law for appellate consideration on these issues. Accordingly, the Board does not have jurisdiction to review these issues on appeal and they are dismissed. II. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2013), provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. It also requires VA to notify the claimant and the claimant's representative of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between an appellant's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board finds that all notification and development action needed to arrive at a decision as to the claims of service connection have been accomplished. Through a November 2010 notice letter, the Veteran was notified of the information and evidence needed to substantiate his claims. The letter advised the Veteran of the information already in VA's possession and the evidence that VA would obtain on his behalf, as well as of the evidence that he was responsible for providing to VA, to include private medical evidence. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)). He was also informed about the general criteria for how VA assigns disability ratings and effective dates. A remand for further notification of how to substantiate the claims is not necessary. Regarding the duty to assist, the Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate his claims. The evidence includes service treatment records, VA treatment records, private medical records, and statements from the Veteran. Social Security Administration (SSA) records are not available. However, the references to SSA record suggest an orthopedic disability as the disabling condition; rather than psychiatric or hypertension disability. See September 2012 Veteran statement; June 2013 hearing transcript. The SSA records are not necessary for these claims. Golz v. Shinseki, 590 F.3d 1317, 1323 (2010). The Veteran had September 2010, December 2010, and September 2012 VA PTSD examinations. He had a September 2012 VA sleep apnea examination. As detailed below, his insomnia reports are considered to be a PTSD symptom. VA obtained an April 2011 medical opinion and furnished a September 2012 examination for the hypertension claim. The medical opinions reflected review of the pertinent medical history and included detailed supporting rationales. The Veteran does not otherwise assert any prejudice from the clinical examination and medical opinions. VA fulfilled its duty to obtain adequate examinations and medical opinions. The Court has held that the provisions of 38 C.F.R. § 3.103(c)(2) (2013) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: The duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam); See also 77 Fed. Reg. 23128-01 (April 18, 2012). At the September 2011 DRO hearing, the DRO explained importance of having medical examiners citing specific clinical evidence in support of their opinion for establishing a secondary nexus. He also encouraged the Veteran to show copies of his VA examination reports to his treating physicians and have them specifically comment on why they disagree. At the June 2013 hearing, the undersigned identified the issues on appeal. The Veteran provided testimony as to all treatment received for these disabilities. The undersigned specifically informed the Veteran of the necessary elements to substantiate the claims and pertinent evidence. The duties imposed by Bryant were thereby met. The Veteran does not otherwise assert prejudice from either hearing. Accordingly, the Board is satisfied that the duty-to-assist requirements under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c) have been satisfied. II. Service connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third elements is through a demonstration of continuity of symptomatology. However, the continuity and chronicity provisions of 38 C.F.R. § 3.303(b) only apply to the chronic diseases enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), overruling Savage v. Gober, 10 Vet. App. 488, 495-96 (1997) (applying 38 C.F.R. § 3.303(b) to a chronic disease not listed in 38 C.F.R. § 3.309(a) as "a substitute way of showing in-service incurrence and medical nexus."). Hypertension is a chronic disease under 38 C.F.R. § 3.309(a). However, hypertension was not demonstrated within a year of separation. The chronic disease presumption is therefore not helpful to the Veteran in this case. A disability may also be service connected if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2013). Moreover, in general, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b). The Federal Circuit has held that "[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); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). Although the Veteran is competent in certain situations to provide a diagnosis of a simple condition, the Veteran is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. Layno v. Brown, 6 Vet. App. 465, 469 (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In relevant part, 38 U.S.C.A. 1154(a) (West 2002) 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). (i) Hypertension Service treatment records do not show any complaints or treatment for hypertension. On his separation examination, the Veteran had a blood pressure reading of 120/80. Hypertension was not exhibited within the first post service year. At the September 2011 DRO hearing, the Veteran stated that he was initially informed about having high blood pressure in 2001. The Veteran does not contend that he had hypertension during service. Rather, he contends that he later developed it as secondary to service connected PTSD. October 2010 private medical records from Dr. C.D. show that the Veteran's blood pressure was normally ok, but spiked during periods of anxiety. Current blood pressure was listed as 124/76. Dr. C.D. diagnosed hypertension. He commented that the Veteran had labile hypertension in the setting of PTSD, which caused anxiety and increased his blood pressure. He continued the Veteran on his current beta-blocker. Dr. C.D. also authored an October 2010 letter stating that PTSD contributes, if not causes, the underlying labile blood pressure. He described the Veteran's blood pressure as generally normal, but spiking when he experienced PTSD symptoms. The Veteran was afforded a December 2010 VA hypertension examination. However, the opinion is not adequate for adjudication purposes and will not be considered. In January 2011, Dr. C.D. submitted another letter. He reported that the Veteran's hypertension was controlled with medication in clinical settings, but spiked when the Veteran experienced PTSD symptoms. VA obtained another medical opinion in April 2011. The examiner reviewed the claims folder and noted the pertinent medical history. He expressed a negative opinion. He cited medical records showing that hypertension was well controlled on a single medication. He noted Dr. C.D.'s reports that the Veteran had increased blood pressure when he experienced PTSD symptoms. However, he characterized such episodes of increased blood pressure as a normal physiological response to anxiety. He explained that catecholamines are released from the adrenal gland and cause a rise in heart rate and blood pressure. However, the transitory nature of the event would not cause a permanent rise in blood pressure or hypertension. A similar process may occur during exercise without permanent blood pressure elevation. He stated that after review of medical literature, he could not find objective evidence suggesting that hypertension is caused by, related to, or aggravated beyond the normal progression by PTSD. He also cited aging and tobacco and alcohol use as potential causes. In July 2011, the Veteran stated that he quit smoking in 1994 and only recently resumed tobacco use due to stress over his VA compensation claims, which triggered active service memories. In August 2011, the Veteran asserted that stress caused hypertension. He believed Dr. C.D.'s letters were sufficient medical evidence of a nexus. However, he submitted two medical articles found on the internet. A July 2008 article was titled "Ask The Mayo Clinic: PTSD, high blood pressure and heart disease can be related." It stated that repeated, prolonged bouts of PTSD activation symptoms "may" lead to other medical problems or exacerbate existing conditions, such as hypertension or heart disease. Another 2009 article from the National Institutes of Health (NIH) compared groups of patients with PTSD and depression, PTSD only, depression only, and no mental health disorder. It found that PTSD appears to be linked to hypertension independent of depression. In September 2012, the Veteran again asserted that stress causes hypertension. He was currently on medication to control his blood pressure. The Veteran was afforded another VA hypertension examination in September 2012. The examiner noted that the Veteran was initially diagnosed with hypertension 20 years ago. The Veteran attributed it to experiencing flashbacks and stressful situations. He was on metoprolol. Blood pressure readings from September 2012 were 144/78 and 140/80. January 2012 reading was 136/94. The examiner expressed a negative opinion on the question of aggravation by PTSD. He explained that PTSD symptoms such as anxiety and flashbacks are associated with transient and medically predictable increases in blood pressure where catecholamine hormones, such as adrenaline or noradrenaline, that facilitate immediate physical reactions associated with "fight or flight" response against a stimuli perceived as threatening. Once the stimuli are removed, the blood pressure returns to normal. He also noted that medical records show that the Veteran's blood pressure is well controlled with current medication despite subjective reports of elevation during anxiety or flashback episodes. At the June 2013 hearing, the Veteran asserted that he had PTSD symptoms prior to hypertension. He dated the onset for hypertension to when he was 42 years old, which would be approximately 1993 or 1994. In this particular case, competent evidence is required to show a nexus. By "competent medical evidence" is meant in part that which is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a). The competent medical evidence includes competing opinions on a nexus to PTSD. When medical opinions conflict, the Board may place greater weight on one medical professional's opinion over another's depending on such factors such as reasoning employed by the medical professionals, and whether or not and to what extent they review prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 336 (1994). The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The Court has held that claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further, a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion is found. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves- Rodriguez v. Peake, 22 Vet. App 295 (2008). The favorable competent medical evidence consists of Dr. C.D.'s October 2010 and January 2011 letters and the internet medical articles indicating a relationship between PTSD and hypertension. Dr. C.D. asserts that PTSD either directly caused hypertension or aggravated it. He references spikes in blood pressure when the Veteran experiences certain PTSD symptoms. He does not explain why the spikes in blood pressure caused by PTSD symptoms should be considered a cause of or permanent aggravation of hypertension in light of the Veteran's history of well controlled hypertension. He does not cite any medical studies to support a finding that PTSD directly caused or resulted in a permanent aggravation of hypertension. There is no measurable increase in the underlying disability identified. The Board does not find Dr. C.D.'s assertions of a cause or of permanent aggravation from PTSD convincing without further explanation in light of the Veteran's history of generally stable blood pressure readings. See id. The July 2008 Mayo Clinic and NIH articles are medical evidence supporting the possibility of a nexus to PTSD based upon causation or aggravation, but do not account for the specific medical history of the Veteran. Wallin v. West, 11 Vet. App. 509, 512 (1998); Ramold v. Shinseki, Vet. App. Slip Op. 2010 WL 1635985 pg 6. (Table) (April 23, 2010). Meanwhile, the April 2011 and September 2012 medical opinions weigh against the claim. Both examiners explained the process of why blood pressure would spike while the Veteran experienced certain PTSD symptoms. However, for this particular Veteran, they agreed that such elevations were of a transitory nature and did not cause a permanent aggravation of hypertension. They cited the Veteran's medical history of hypertension which has been well controlled by medication for many years. The April 2011 examiner also noted that his review of online medical literature do not locate any clinical studies showing hypertension is caused or aggravated by PTSD. The Board considers the rationales in the April 2011 and September 2012 medical opinions weighing against a permanent aggravation to be plausible and consistent with the Veteran's medical history. See Nieves- Rodriguez, 22 Vet. App 295. They are probative to show that the Veteran had not experience a permanent aggravation in hypertension due to PTSD symptoms. Id. The Veteran contends that he developed hypertension after service and it is secondary to PTSD. Competent lay evidence may be used to substantiate the elements of a service connection claim. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If the witness is not testifying as an expert, his testimony in the form of opinions or inferences is limited to those opinions or inferences which are rationally based on perception of the witness and helpful to a clear understanding of his testimony or the determination of a fact in issue. FED. R. EVID. 701. Generally, this rule does not permit a lay witness to express an opinion as to matters which are beyond the realm of common experience and which require the special skill and knowledge of an expert witness. Randolph v. Collectramatic, Inc., 590 F.2d 844, 846 (10th Cir. 1979). In this case, the Veteran claims that his hypertension is exacerbated by his PTSD and in fact may be the underlying cause. The evidence of record shows that the Veteran did not diagnose himself with hypertension, it was diagnosed based on elevated blood pressure readings taken by medical providers around 2001. The Board finds that the diagnosis of hypertension is not within the ability of a lay person to diagnose because a competent medical expert could not diagnose the Veteran based on reported symptoms alone and required specialized testing beyond ordinary clinical evaluation. See Mattke v. Deschamps, 374 F.3d 667, 670 (8th Cir. 2004) (a diagnosis by laboratory testing is distinctly not within the realm of common lay knowledge). Moreover, the Veteran's statements are also not competent evidence of nexus. The causes of hypertension are not so well known that a lay person may be expected to know them. The complexity regarding the causes of hypertension is reflected in the treatise evidence offered by the Veteran and the medical opinions of record. The Veteran's own non-expert opinion is of little probative value. In summary, the preponderance of the probative competent evidence weighs against a nexus to service or service connected PTSD. The benefit-of-the-doubt doctrine is therefore not helpful to the Veteran, and the claim for service connection for hypertension must be denied. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57 (ii) Insomnia Service treatment records (STRs) are negative for a sleep disorder. On his August 1971 separation examination, the Veteran described his physical condition as "excellent." January 2010 private mental health records show that the Veteran had sleep disturbances. He stated that he was hypervigilant about the safety of his home and slept with a loaded gun. He also had nightmares. At the September 2010 VA PTSD examination, the Veteran reported having nightmares four to five times per week. In his October 2010 claim, the Veteran reported that he had insomnia secondary to PTSD. April 2011 VA treatment records reflect complaints about increased nightmares. The Veteran reported decreasing his alcohol consumption to three or four servings per night and declined to attribute his sleep problems to alcohol. Currently, he took sleep medication and was able to sleep for about six hours. In January 2012, the Veteran reported that he had insomnia caused by PTSD, nightmares, and sleep apnea. He recently changed his sleep medication due to their inefficacy. In September 2012, the Veteran had a VA examination with review of the claims folder. He reported waking up at night and exhibited hypervigilant behavior. He reported having persistent daytime hypersomnolence, snoring, and apnea periods. The examiner stated that the Veteran's insomnia is associated with PTSD. He cited a recent VA mental health clinic note which characterized nightmares and night sweats as PTSD symptoms. In November 2012, a VA telehealth provider attempted to contact the Veteran. Her notes reflect that the Veteran had previously reported trouble falling and staying asleep. He attributed his sleep problems to anxiety. The Veteran visited a VA outpatient clinic for psychiatric medication management in November 2012. He reported a recent exacerbation of PTSD symptoms without any identifiable cause. The examiner noted that the Veteran had good sleep on most nights and woke up feeling rested when he was not consuming alcohol. In January 2013, the Veteran contacted VA over the phone. He was vacationing in Florida and had difficulty sleeping. He acknowledged that he had been consuming approximately six alcoholic beverages per day. He requested medication to alleviate his sleep problems and, in turn, reduce his alcohol and tobacco dependency as coping mechanisms. At the June 2013 hearing, the Veteran reported that insomnia was a recent diagnosis. His VA physician was hesitant to provide a nexus statement due to a conflict of interest. The Veteran contends that service connection is warranted for insomnia. He is currently receiving disability compensation for PTSD, which expressly contemplates "chronic sleep impairment" as a symptom. 38 C.F.R. § 4.130, Diagnostic Code 9411. Consequently, the currently claimed insomnia disability must consist of distinct symptoms that are wholly separate from PTSD. See id.; 38 C.F.R. § 4.14 (pyramiding is rating the same manifestation, pain, of a disability, under different Diagnostic Codes, which is to be avoided). Here, the complaints of insomnia have been attributed to the currently service connected PTSD symptoms. His reports of insomnia are made in the context of PTSD treatment. The evidence does not in any way suggest that the Veteran has insomnia or similar sleep impairment that is not already contemplated in the currently assigned PTSD disability rating. Id. In sum, the preponderance of the evidence is clearly against any finding that the Veteran has any separate insomnia or similar sleep disorder beyond the currently service connected PTSD symptoms which include chronic sleep impairment. The benefit of the doubt doctrine is not applicable, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for hypertension is denied. Service connection for disability exhibited by insomnia is denied. The appeal for service connection for disability exhibited by acid reflux is dismissed. The appeal for a higher initial rating for PTSD is dismissed. REMAND A VA examination is necessary for the TDIU claim. The Veteran asserts that he is unemployable due to PTSD symptoms. However, the clinical assessments from May 2010 and September 2012 VA PTSD examination reports indicate that the severity of the Veteran's PTSD symptoms is productive of reduced reliability in occupational function. An examination with specific findings as to his occupational capabilities is needed to resolve the conflicting reports. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran identify any recent treatment for his service connected disabilities. Take appropriate action based upon his response and incorporate any newly identified medical records into the claims folder. 2. After associating any newly generated medical records with the claims folder, schedule the Veteran for a VA TDIU examination. The claims folder, a copy of the remand and any pertinent documents in the Virtual VA or VBMS efolders must be available and reviewed by the examiner. (If a clinical examination is deemed necessary, this must also be scheduled). The examiner must note that the Veteran is service connected for the following disabilities: PTSD, rated as 70 percent disabling; irritable bowel syndrome, 10 percent disabling; erectile dysfunction, noncompensable. His overall disability rating is 70 percent. The examiner is asked to opine on whether the Veteran's service connected disabilities (PTSD, irritable bowel syndrome, and erectile dysfunction), alone and without consideration to non-service connected disabilities, are more likely than not (i.e. 50 percent probability or greater) productive of unemployability consistent with the Veteran's high school education and occupational experience in utility construction labor. The examiner must specifically consider and discuss the Veteran's reports and assessments given by the May 2010 and September 2012 VA examiners indicating PTSD symptoms productive of reduced reliability in occupational function. If the examiner determines that he/she cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. (The RO/AMC should ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.) 3. Following the completion of the requested action and any additional development deemed necessary, the RO should then re-adjudicate the Veteran's TDIU claim. If the benefits on appeal remain denied, the Veteran and his representative should be provided with a supplemental statement of the case (SSOC) and afforded an opportunity to respond. Thereafter, the case should be returned to the Board, if in order. No action is required of the Veteran until notified by the RO; however, the veteran is advised that failure to report for any scheduled examination may result in denial of the claim. 38 C.F.R. § 3.655 (2013). The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013). Department of Veterans Affairs