Citation Nr: 1530579 Decision Date: 07/17/15 Archive Date: 07/24/15 DOCKET NO. 14-02 999 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a chipped tooth. 2. Entitlement to service connection for bilateral upper extremity neuropathy. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for tinnitus. 5. Entitlement to service connection for migraine headaches. 6. Entitlement to service connection for chronic fatigue syndrome. 7. Entitlement to service connection for vertigo. 8. Entitlement to service connection for left nasal polyp. 9. Entitlement to service connection for sinusitis. 10. Entitlement to service connection for epididymitis. 11. Entitlement to service connection for bilateral leg sciatica. 12. Entitlement to service connection for bilateral pes planus. 13. Entitlement to service connection for a disorder causing generalized joint pain. 14. Whether new and material evidence has been received to reopen the claim for service connection for low back disability. 15. Whether new and material evidence has been received to reopen the claim for service connection for left knee disability. 16. Entitlement to service connection for a right foot disability. 17. Entitlement to service connection for bilateral hearing loss disability. 18. Entitlement to service connection for traumatic brain injury (TBI). 19. Entitlement to service connection for sleep apnea. 20. Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with anxiety. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Lawson, Counsel INTRODUCTION The Veteran served on active duty from October 1985 to October 1989, January 2002 to April 2002, and January 2003 to April 2004. This matter comes to the Board of Veterans' Appeals (Board) on appeal from July 2010 and July 2012 rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA). The ratings granted service connection for PTSD and anxiety and assigned a 30 percent rating effective from the February 8, 2010 date of claim. The Veteran presented testimony at an RO hearing in May 2011 and at a Board hearing in July 2014, and transcripts of the hearings are associated with his claims folder. The issues of service connection for low back disability, left knee disability, right foot disability, bilateral hearing loss disability, TBI, and sleep apnea, and a higher rating for PTSD with anxiety are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). The Veteran raised the issue of service connection for erectile dysfunction in February 2013. This matter has not been addressed by the RO and is referred to the RO for appropriate action. FINDINGS OF FACT 1. During the Veteran's July 2014 hearing, he withdrew his appeals on the issues of service connection for chipped tooth and bilateral upper extremity neuropathy. 2. The Veteran's current hypertension and tinnitus were manifest within 1 year of service separation in April 2004. 3. The Veteran's current migraine headaches were not manifest in service or to a degree of 10 percent within 1 year of separation and are unrelated to service. 4. The Veteran does not have a current chronic fatigue syndrome disability. 5. The Veteran does not have a current vertigo disability. 6. The Veteran does not have a current nasal polyp disability. 7. The Veteran does not have a current chronic sinusitis disability. 8. The Veteran does not have a current epididymitis disability and his varicoceles are unrelated to any incident of service. 9. The Veteran does not have a current sciatica disability of either leg. 10. The Veteran's bilateral pes planus had its onset in service. 11. The Veteran does not have a current disorder causing generalized joint pain or objective indications of a disorder causing generalized joint pain. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the issues of service connection for chipped tooth and bilateral upper extremity neuropathy are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. §§ 20.202, 20.204 (2014). 2. The criteria for service connection for hypertension are met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2014). 3. The criteria for service connection for tinnitus are met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2014). 4. The criteria for service connection for migraine headaches are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2014). 5. The criteria for service connection for chronic fatigue syndrome are not met. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2014); 38 C.F.R. § 3.303, 3.317 (2014). 6. The criteria for service connection vertigo are not met. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2014). 7. The criteria for service connection for a left nasal polyp disability are not met. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2014). 8. The criteria for service connection chronic sinusitis are not met. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2014). 8. The criteria for service connection epididymitis are not met. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2014). 9. The criteria for service connection for bilateral leg sciatica are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2014). 10. The criteria for service connection for bilateral pes planus are met. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2014). 11. The criteria for service connection for a disorder causing generalized joint pain are not met. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2014); 38 C.F.R. § 3.303, 3.317 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS During the Veteran's July 2014 hearing, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that he wanted to withdraw his appeals concerning the issues of service connection for chipped tooth and bilateral upper extremity neuropathy. Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A Substantive Appeal may be withdrawn on the record during a hearing or in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. With regard to the issues withdrawn by the Veteran, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeals as to these issues and they are dismissed. No assistance or notice under 38 U.S.C.A. Chapter 51 (West 2002) is necessary for the claims since the appeals have been withdrawn. VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). As the claims for service connection for hypertension, tinnitus, and bilateral pes planus have been granted, no further notification or assistance is necessary, and deciding these appeals is not prejudicial to the Veteran. Regarding the other claims being decided, VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2014). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Adequate notice was provided in December 2009. VA has obtained service treatment records; assisted the Veteran in obtaining evidence; obtained VA medical opinions or examinations in 2012; and afforded the Veteran the opportunity to give testimony before the Board. The examinations are adequate as they show consideration of the claims record and the Veteran's contentions, and render medical opinions in light of the evidence. VA examinations are not necessary for the claims for service connection for left nasal polyp, sinusitis, sciatica, or a disorder causing generalized joint pain, as the evidence does not contain competent evidence of a current diagnosed disability or persistent or recurrent symptoms of disability. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims record; and the Veteran has not contended otherwise. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claims at this time. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet.App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Service connection may be awarded on a presumptive basis for certain chronic diseases listed in 38 C.F.R. § 3.309(a) that manifest to a degree of 10 percent within 1 year of service separation or during service and then again at a later date. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed.Cir.2013). Organic disease of the nervous system and cardiovascular-renal disease, including hypertension, are listed as chronic diseases. Evidence of continuity of symptomatology may be sufficient to invoke this presumption if a claimant demonstrates (1) that a condition was "noted" during service; (2) evidence of postservice continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the postservice symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (citing Savage v. Gober, 10 Vet.App. 488, 496-97(1997)); see 38 C.F.R. § 3.303(b). Service connection may be established on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more thereafter, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on undiagnosed illness, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Laypersons are competent to report objective signs of illness. Id. The term "Persian Gulf Veteran" means a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(d)(1). The Veteran is a Persian Gulf Veteran. Service connection may be granted, on a secondary basis, for a disability which is proximately due to, or the result of an established service-connected disorder. 38 C.F.R. § 3.310 (2014). Similarly, any increase in severity of a non-service 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. Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the non-service connected disease or injury is said to have been aggravated by the service-connected disease or injury. 38 C.F.R. § 3.310. Hypertension and tinnitus On service examination in March 2004, the Veteran's blood pressure was 135/57. A VA examiner noted in March 2010 that the Veteran's hypertension was less likely than not caused by his service. However, a VA examination report from August 2004, within 1 year of the Veteran's service separation, contains a diagnosis of essential hypertension and indicates that 3 blood pressure readings at that time were 110 diastolically. Under 38 C.F.R. § 4.104, Diagnostic Code 7101 (2014), this was hypertension manifest to a degree of 10 percent or more. Since it appears that the Veteran had hypertension manifest to a compensable degree within 1 year of service separation, service connection is warranted for his hypertension on a presumptive service connection basis. On VA examination in August 2004, intermittent right ear tinnitus was diagnosed, and tinnitus is shown in a June 2012 VA examination report. As the August 2004 VA examination report is acceptable evidence of tinnitus manifest to a degree of 10 percent within 1 year of service separation, presumptive service connection is warranted for the Veteran's current tinnitus. Migraines Service treatment records note the Veteran's report in March 2004 of having headaches during his deployment, but not currently. On service examination in March 2004, the Veteran indicated that he had never had frequent or severe headaches. On VA evaluation in February 2011, there was an impression of history of blast exposure resulting in post-concussive symptoms including headaches. A March 2011 VA CT scan of the Veteran's head for a history of prior injury to it was normal. A VA examiner in June 2012 opined that the Veteran's current migraine headaches are less likely than not caused by or a result of service. The rationale was that although the Veteran indicated in a March 2004 post-deployment questionnaire that he had headaches, there was no indication that these were migraine headaches. Ordinary headaches are a universal occurrence in everybody, and would be transient and resolve with medication. The service treatment records are silent for migraine headaches, as were available reports of medical history/examination of record and the August 2004 VA examination report. The Veteran had denied headaches on private treatment in October 2007, and had medical visits between 2006 and 2008 without notation of headaches. Migraine headaches were first diagnosed in 2011, at which time the Veteran stated that he had had them for many years and claimed that they were due to a rocket propelled grenade attack in 2003, which was about 8 years prior. This had not been confirmed by objective documentation of medical treatment notes during active duty. Also, the Veteran himself stated in his history that he really did not have time to go to the hospital and didn't go to the doctor until about 2 or 3 years ago. The examiner felt that it would be highly unlikely if an RPG was causing migraine headaches that it would not be manifest right after or soon after the incident. It would also be highly unlikely for the Veteran to not have sought medical attention earlier for migraine headaches, as they are significantly more troublesome than ordinary headaches. The examiner stated that the given history and review of documented records indicated that the Veteran may have had ordinary non-specific headaches prior to 2011, but that the objective documentation of migraine headaches started in 2011, long after separation from active duty. The examiner thus felt that there was no sound medical basis for attributing the migraine headaches to incidents from active duty. Based on the evidence, the Board concludes that service connection is not warranted for the Veteran's current migraine headaches disability. The preponderance of the evidence indicates that they were not manifest in service and are unrelated to service. Instead, they were first documented in 2011, and the examiner in June 2012 indicated that based on the record, it did not appear that they were attributable to service. In doing so, he considered the Veteran's testimony to the effect that he had had headaches in and since service, but found essentially that the Veteran probably would have sought treatment for migraine headaches much earlier if they were related to service and/or had continued since service. There was an impression of blast injury resulting in headaches in February 2011, but it is unclear from that that the evaluator was relating the Veteran's current migraine headaches to service, and the evaluator evidenced no review of material evidence in the Veteran's claims folder. Clearly that report is not as probative as the June 2012 VA examination report. Chronic fatigue syndrome Service treatment records do not report chronic fatigue syndrome, and on VA examination in April 2012, the examiner reviewed the Veteran's medical records, examined him, and indicated that the Veteran had never been diagnosed with chronic fatigue syndrome. As there is no diagnosis of chronic fatigue syndrome of record, service connection cannot be granted for it. In the absence of a current disability, service connection cannot be granted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-144 (1992). Vertigo Service treatment records do not show vertigo, but the Veteran reported in March 2004 that he had dizziness. A VA examiner examined the Veteran in July 2012 and indicated that the Veteran does not have vertigo and that there was no objective evidence of the claimed vertigo condition. In light of the above, service connection is not warranted for the Veteran's claimed vertigo. While the Veteran stated in October 2011 that a VA physician documented his vertigo in or after 9/9/11 consultation, the September 2011 VA medical record to which he apparently refers does not diagnose vertigo or contain neurological findings indicative of it but instead indicates that he was to have occupational therapy for vertigo, which is not the same thing as a diagnosis of vertigo. The preponderance of the evidence indicates that he does not have vertigo. This is supported by the report of the VA examiner who indicated that he does not have it and that there is no objective evidence of it. Other medical records mentioning reports by the Veteran of symptoms that might be considered part of vertigo are silent for reference to a diagnosis of vertigo. In the absence of a current disability, service connection cannot be granted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-144 (1992). Left nasal polyp While the Veteran reported in March 2004 that he had had recurrent nose bleeds while deployed in service, the preponderance of the evidence of record indicates that the Veteran does not have a current nasal polyp disability. A large polyp in the Veteran's left nostril was reported on VA evaluation in February 2011. However, the addendum to that report indicates that there was no definite polyp in his nose, but mucous which was cleared, and no polyps were found on VA evaluation in March 2011. No polyps were found on VA ear, nose, and throat evaluation in February 2012, and the 2012 VA examination report definitively shows that there were no polyps. It indicates that the Veteran's nose was examined for polyps, and that none were found. None are demonstrated elsewhere in the record at any point since the claim was filed in October 2009. In the absence of a current nasal polyp disability, service connection cannot be granted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-144 (1992). Chronic sinusitis Service treatment records are silent for reference to sinusitis, and on service examination in March 2004, the Veteran did not mention having sinusitis. On VA evaluations in February and March 2011, the Veteran complained of sinus infections. He was examined and sinusitis was not found. A CT scan of his head in March 2011 showed multiple retention cysts in the maxillary sinuses, and mild mucosal thickening in the right frontal sinus, but the impression was normal CT scan. An assessment of sinusitis was reported on VA evaluation in June 2011, but the report does not indicate that the Veteran's sinuses were examined. More recent medical records do not show sinusitis. Based on the evidence of record, the Board concludes that the Veteran does not have a chronic sinusitis disorder. None is appropriately diagnosed in any of the current medical records, and a CT scan was normal in March 2011. In the absence of a current disability, service connection cannot be granted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-144 (1992). Epididymitis The Veteran's testicles were normal on VA examination in August 2004. On VA examination in April 2012, the examiner reviewed the Veteran's service treatment records and indicated that the Veteran had had acute left epididymitis in 1988, and that it had resolved. Bilateral varicoceles had been diagnosed in about 2010. The examiner noted that the Veteran had indicated in reports of medical history that he was in good health, that there was no documentation of further treatment for recurrent epididymitis, and that on physical examination after deployment in 2004, his testicles were normal. A testicular ultrasound in November 2010 found multiple bilateral varicoceles. The examiner indicated that varicoceles were entirely different from epididymitis, and that there was no known relationship between them. Based on the evidence, the Board finds that service connection is not warranted for epididymitis. The preponderance of the evidence including the 2012 VA examination report indicates that the Veteran's 1988 epididymitis resolved, and that he no longer has epididymitis. In the absence of a current disability, service connection cannot be granted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-144 (1992). While the Veteran may be claiming service connection for varicoceles under the guise of epididymitis, they were not shown in service and the examiner in April 2012 indicated that there is no known relationship between epididymitis and varicoceles. Bilateral leg sciatica Service treatment records are silent for reference to leg sciatica. Additionally, a VA examiner in April 2012 indicated that there was no objective evidence of bilateral lower extremity radiculopathy, and no evidence of claimed peripheral neuropathy. Instead, the Veteran's motor strength was 5/5, he had no muscle atrophy, and sensory examination was normal. There is no current diagnosis of sciatica of either leg of record. In light of the evidence, the Board concludes that service connection is not warranted for bilateral leg sciatica. In the absence of a current disability, service connection cannot be granted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-144 (1992). (states started having them from his chronic back pain). The Board notes that in October 2011, the Veteran stated that a VA physician documented neuropathy during an examination of him. However, the Veteran's nerves were examined and found to be normal by VA in February, March, and September 2011 also. Bilateral pes planus Service treatment records are silent for reference to pes planus, and the Veteran's March 2004 service examination report indicates that his feet had normal arches. However, bilateral pes planus was noted on VA examination in August 2004, which was within months after service discharge, and the Veteran testified in July 2014 that he started having foot pain during service in the Middle East and had been in combat boots all the time over there and had to jump off Humvees to get patients. Based on this evidence, the Board finds that service connection is warranted for the Veteran's pes planus as having its onset in service. Reasonable doubt is resolved in his favor, in part because it was diagnosed so soon after service and also in light of his testimony that he had symptoms in the Middle East. Chronic joint pain Service treatment records do not mention chronic joint pain, but the Veteran did mention having had swollen, stiff, or painful joints during deployment on service examination in March 2004. No disorder manifested by chronic joint pain was reported on VA examination in August 2004, except perhaps for the bilateral pes planus, low back strain, and left knee strain which are the subject of separate issues on appeal. Additionally, the medical evidence of record does not show a current diagnosis of or objective indications of a disorder manifested by chronic joint pain. In the absence of a current chronic joint pain disability, service connection cannot be granted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-144 (1992). ORDER The appeals on the issues of service connection for chipped tooth and bilateral upper extremity neuropathy are dismissed. Service connection for hypertension and tinnitus is granted. Service connection for migraine headaches is denied. Service connection for chronic fatigue syndrome is denied. Service connection for vertigo is denied. Service connection for left nasal polyp is denied. Service connection for chronic sinusitis is denied. Service connection for epididymitis is denied. Service connection for bilateral leg sciatica is denied. Service connection for bilateral pes planus is granted. Service connection for a disorder causing generalized joint pain is denied. REMAND The Veteran was issued a statement of the case on the matters of service connection for low back, left knee, and right foot disability and a higher rating than 30 percent for PTSD with anxiety in December 2013. In January 2014, he submitted a VA Form 9 which indicates that arguments for the claims were contained in continuation sheets. He labelled the VA Form 9 page 1 of 24. The continuation sheets and/or other 23 pages of the submission are not incorporated into the claims folder and should be, in order to provide him with due process of law. The RO denied service connection for low back and left knee disability in November 2004, and notified the Veteran of its decision and of his right to appeal it within 1 year thereof. He did not appeal that decision or submit new and material evidence within 1 year of it, and so it is final. At the time, the Veteran had reported in-service low back and left knee symptoms on service examination in March 2004, and a VA examiner in August 2004 had diagnosed him with low back and left knee strain. Essentially, there was evidence of record of symptoms in service as well as a current diagnosis of low back and left knee strain at the time of that decision. There was no competent medical evidence of record a nexus between the low back and left knee strain shown in August 2004 and any incident of service. In light of this, for evidence to be new and material, it would need to show a nexus between the Veteran's current low back and left knee disabilities and service. However, the statutory notice given to the Veteran in December 2009 advised him that his claims were denied because he failed to report for the VA examination, which he did not. Remand is required to provide the Veteran with the notice required by Kent v. Nicholson, 20 Vet. App. 1 (2006), concerning reopening these claims. The Veteran claims service connection for a right foot disorder in part as due to his left knee disability. Plantar fasciitis was diagnosed on VA examination in April 2010, and the examiner attributed it to a left knee disability. A right foot plantar calcaneal spur was found on VA evaluation in June 2010. A private health care provider reported in January 2010 that left knee pain has caused right heel pain. Accordingly, appellate review of this matter is deferred pending completion of action ordered in the remand section below, concerning the Veteran's left knee disability. A June 2012 VA examination report indicates that the Veteran's hearing loss is less likely than not due to service noise exposure. However, service connection has been granted for tinnitus, and in October 2011, the Veteran asserted that his hearing loss disability is part of his tinnitus. This raises the matter of service connection for bilateral hearing loss disability as secondary to his service-connected tinnitus. In light of the above and the provisions of 38 C.F.R. § 3.159, the Board finds that a medical opinion is necessary on the matter of whether the Veteran's service-connected tinnitus has caused or aggravated his bilateral hearing loss disability. Regarding the claim for service connection for TBI, the Veteran claims that a rocket propelled grenade (RPG) was fired on his convoy in service, and that the RPG hit a building, causing him to hit his face on the front of the Humvee. There is some indication in the record that the Veteran may have a TBI. For instance, VA medical records show complaints of a TBI and visits with a TBI coordinator from January 2010 to March 2012, and records note that he was diagnosed with and received treatment for TBI. However, a VA examiner in 2012 noted that service treatment records contained a post-deployment questionnaire from March 2004 which indicated that the Veteran had developed symptoms including headaches, dizziness, fainting, and light-headedness during deployment, but that neither the Veteran nor the examiner (in March 2004?) mentioned loss of consciousness, alteration of consciousness, or post-traumatic amnesia or anything suggestive of a concussion or TBI by VA definition. The Veteran had reported multiple somatic symptoms which had become progressively worse over time, with an inconsistent history of this, and this was more consistent with a psychological condition than an organic pathology. Essentially, it is unclear at this point that the Veteran has a TBI, and if so, whether it is related to service. In light of the above, a VA examination as indicated below is required. Obstructive sleep apnea was found on VA evaluation in February 2011. During the Veteran's July 2014 hearing, he indicated that his sleep apnea is due to TBI, service connection for which is also on appeal. Accordingly, a VA medical opinion will be obtained on this matter to assist the Veteran in accordance with 38 C.F.R. § 3.159. It does not appear that the Veteran has been afforded a compensation examination for his PTSD with anxiety since 2010, and during his July 2014 hearing, it was indicated that an April 2010 VA medical record noting no suicidal thoughts contrasts with the reports of other doctors who he has seen since then. The Board notes that a January 2011 VA medical record contains a report that the Veteran had suicidal ideation, that a March 2011 VA medical record notes that he appeared to be at high risk for suicidal/homicidal ideation, and that an August 2011 VA psychology note grades the Veteran's PTSD as moderate to severe. In light of the above, a VA psychiatric examination will be obtained on remand, as indicated below. Any additional relevant medical records of treatment which the Veteran has received should be obtained on remand, to ensure the record is a complete one. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with the notice required by Kent concerning his attempts to reopen his claims for service connection for low back and left knee disability. Specifically, advise him that he must provide medical evidence of a nexus between his current low back and left knee disabilities and service. Make arrangements to incorporate into the Veteran's claims folder the continuation sheets (apparently 23 pages) to his January 2014 VA Form 9 concerning the claims for a higher rating for PTSD with anxiety and service connection for low back and left knee disability, as well as any additional relevant medical records of treatment which are not of record. 2. After the above development is completed, the RO should schedule the Veteran for a VA psychiatric examination for his PTSD with anxiety, to determine its severity. The Veteran's claims file must reviewed by the examiner in conjunction with the examination. The examiner must also be provided a copy of the criteria for rating psychiatric disorders. The examiner should note the presence or absence of each symptom in the criteria for ratings in excess of 30 percent, and should also comment on the impact of the symptoms found on the Veteran's social and occupational functioning. 3. The Veteran should be afforded an appropriate examination or medical opinion to determine whether his bilateral hearing loss disability was caused or aggravated by his service-connected tinnitus. The claims file must be provided to the examiner for review in conjunction with the examination or opinion. After reviewing the file and the remand, the examiner should offer an opinion as to the following: a) Is it at least as likely as not (a probability of at least 50 percent or higher) that the Veteran's current bilateral hearing loss disability is proximately due to or caused by the service-connected tinnitus disability? b) Is it at least as likely as not (a probability of at least 50 percent or higher) that the Veteran's current bilateral hearing loss disability has been aggravated (chronically made worse) by the service-connected tinnitus disability? Detailed reasons for the responses must be furnished. 4. The Veteran should be afforded a TBI examination to determine whether he has a TBI, and if so, whether it is related to service. The claims file must be provided to the examiner for review in conjunction with the examination or opinion. After reviewing the file and the remand, the examiner should offer an opinion as to the following: a) Is it at least as likely as not (a probability of at least 50 percent or higher) that the Veteran has a current TBI disability? b) If so, is it at least as likely as not (a probability of at least 50 percent) that it had its onset in or is related to service, to include the RPG incident which has been reported, or that it was manifest to a degree of 10 percent within 1 year of separation? 5. The Veteran should be afforded an appropriate examination or medical opinion to determine whether his current sleep apnea disability was caused or aggravated by any existing TBI. The claims file must be provided to the examiner for review in conjunction with the examination or opinion. After reviewing the file and the remand, the examiner should offer an opinion as to the following: a) Is it at least as likely as not (a probability of at least 50 percent or higher) that the Veteran's current sleep apnea disability is proximately due to or caused by any existing TBI? b) Is it at least as likely as not (a probability of at least 50 percent or higher) that the Veteran's current sleep apnea disability has been aggravated (chronically made worse) by any existing TBI? Detailed reasons for the responses must be furnished. 6. Thereafter, readjudicate the Veteran's pending claims in light of the expanded record. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. 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 2014). ______________________________________________ Michael Martin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs