Citation Nr: 1328205 Decision Date: 09/04/13 Archive Date: 09/10/13 DOCKET NO. 05-29 529 ) DATE ) ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for a back disability, to include as secondary to service-connected disability. 2. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected disability. 3. Entitlement to service connection for gastrointestinal (GI) disorder, to include as secondary to service-connected disability. 4. Entitlement to service connection for neuropathy, to include as secondary to service-connected disability. 5. Entitlement to service connection for headaches, to include as secondary to service-connected disability. 6. Entitlement to service connection for coronary artery disease (CAD), to include as secondary to service-connected disability. 7. Entitlement to service connection for a psychiatric disorder (other than posttraumatic stress disorder (PTSD), dysthymia, and panic disorder). 8. Whether new and material evidence has been received to reopen a claim for service connection for dysthymia and panic disorder. 9. Entitlement to an initial rating in excess of 10 percent for tinnitus. 10. Entitlement to an initial rating in excess of 10 percent for PTSD prior to April 15, 2009. 11. Entitlement to a rating in excess of 30 percent for PTSD since April 15, 2009. 12. Entitlement to an effective date earlier than April 9, 2010 for the grant of service connection for tinnitus. 13. Entitlement to an effective date earlier than December 14, 2001 for the grant of service connection for PTSD. 14. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Lori N. Chism, Attorney at Law ATTORNEY FOR THE BOARD R. Giannecchini, Counsel INTRODUCTION The Veteran had active military service from August 1965 to August 1968. These matters come to the Board of Veterans' Appeals (Board) on appeal following rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. In March 2013, the Board received a motion from the Veteran's then-appointed attorney to withdraw as his representative. In April 2013, the Board granted the attorney's motion. Thereafter, the Veteran granted a power-of-attorney in favor of his current attorney/representative. In June 2013, the Board sent a letter to the attorney and provided an opportunity for the submission of additional evidence or argument in support of the Veteran's claims. A review of the claims folders does not reflect a reply from the attorney in response to the June 2013 Board letter. Also, in a February 2012 statement (VA Form 21-4138), it was noted by the Veteran's previous attorney that, "We agree with the denial for an earlier effective date for PTSD . . . ." A reading of the statement would appear to reflect a withdrawal of the issue of claim for an effective date prior to December 14, 2001 for the grant of service connection for PTSD. However, the RO has continued to deny the issue in subsequent supplemental statements of the case (SSOCs), to which the Veteran's then-appointed attorney continued to disagree. Absent any statement explicitly withdrawing the noted issue, the Board considers the issue for an effective date prior to December 14, 2001 for the grant of service connection for PTSD to remain in appellate status. By way of background, in February 2008, the Board denied the Veteran's claim of service connection for PTSD as well as the claim to reopen a previously denied (and final) claim for service connection for a psychiatric disorder other than PTSD. In an April 2009 order, the United States Court of Appeals for Veterans Claims (Court) vacated and remanded the Board's February 2008 decision. Thereafter, in a May 2009 remand, the Board rephrased the issues on appeal as service connection for PTSD, whether new and material evidence had been received to reopen the claim for service connection for dysthymia and panic disorder without agoraphobia, as well as service connection for a psychiatric disorder (other than PTSD, dysthymia, and panic disorder without agoraphobia). In an August 2009 rating decision the RO granted service connection and assigned an initial rating of 10 percent for PTSD, effective December 14, 2001. The RO later granted a 30 percent rating for PTSD effective April 15, 2009. Thereafter, in a November 2009 rating decision, the RO denied the Veteran entitlement to a TDIU. In an April 2010 rating decision, the RO denied the Veteran service connection for coronary artery disease. Thereafter, in an August 2010 rating decision, the RO denied the Veteran's claims for service connection for a gastrointestinal disorder, for neuropathy, and also denied the claim for an earlier effective date for the grant of service connection for PTSD. In a subsequent May 2011 rating decision, the RO granted service connection and assigned a 10 percent rating for tinnitus, effective April 9, 2010. It otherwise denied service connection for tension headaches, for erectile dysfunction (claimed as impotency), and for a back disability. In addition, the Board notes that in October 2012, the Veteran filed a claim for claustrophobia. In a January 2013 VA disability benefits questionnaire (DBQ), the examiner commented that the Veteran described symptoms consistent with agoraphobia. The examiner noted that the agoraphobia was related to the Veteran's panic disorder. In so finding, the examiner commented that he reviewed the DSM-IV criteria with the Veteran and that a finding of agoraphobia was consistent with the Veteran's reported symptoms. In light of this finding, the Board has recharacterized the issue on appeal with regard to the reopening of the Veteran's claim for service connection for "dysthymia and panic disorder without agoraphobia." In light of the examiner's finding, the issue has been recharacterized as "dysthymia and panic disorder." Furthermore, in his May 2010 notice of disagreement (NOD), the Veteran first raised the issues of service connection for hypertension and for hyperlipidemia. The Board does not consider these issues to have been implicitly raised at the time the Veteran filed his claim for service connection for coronary artery disease (CAD) in October 2009. Also, the claims appear to be in response to a report of March 2010 VA examination in which the examiner related the Veteran's CAD to hypertension and hyperlipidemia but not to service-connected PTSD. With that said, the claims for service connection for hypertension and for hyperlipidemia have not been adjudicated by the RO, and thus, are not before the Board. They are thus referred to the RO for appropriate development. (The issues of service connection for erectile dysfunction; service connection for a gastrointestinal disorder; service connection for coronary artery disease; service connection for a psychiatric disorder (other than PTSD, dysthymia, and panic disorder); whether new and material evidence has been received to reopen a claim for service connection for dysthymia and panic disorder; an initial rating in excess of 10 percent for PTSD prior to April 15, 2009 and a rating in excess of 30 percent for PTSD since April 15, 2009; as well as a claim for a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO.) FINDINGS OF FACT 1. The medical evidence does not reveal the Veteran to have a diagnosed back disability. 2. Headaches did not have their onset in service and are not otherwise related to active service; headaches are not proximately due to or aggravated by service-connected disability. 3. The Veteran's active military service did not involve duty or visitation in the Republic of Vietnam. 4. Neuropathy did not have its onset in service and is not otherwise related to active service, nor was it exhibited within the first post-service year. 5. Neuropathy is not proximately due to or aggravated by service-connected disability. 6. The Veteran is in receipt of the highest available disability rating for tinnitus under the applicable diagnostic code. 7. On April 6, 2010 the RO received a VA Form 21-4142 ((Authorization and Consent to Release Information to the Department of Veterans Affairs) which noted "ringing in ears; the VA Form 21-4142 has been accepted by the RO as an informal claim for service connection for tinnitus. 8. There was no communication from the Veteran prior to April 6, 2010 that may be construed as a formal or informal claim for service connection for tinnitus. 9. In a September 1995 rating decision, the RO denied the Veteran's claim for service connection for PTSD; the Veteran was notified of that decision but did not appeal. 10. On December 14, 2001, the RO received a statement from the Veteran in which he sought to reopen his claim for service connection for PTSD. CONCLUSIONS OF LAW 1. A back disability was not incurred in or aggravated by service, nor is it proximately due to or aggravated by service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 2. Headaches were not incurred in or aggravated by service, nor are they proximately due to or aggravated by service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 3. Neuropathy was not incurred in or aggravated by service, exhibited within the first post-service year, nor is it proximately due to or aggravated by service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 4. The criteria for an initial rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.87, Diagnostic Code 6260 (2012). 5. The criteria for an effective date of April 6, 2010, for the award of service connection for tinnitus have been met. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2013); 38 C.F.R. § 3.400 (2012). 6. The criteria for an effective date prior to December 14, 2001 for the award of service connection for PTSD have not been met. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2013); 38 C.F.R. § 3.400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2013). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). (The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008. See 73 Fed. Reg. 23353-56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the claimant to provide any evidence in his possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1).) The Board finds that all notification action needed to make a decision on the claims for service connection for a back disability, for headaches, and for neuropathy have been met. Through April 2010, June 2010, and August 2010 notice letters, the Veteran was notified of the information and evidence needed to substantiate his claims for service connection. The Board also finds that the notice letters satisfy the statutory and regulatory requirement that VA notify a claimant which evidence, if any, will be obtained by the claimant and which evidence, if any, will be obtained by VA. 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)). In the letters, the Veteran was notified that VA was responsible for obtaining relevant records from any Federal agency and that VA would make reasonable efforts to obtain relevant records not held by a Federal agency, such as from a state, private treatment provider, or an employer. Also, in the notice letters, the RO provided the Veteran with the general criteria for assigning disability ratings and effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). As such, a remand of the claims for further notification is not necessary. With regard to the issue of an initial rating in excess of 10 percent for tinnitus, and earlier effective date claims for service connection for tinnitus and for PTSD, all three claims are considered "downstream" issues in that they arose from initial grants of service connection. Prior to the grants of service connection the Veteran was advised in December 2005 and June 2010 notice letters of the evidence necessary to substantiate his claims for service connection and of his and VA's respective obligations with regard to obtaining evidence. Quartuccio, supra. Also, in March 2006, the RO provided the Veteran with the general criteria for assigning disability ratings and effective dates. Importantly, where, as here, service connection has been granted and the initial rating and effective date have been assigned, the claim for service connection has been more than substantiated. Once a claimant disagrees with an initial determination, other provisions apply to the remainder of the adjudication process, particularly those pertaining to the issuance of rating decisions and statements of the case (SOCs). See 38 U.S.C.A. §§ 5104(a), 7105(d) (West 2002); 38 C.F.R. §§ 3.103(b)(1), 19.29 (2012); see also Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007). There is also no indication that any additional action is needed to comply with the duty to assist in connection with the claims the Board has decided. The Veteran's service treatment records (STRs) are associated with the claims folders as are his VA and private treatment records, and his Social Security Administration (SSA) records. Of note, the Veteran identified having received treatment at the VA Medical Center (VAMC) in Madison, Wisconsin beginning in 1972. A January 2004 search by VA of its medical records, to include those archived, did not reveal records earlier than February 1983. The Veteran was notified of this fact per a May 2005 notice letter and requested to submit copies of any VA treatment records in his possession. Also, a number of identified private medical facilities and/or physicians have responded that they do not have requested medical records associated with the Veteran's claimed treatment. The Veteran's own search for treatment records has revealed that certain records are no longer available. Otherwise, medical literature has been submitted in support of the Veteran's claims. The Veteran has been provided VA medical examinations associated with his claims for service connection for headaches and for neuropathy. The examiners have provided opinions. The Board finds the opinions to be sufficient for the purpose of deciding the Veteran's claims. Regarding the opinion for the claim of service connection for neuropathy, the examiner was not requested to comment on whether neuropathy was related to the Veteran's period of active service. As will be discussed in more detail below, the Veteran's STRs do not reflect complaints, diagnoses, or treatment for neuropathy. There is also no post-service medical evidence relating the disability to service. The Veteran has not necessarily alleged that the disability is the result of his active service. On the contrary, the Veteran's arguments appear predicated on his neuropathy being related to or aggravated by his service-connected PTSD. In light of the lack of any evidence in service of the disability and the lack of post-service medical evidence connecting the disability to service, the lack of an opinion from the VA examiner regarding a relationship between the neuropathy and the Veteran's active service does not preclude the Board from deciding the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); 38 U.S.C.A. § 5103A(d)(2) (West 2002). Otherwise, the Veteran has been provided a VA examination regarding his claim for service connection for tinnitus. In addition, as will be discussed in further detail below, at no time during the current appeal period has the Veteran been found to have a back disability, although the medical evidence documents complaints of low back pain. As there is no evidence of a back disability, the Board concludes, per McClendon, that VA's duty to assist does not require providing the Veteran with a VA examination on that issue. Finally, as the outcome of the appeals for earlier effective dates turns on a determination as to when a formal or informal claim for service connection was filed based on information and evidence associated with the claims folders, there is no need for a medical examination and or opinion. Therefore, there is no indication that any additional action is needed to comply with the duty to assist in connection with the claims decided herein. II. Analysis Service Connection Under applicable law, service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Generally, in order to prove service connection, there must be (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease; and (3) medical evidence of a nexus, or link, between the current disability and the in-service disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board has reviewed all evidence in the claims folders and in the Veteran's electronic claims file (Virtual VA), with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, the Board is not required to discuss, in detail, every piece of evidence of record. See Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board will summarize the relevant evidence as appropriate and the analysis will focus on what the evidence shows, or fails to show, as to the claims. Furthermore, while the Veteran's claims for service connection appear to have been raised solely on a secondary basis to his service-connected PTSD, the RO has considered all theories of entitlement that may warrant a grant of service connection. As such, the Board will likewise do the same. Back Disability A review of the Veteran's STRs does not reflect evidence regarding complaints of low back pain or a clinical finding of a low back disability. After service, a May 1983 VA treatment record noted that the Veteran did a great deal of bending at work. A September 2002 VA treatment record documented the Veteran's report of an 8-9 year history of low back pain without trauma. Also, in September 2002 a diagnosis of "non specific low back pain" was reported. A January 2005 VA treatment record documents a history of left back pain and hematuria with a history of kidney stones. A November 2011 VA treatment record (per Virtual VA) notes the Veteran's continued report of low back pain. The Board notes that generally speaking, pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001) Since its decision in Sanchez-Benitez, the Court has elaborated further on the issue of pain as a disability. The Court has noted that pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system. Still, pain in a particular joint could result in functional loss, but only if it limited the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 36 (2011) (citing to 38 C.F.R. § 4.40). Thus, pain is only compensable as a disability if it causes functional loss as described in Mitchell. See Bosse v. Shinseki, U.S. Vet. App. No. 09-4624 (October 14, 2011). (While the Board recognizes that a single-judge decision, such as Bosse, carries no precedential weight, such a decision may be relied upon for any persuasiveness or reasoning it contains. See Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992).) Even if the Board were to assume that the Veteran suffered from functional loss of his back as per Mitchell, supra, in the present case, not only do the Veteran's STRs not reflect complaints or treatment of back pain or a back disability, but the Veteran has not necessarily alleged that he suffered from back pain or disability as a result of service. Furthermore, he has not submitted medical evidence relating any current back pain/disability to service. The evidence supports the onset of low back pain following active service. As noted above, a September 2002 VA treatment record documents the Veteran's report of an 8-9 year history of low back pain without trauma; thus, the Veteran reports back pain first beginning some 25 years following his release from active service in 1968. Otherwise, the Veteran's argument concerning his claim for service connection appears predicated on a back disability being related to his service-connected PTSD. Medical literature has been submitted discussing a possible connection between PTSD and musculoskeletal disability and chronic pain. The Board finds this evidence to be generic. The literature does not address the Veteran's specific factual situation and is thus not probative evidence. A nexus may be proved if a medical article or treatise evidence, standing alone, discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts. See Sacks v. West, 11 Vet. App. 314, 317 (1998). The medical literature submitted in this case, however, does not demonstrate causality but instead only loose associations. Therefore, the Board has not assigned substantial weight to the literature in its consideration of the Veteran's claim. The Board also notes that in a February 2010 VA Form 21-4142 (see Volume 3 of the claims folders), the Veteran identified that lumbar spurring had been identified on a VAMC Madison X-ray in the year 2000. The Veteran is also noted to have reported a similar history in June 2002 and March 2010 VA treatment records. The Board notes that VA records have been obtained from the VAMC Madison, as noted above, dating back to 1983. A review of these records does not reflect X-ray evidence of lumbar spine spurring. Nonetheless, even assuming such evidence, the Veteran has not alleged any back disability is related to any incident in service, nor has he reported a history of service-related back pain in post-service treatment notes. On the contrary, the Board finds persuasive that the Veteran, as noted above, reported a history of back pain first beginning some 25 years after his release from active service. Otherwise, the Veteran has not submitted evidence relating any current back pain or disability to his period of service. Furthermore, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case-whether the Veteran has a back disability that was incurred in or aggravated by service or is secondary to service-connected disability, falls outside the realm of common knowledge or expertise of the Veteran. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). Therefore, the Board finds that the Veteran does not have a back disability that is related to service or is proximately due to or aggravated by service-connected disability. Thus, service connection is not warranted for a back disability on either a direct or secondary basis. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. Headaches The Veteran's STRs document a report of headaches in May 1968. A review of the report of April 2011 VA examination reflects the examiner's comment that the headaches noted were associated with a diagnosis of early pneumonitis. The examiner ultimately opined that the Veteran's current headaches were more likely tension headaches and that the headaches were not the same headaches as documented in the May 1968 STR or otherwise related to the Veteran's service-connected PTSD. Otherwise, the Veteran's history regarding his headaches has been inconsistent. In an August 1983 VA treatment record, he reported a five-year history of headaches. Thereafter, a February 1986 VA treatment record documents the Veteran's report of headaches since 1969. In 2001, the Veteran reported that his headaches were related to sinus problems. More recently, the Veteran has contended that his headaches first began in service and were related to the firing of the guns of the ship to which he was assigned, the USS Picking (DD-685), a United States Navy destroyer. The Board notes that the Veteran is competent to report experiencing headache pain. Thus, the lack of any report in service of headaches (other than the discussed May 1968 STR) is not necessarily fatal to the Veteran's claim. See McClendon, 20 Vet. App. at 85 (the lack of medical evidence in service does not constitute substantive negative evidence). Nonetheless, the Board finds persuasive the lack of any documented report of treatment for headaches (other than that associated with a diagnosis of early pneumonitis) or a report of headaches at that time of the Veteran's separation from service. See e.g. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011). Also, the Board recognizes that it is not the fault of the Veteran that he cannot procure treatment records from doctors who allegedly treated him for headaches in the 1970s. Still, the fact remains that there is lack of objective evidence of any treatment for headaches prior to 1983. This fact, combined with the lack of any diagnoses or treatment for headaches in service, other than the report of heachaches associated with early pneumonitis, tends to undermine the veracity of the Veteran's statement attributing his headaches to his service period. See e.g., Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (indicating that evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the Veteran's health and medical treatment during and after military service, as evidence of whether a pre-existing condition was aggravated by military service). The Board also finds, as noted above, the Veteran's current allegation that his headaches are due to service conflicts with his earlier reported history. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). See also Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, and/or inconsistency with other evidence of record). When the Board reviews the Veteran's statements in asserting in-service injury and continuity of symptomatology since service, the statements are not entirely consistent with the overall evidence of record or convincing. See, e.g. Madden v. Gober, 125 F.3d 1477, 1481 (1997) (the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration a Veteran's statements, it may consider whether self-interest may be a factor in making such statements). Therefore, in light of the above, the Board finds the Veteran's reported lay history regarding the onset of headaches in service to lack credibility. Otherwise, medical literature has been submitted discussing a possible connection between PTSD and headaches. However, the Board finds this evidence submitted to again be generic. As was discussed with regard to the Veteran's back disability claim, the literature does not address the Veteran's specific factual situation and is thus not probative evidence. Here, a nexus may be proved if a medical article or treatise evidence, standing alone, discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts. Sacks, supra. The medical literature submitted in this case, however, does not demonstrate causality but instead only loose associations. The Board has reviewed all the medical literature submitted, to include articles that address PTSD and physical illness, PTSD and headaches, as well as VA's own literature on PTSD and its health effects. While the literature raises a possible relationship between PTSD and various physical problems, no clear causality is suggested. Therefore, the Board has not assigned substantial weight to the literature in its consideration of the Veteran's claim. The Board does, however, assign substantial probative value to the medical opinion of the above-noted April 2011 VA examiner. The examiner opined that the Veteran's current headaches were more likely tension headaches and that the headaches were not the same headaches as documented in the May 1968 STR. Furthermore, the opinion noted that there was no relationship between the Veteran's PTSD and the occurrence of his headaches as there did not seem to be a time relationship between an exacerbation of the Veteran's PTSD and the Veteran experiencing headaches. The opinion is based on the Veteran's reported history of his headaches as well as a review by the examiner of the claims folders. The examiner provided the rationale for his opinion. The Board finds the opinion to be persuasive. The Veteran has not submitted any medical evidence that necessarily refutes the ultimate conclusion of the examiner. Furthermore, while the examiner did not specifically address the Veteran's lay statements regarding the onset of headaches in service, as the Board has found the Veteran's lay history lacks credibility, any lack of discussion by the examiner does not lessen the probative value of his opinion. Furthermore, although lay persons are competent to provide opinions on some medical issues, Kahana, supra, as to the specific issue in this case-whether the Veteran has headaches that were incurred in or aggravated by service, or are secondary to service-connected disability, falls outside the realm of common knowledge or expertise of the Veteran. Jandreau, supra. Therefore, the Board finds that the Veteran does not have headaches that are related to service or are proximately due to or aggravated by service-connected disability. Thus, service connection is not warranted for headaches on either a direct or secondary basis. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. Neuropathy A review of the Veteran's STRs does not reflect complaints, diagnoses, or treatment for neuropathy, to include peripheral neuropathy. Post-service medical evidence documents an August 2006 VA treatment record in which the Veteran was noted to complain of numbness on the balls of his feet. In September 2006, he was noted to report tingling in his lower extremities. The Veteran has been diagnosed with idiopathic peripheral neuropathy. In the August 2011 VA DBQ, the examiner noted the Veteran's history of a possible onset of neuropathy in 1995 with progressive needle-like pain of the bilateral feet and ankles. The Veteran was noted as not having a diagnosis of diabetes mellitus, and he reported using Gabapentin for nearly a decade. The examiner's diagnosis was unspecified idiopathic peripheral neuropathy. In a September 2011 addendum to her August 2011 DBQ, the examiner commented that the Veteran's service-connected PTSD did not cause or aggravate (permanently worsen) the Veteran's peripheral neuropathy. The examiner explained that peripheral neuropathy was a physical abnormality and PTSD was a mental disorder, and there was nothing anatomically connecting the Veteran's mental disorder to his physical abnormality (peripheral neuropathy). The Board finds the examiner's opinion in this instance to be persuasive. It is based on the Veteran's reported history of his disability as well as a review by the examiner of the claims folders. The examiner provided the rationale for her opinion and the Veteran has not submitted any medical evidence that necessarily refutes the conclusion of the examiner. Medical literature has been submitted discussing a possible connection between PTSD and nervous system disorders (e.g. peripheral neuropathy). However, as the Board has discussed above, the evidence submitted by the Veteran is found to be generic. In this regard, the literature does not address the Veteran's specific factual situation and is thus not probative evidence. A nexus may be proved if a medical article or treatise evidence, standing alone, discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts. Sacks, supra. The medical literature submitted in this case has been reviewed, in particular, the above-discussed articles that address PTSD and physical illness to include VA's own literature on PTSD and its health effects. While the literature raises a possible relationship between PTSD and various physical problems, no clear causality is suggested. Therefore, the Board has not assigned substantial weight to the literature in its consideration of the Veteran's claim. Also, the medical evidence of record does not reflect a diagnosis of peripheral neuropathy within the first post-service year following the Veteran's active service. Thus, service connection for peripheral neuropathy on a presumptive basis (for organic diseases of the nervous system) to service is not warranted. 38 C.F.R. §§ 3.307, 3.309. Also, service connection for peripheral neuropathy on a presumptive basis due to Agent Orange exposure has also been considered. Under 38 C.F.R. § 3.309(e), acute or subacute peripheral neuropathy is a listed disease associated with exposure to certain herbicide agents. Under Note 2, acute or subacute peripheral neuropathy is defined as transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of date of onset. As noted above, the record on appeal reflects that the Veteran was assigned to the USS Picking (DD-685). The ship is documented to have operated on the Saigon River on November 16, 1965. Under 38 CFR § 3.307(a)(6)(iii), eligibility for the presumption of Agent Orange exposure requires that a Veteran's military service have involved "duty or visitation in the Republic of Vietnam" between January 9, 1962 and May 7, 1975. This includes service within the country of Vietnam itself or aboard a ship that operated on the inland waterways of Vietnam. However, this does not include service aboard a large ocean-going ship that operated only on the offshore waters of Vietnam, unless evidence shows that a Veteran went ashore. Inland waterways include the rivers, canals, estuaries, delta areas, and enclosed bays of Vietnam. They do not include open deep-water harbors such as those at Da Nang, Nha Trang, Cam Ranh, or Vung Tau. A review of the Veteran's personnel records reflects that he reported aboard the USS Picking on November 20, 1965. Thus, he was not aboard the USS Picking when the ship operated on the Saigon River. Furthermore, there is a lack of any other evidence that the Veteran's military service involved duty or visitation in the Republic of Vietnam. Thus, the Veteran is not presumed to have been exposed to Agent Orange. Additionally, the evidence does not reflect any manifestation of acute or subacute (i.e. transient) peripheral neuropathy as defined in Note 2 under 38 C.F.R. § 3.309(e). It has been argued that the USS Picking's single day operation on the Saigon River resulted in its exposure to Agent Orange and as a result, the Veteran was later exposed to residuals of Agent Orange still present on the ship when he reported aboard four days later. Thus, it would appear an argument for service connection on a direct basis related to alleged herbicide exposure has been raised. Here, even assuming for the sake of argument that the USS Picking was exposed to herbicides (a fact that has not been substantiated) and that the Veteran did in fact experience incidental exposure four days later, the Veteran has not submitted any medical evidence that attributes his diagnosed idiopathic peripheral neuropathy (as compared to acute or subacute peripheral neuropathy) to alleged in-service herbicide exposure. Thus, service connection on a direct basis for peripheral neuropathy due to herbicide exposure is not warranted. Furthermore, although lay persons are competent to provide opinions on some medical issues, Kahana, supra, as to the specific issues in this case-whether the Veteran has neuropathy (peripheral) that was incurred in or aggravated by service to include alleged herbicide exposure, manifested the first post-service year, or is secondary to service-connected disability, falls outside the realm of common knowledge or expertise of the Veteran. Jandreau, supra. Therefore, the Board finds that the Veteran does not have neuropathy that was incurred in or aggravated by service, manifested within the first post-service year following service; or is proximately due to or aggravated by service-connected disability. Thus, service connection is not warranted for neuropathy on either a direct, presumptive, or secondary basis. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. Increased Rating Tinnitus Disability evaluations are determined by comparing a veteran's present symptoms with criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found), is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran has asserted that he is entitled to a higher disability rating than the currently assigned 10 percent for his service-connected tinnitus. In a report of April 2011 VA examination, the Veteran reported a history of tinnitus in his left ear that began in 1966 after exposure to weapons' noise. The examiner's diagnosis was left ear tinnitus. The Veteran's disability is currently evaluated under 38 C.F.R. § 4.87, Diagnostic Code 6260. Under this diagnostic code, a 10 percent evaluation represents the maximum schedular rating allowable for tinnitus. The Notes following the diagnostic code indicate that only a single evaluation is to be assigned for recurrent tinnitus, whether the sound is perceived in one ear, both ears, or in the head. Thus, a rating in excess of the currently assigned 10 percent for tinnitus is not warranted. Therefore, the Board finds that since the initial grant of service connection, the Veteran's service-connected tinnitus has been assigned the highest allowable schedular rating of 10 percent. 38 C.F.R. §4.87, Diagnostic Code 6260. Consideration has also been given by the Board as to whether the schedular evaluations are inadequate, requiring that the RO refer any of the claims to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra-schedular evaluation. Such a referral is warranted where a service-connected disability presents an exceptional or unusual disability picture that renders impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a claimant's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Analysis must include a discussion of whether the rating criteria adequately address all of the claimant's symptomatology. Extra-schedular ratings under 38 C.F.R. § 3.321 are awarded on a disability-by-disability basis for each individual disability being considered and not on the combined effect of all of a claimant's service-connected disabilities. See Johnson v. Shinseki, 26 Vet. App. 237 (2013). The Veteran's only symptom associated with his tinnitus is ringing in his left ear. The rating criteria under 38 C.F.R. § 4.87, Diagnostic Code 6260 (for recurrent tinnitus) contemplate ringing of the ear or ears. Also, the April 2011 VA examiner noted that the Veteran's tinnitus (and hearing loss) did not have an effect on his occupation or usual daily activities. Thus, the first step of the Thun analysis, whether the rating criteria adequately addresses all of the claimant's symptomatology, has been addressed. As such, the Board's extra-schedular analysis ends, and consideration of the second step-whether the claimant's exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization-is not warranted. Without sufficient evidence reflecting that the Veteran's individual disability picture associated with tinnitus is not contemplated by the rating schedule, referral for a determination of whether the Veteran's disability picture related to tinnitus requires the assignment of an extra-schedular rating is not warranted. 38 C.F.R. § 3.321(b)(1); Thun, supra. Therefore, for all the foregoing reasons, the Board finds since the initial grant of service connection, a rating greater than 10 percent for service-connected tinnitus is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for any higher rating than that assigned, that doctrine is not helpful to the Veteran. See 38 U.S.C.A § 5107(b); 38 C.F.R. § 3.102. Effective Dates The assignment of effective dates of awards is generally governed by 38 U.S.C.A. § 5110 and 38 C.F.R. § 3.400. Unless specifically provided otherwise, the effective date of an award based on a claim for service connection and claim reopened after final adjudication "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefore." 38 U.S.C.A. § 5110(a). The implementing regulation clarifies this to mean that the effective date of service connection based on a claim for service connection will be the "[d]ate of receipt of claim or date entitlement arose, whichever is later." 38 C.F.R. § 3.400. A specific claim in the form prescribed by the Secretary of VA must be filed in order for benefits to be paid to any individual under the laws administered by the VA. 38 U.S.C.A. § 5101(a). A "claim" is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p) (2012). Any communication indicating an intent to apply for a benefit under the laws administered by the VA may be considered an informal claim provided it identifies, but not necessarily with specificity, the benefit sought. See 38 C.F.R. § 3.155(a) (2012). Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. An application is defined as a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). Service connection grant for tinnitus By a May 2011 rating decision, the RO granted service connection and assigned a 10 percent rating for tinnitus. The RO made the award effective from April 9, 2010. The RO accepted a VA Form 21-4142, date stamped April 9, 2010, as an informal claim for service connection for tinnitus. A review of the record reveals that the earliest correspondence that references ringing in the ears is a September 2001 VA Form 21-4138 (Statement in Support of Claim) which was filed in conjunction with a September 2001 VA Form 21-526 (Veteran's Application for Compensation or Pension). The VA Form 21-526 reflects only a claim for service connection for PTSD. Both documents appear to have been received by the RO in December 2001. Thereafter, in a February 2002 notice letter, the RO requested the Veteran clarify (in an enclosed VA Form 21-4138) whether he was seeking service connection for tinnitus. The Veteran submitted a blank VA Form 21-4138 along with a hand written letter in which he discussed his claim for a psychiatric disability but did not reference tinnitus or ringing of the ears. Thus, in light of the lack of response from the Veteran to the RO's clarification request, the Board does not find that an informal claim for service connection for tinnitus was raised by the September 2001 VA Form 21-4138. Since the September 2001 VA Form 21-4138, the first correspondence concerning tinnitus is the above-noted VA Form 21-4142 (noting "ringing in ears" as a disability). A review of the claims folders reflects that the VA Form 21-4142 is date stamped April 9, 2010. At the same time, the document is noted to have been electronically transmitted (faxed) on April 6, 2010. In May 2010, the Veteran's previous representative submitted an informal claim requesting service connection for tinnitus. Reasonable doubt will be found in the Veteran's favor and the date of receipt of the VA Form 21-4142 will be accepted as April 6, 2010 (it being assumed that the document was received at the RO on April 6, 2010, the day it was faxed). The Board notes that there is no correspondence in the claims folders prior to the April 2010 VA Form 21-4142 that can be construed as a claim of service connection for tinnitus. As noted above, the Veteran did not clarify, as requested, his September 2001 statement regarding tinnitus. As the RO has accepted the VA Form 21-4142 as an informal claim, and there is an indication that the document was received by the RO on April 6, 2010. As such, the Board finds that an effective date of April 6, 2010 for the grant of service connection for tinnitus is warranted. As the effective date assigned is the date of receipt of the claim, and because the effective date of an award of service connection is the date of receipt of claim or date entitlement arose, whichever is later, the April 6, 2010 date is the earliest assignable effective date. The Board also notes that 38 C.F.R. § 3.157 (2012) allows for VA examination or hospitalization reports to be considered an informal claim in some instances. However, these provisions are only applicable to claims to reopen and claims for an increase. The Veteran's claim pertaining to tinnitus was an original claim. Thus, § 3.157 does not apply. See e.g. Lalonde v. West, 12 Vet. App. 377, 382 (1999) (The mere presence of medical evidence in the claims file does not constitute a claim of service connection). Consequently, the Board concludes that the criteria for an effective date of April 6, 2010, and no earlier, for the award of service connection for tinnitus have been met. 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400. Service connection grant for PTSD In a September 1995 rating decision the RO denied the Veteran's claim for service connection for PTSD. The Veteran was notified of the decision but did not appeal. Therefore, the Board finds the September 1995 RO decision to be final. 38 U.S.C.A. § 7105 (West 2002). As noted above, on December 14, 2001, the RO received a VA Form 21-526 from the Veteran in which he sought to reopen his claim for PTSD. Under pertinent legal authority, VA may reopen and review a claim which has been previously denied if new and material evidence is submitted by or on behalf of the Veteran. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). The Board notes that there is no correspondence in the claims folders prior to December 14, 2001 that can be construed as a reopened claim of service connection for PTSD. Furthermore, there is no pertinent evidence of record submitted within the appeal period following the September 1995 rating decision that would preclude finality of the September 1995 rating decision. See 38 C.F.R. § 3.156(b). With regard to 38 C.F.R. § 3.157 and its applicability to reopened claims, as noted above, VA examination or hospitalization reports are to be considered an informal claim in some instances. However, per the regulation, the medical reports may be accepted as a claim only when a formal claim for compensation was disallowed for the reason that the service-connected disability was not compensable in degree. That very narrow exception under 38 C.F.R. § 3.157 does not apply in the present case. Here, as the effective date assigned is the date of receipt of the reopened claim, and because the effective date of an award of service connection based on a claim received after a final disallowance (or based on a reopened claim) is the date of receipt of claim or date entitlement arose, whichever is later, the December 14, 2001 date is the earliest assignable effective date. See 38 C.F.R. § 3.400(q)(2), (r). Consequently, the Board concludes that the criteria for an effective date earlier than December 14, 2001 for the grant of service connection for PTSD have not been met. 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400. ORDER Service connection for a back disability is denied. Service connection for headaches is denied. Service connection for neuropathy is denied. An initial rating in excess of 10 percent for tinnitus is denied. An effective date of April 6, 2010 for the grant of service connection for tinnitus is granted, subject to the laws and regulations governing payment of monetary benefits. An effective date prior to December 14, 2001 for the grant of service connection for PTSD is denied. REMAND Service connection for psychiatric disabilities other than PTSD The Veteran is seeking service connection for psychiatric disorders other than his service-connected PTSD. In the Board's May 2009 remand instructions, it was requested that a VA examiner, in particular, identify all psychiatric diagnoses and provide an opinion as to the medical probabilities that each diagnosed disability was attributable to the Veteran's period of active military service. Specific consideration was to be given to anxiety disorder NOS (not otherwise specified), major depressive disorder, and depressive disorder NOS. In the report of July 2009 VA examination, the examiner diagnosed the Veteran with PTSD, panic disorder without agoraphobia, and depressive disorder NOS. The examiner failed to provide a medical opinion as to whether the Veteran's panic disorder without agoraphobia (as the condition was diagnosed at that time) was related to military service. Furthermore, the examiner commented with respect to the diagnosed depressive disorder NOS: The [V]eteran's depressive symptoms at this time are predominantly attributable to his son's suicide and effects of this, as outpatient records indicated that the [V]eteran was generally stable in regard to his depression and PTSD prior to that time. Current depressive symptoms are therefore less likely than not attributable to military experience and at least as likely as not attributable to other severe current stressors. Here, the medical evidence reflects that the Veteran's depressive disorder has been longstanding for many years prior to his son's suicide in April 2009. The examiner's opinion with regard to the depressive disorder appears to focus only on current depressive symptoms/disorder. The examiner's opinion does not clearly address whether any depressive disorder diagnosed prior to the suicide of the Veteran's son was related to service. See e.g. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even though the disability resolves prior to VA's adjudication of the claim). Additionally, in the body of his report, the July 2009 VA examiner references a previously diagnosed anxiety disorder, NOS. While he does not ultimately list an anxiety disorder as an Axis I diagnosis, the Board notes that since the July 2009 examination (per VA outpatient mental health treatment records), the Veteran has been diagnosed with an Axis I anxiety disorder NOS. Therefore, Board concludes that an additional psychiatric examination should be scheduled and the examiner, following his interview of the Veteran and a review of claims folders, should provide an opinion as to the medical probabilities that any diagnosed psychiatric disorder other than PTSD is related to the Veteran's period of service or is otherwise secondary to the Veteran's service-connected PTSD. Higher ratings for service-connected PTSD With regard to the Veteran's claim for a higher rating for his service-connected PTSD, the Board notes that in an August 2011 DBQ, a VA examiner commented, The Veteran's panic attacks are at least as likely as not caused by his panic disorder. Depressed mood and suicidal ideations are at least as likely as not related to his depressive disorder NOS. As symptoms of panic attacks, depressed mood, and suicidal ideation are associated with the rating criteria by which PTSD is evaluated, see 38 C.F.R. § 4.130 (2012), and any grant or denial of the Veteran's pending claims for service connection for a psychiatric disorder (other than PTSD) could have a bearing on the Board's overall evaluation of the Veteran's psychiatric disability, which includes PTSD, the claim for higher staged ratings for PTSD is considered inextricably intertwined with the claims for service connection for psychiatric disabilities other than PTSD. As such, consideration of the merits of the Veteran's claims for an initial rating in excess of 10 percent for PTSD prior to April 15, 2009, as well as the claim for a rating in excess of 30 percent for PTSD since April 15, 2009 is deferred pending completion of the above development and readjudication. Service connection for coronary artery disease As noted in the introduction, supra, in a report of March 2010 VA examination, the examiner related the Veteran's coronary artery disease to hypertension and to hyperlipidemia, following which the Veteran raised claims for service connection for hypertension and for hyperlipidemia. As the RO's decision on the issues of hypertension and/or hyperlipidemia could have a bearing on the Veteran's claim for service connection for coronary artery disease, such claims are inextricably intertwined. As such, consideration of the merits of the Veteran's claim for service connection for coronary artery disease is deferred pending adjudication of his claims for service connection for hypertension and for hyperlipidemia. Service connection for erectile dysfunction In an August 2010 statement, the Veteran filed a claim for service connection for impotency (erectile dysfunction), claiming the condition was secondary to his PTSD medication. Of note, in a December 1995 Monroe Clinic treatment record, the clinician noted that the Veteran was to be tapered off Luvox due to insomnia and sexual dysfunction. In a February 1996 Monroe Clinic treatment record, the Veteran was noted to be taking Luvox and Klonopin and that his sex life was very good. A June 2001 VA treatment record notes that the Veteran had been maintained pretty well on Luvox and Klonopin for the past five years. A June 2002 VA treatment record indicated that the Veteran was not taking medications that contributed to erectile dysfunction. In a report of April 2003 VA examination, it was noted that the Veteran was currently taking Clonazepam (Klonopin) and Fluvoxamine (Luvox) for symptoms of anxiety. An August 2010 VA treatment note reflects the Veteran's reported history of erectile dysfunction for 12 years. The clinician noted that the Veteran had been on Citalopram, which could be contributing to erectile dysfunction, but that the Veteran had not been on Citalopram for the full 12 years during which he reportedly suffered from erectile dysfunction. In a report of September 2010 VA PTSD examination, the examiner (a clinical psychologist) opined that whether the Veteran's erectile dysfunction was related to his PTSD could not be adequately determined without resorting to speculation. The examiner's opinion did not include any reference to the Veteran's use of psychotropic medications. In a report of September 2010 VA genitourinary examination, a VA examiner noted that the Veteran had a long history of psychiatric problems dating back into the 1990s. He had been on various medications for these disorders, and four to six months prior to the examination he had been changed to a combination of Citalopram and Trazodone. The examiner also noted that the Veteran's onset of erectile dysfunction was prior to the use of Citalopram and Trazodone. The examiner opined that from the Veteran's history, as well as from what was documented in the Veteran's medical records, the Veteran's erectile dysfunction predated the onset of the diagnosis of PTSD and certainly predated the use of Citalopram. She concluded that the Veteran's erectile dysfunction was not caused by or permanently aggravated by PTSD or the use of Citalopram. The September 2010 VA examiner's comment that the Veteran's erectile dysfunction predated the "onset of the diagnosis of PTSD," does not appear to be supported by the evidence. Private medical records dated prior to 1998 (the year 1998 being approximately 12 years prior to the September 2010 VA examination) document diagnoses for PTSD as well as other psychiatric conditions. Whether the misreading of the medical evidence influenced the examiner's opinion is unknown. At the same time, the Board notes that the examiner's rationale that the Veteran's erectile dysfunction was not caused by or permanently aggravated by Citalopram appears based on the fact that, per the Veteran's report, he was already suffering from erectile dysfunction at the time he began to use Citalopram. While the examiner reported that she reviewed the Veteran's medical records, it is not clear from her opinion whether the use of the above-noted Luvox (Fluvoxamine) and Klonopin (Clonazepam) during the prior 12-year period played any role in the Veteran's reported erectile dysfunction during that period. Thus, the Veteran should be provided with an additional VA examination to allow for a fully informed medical opinion as to whether any erectile dysfunction diagnosed is proximately due to or aggravated by his PTSD, to include the use of psychotropic medications. Service connection for gastrointestinal disorder A review of the Veteran's STRs reflect an August 1967 treatment note in which the Veteran complained of stomach cramps as well as reported a history of stomach cramps during service. Physical examination at that time revealed mild tenderness of the abdominal wall. The diagnosis was recurrent abdominal wall cramps. A report of medical separation examination does not reflect a finding or complaint regarding a gastrointestinal disorder. Post-service medical evidence documents that in December 1994, the Veteran reported a history of dyspepsia. A recent VA medical problem list notes gastroesophageal reflux disease (GERD). In an August 2011 VA DBQ, the examiner noted that in 2000 the Veteran began to have problems with nausea and vomiting. He was prescribed Ranitidine for the problem. The Veteran reported that currently he was vomiting twice a month and the only thing he could attribute to the vomiting was his anxiety. Otherwise, the Veteran had no lower gastrointestinal complaints such as diarrhea, abdominal cramps, or constipation. It was also reported by the Veteran that he would eat everything and that when he did vomit, it was usually after food consumption. The examiner's diagnosis included GERD. In a September 2011 addendum to her August 2011 DBQ, the examiner commented that the Veteran's service-connected PTSD did not cause or aggravate (permanently worsen) the Veteran's gastrointestinal disorder. The examiner explained that the gastrointestinal disorder was a physical abnormality and PTSD was a mental disorder, and there was nothing anatomically connecting the Veteran's mental disorder to his physical abnormality (gastrointestinal disorder). The Board's review of the medical evidence does not appear to reflect any connection between the Veteran's abdominal cramping in service and his post-service gastrointestinal complaints and the diagnosis of GERD. Nonetheless, since the underlying issue is a medical matter requiring medical evidence for its resolution, the Board may not render its own unsubstantiated determination on the matter. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). In disability compensation claims, VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McClendon, 20 Vet. App. at 81. The Court further characterized the third requirement of "an indication" that a disability "may be" associated with service as a "low threshold." Id at 83. In light of the Veteran's complaints in service, his post-service diagnosis and complaints, and the fact that the August 2011 VA examiner did not comment on whether the Veteran's current digestive disease problems may be related to his complaints of stomach cramps in service, the Board concludes that an additional medical examination and opinion is required before deciding the Veteran's claim on appeal. TDIU The RO's decision on the claims being developed, above, could have a bearing on the Veteran's claim for a TDIU; thus, they are inextricably intertwined. As such, consideration of the merits of the Veteran's claim for a TDIU is deferred pending completion of the requested development. Accordingly, the claims are REMANDED for the following action: 1. Obtain the Veteran's most recent VA treatment records dated from November 2012. (The Veteran's treatment appears to be through the Madison VAMC.) 2. After completion of the above (and allowing a reasonable amount of time to obtain any identified records), schedule the Veteran to undergo appropriate VA examinations pertaining to his psychiatric disorders and his erectile dysfunction. The claims folders and a copy of this remand must be reviewed by the examiners in conjunction with their examinations. Any tests and studies deemed necessary should be conducted and the clinical findings should be reported in detail. Psychiatric Disorders & PTSD The examiner should elicit a detailed history from the Veteran concerning his psychiatric issues and conduct a mental assessment. All necessary tests and studies, including appropriate psychological studies (if determined to be necessary by the examiner) should be conducted. The examiner's review of the claims folders should include the reports of May 1995, April 2003, July 2009, January 2010 (noting a history of panic attacks soon after the Veteran was married in March 1969), and September 2010 VA examinations; as well as August 2011 and January 2013 VA disability benefits questionnaires (DBQ). Review should also include Monroe Clinic treatment records, which document the Veteran's private psychiatric treatment, as well a VA mental health treatment records, documenting (as recently as September 2011) diagnoses of PTSD, anxiety disorder, and depressive disorder. a) The examiner should identify all psychiatric diagnoses and provide an opinion as to the medical probabilities that each diagnosed disability is attributable to the Veteran's period of active military service. (The Veteran is currently service-connected for PTSD). The examiner should also opine as to the medical probabilities that any previously diagnosed psychiatric disability not found on examination by this examiner during his or her examination (e.g. anxiety disorder, panic disorder with or without agoraphobia, depressive disorder), is attributable to the Veteran's period of active military service. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even though the disability resolves prior to VA's adjudication of the claim). The medical basis for any conclusion reached should be thoroughly explained, to include an explanation for a finding that the examiner is unable to render an opinion without resorting to speculation. b) The examiner should evaluate the Veteran's PTSD symptomatology identifying the degree of social and occupational impairment attributable to the Veteran's disability. The evaluation should contain a detailed account of all manifestations of PTSD found to be present. A multi-axial assessment should be provided, and a thorough discussion of Axis V, with an explanation of the numeric code assigned, should be included. The medical basis for any conclusion reached should be thoroughly explained. Erectile dysfunction The examiner should elicit a detailed history from the Veteran concerning his issue with erectile dysfunction. The examiner should review the claims folders, to include the report of September 2010 VA examination as well as review the Board's discussion of the evidence noted in the body of the remand section, above. Thereafter, the examiner should offer an opinion as to the etiology of the Veteran's erectile dysfunction, if diagnosed, and the medical probabilities that any erectile dysfunction was caused or aggravated (permanently worsened beyond its normal progression) by service-connected disability, to include PTSD and/or the use of psychotropic medications (e.g., Luvox (Fluvoxamine), Klonopin (Clonazepam), Citalopram and/or Trazodone)). The medical basis for any conclusion reached should be thoroughly explained, to include discussion of the Veteran's treatment history with psychotropic medications and any adverse sexual effects this may have caused. If the examiner finds that he or she is unable to render an opinion without resorting to speculation, the basis for that conclusion should also be thoroughly explained. Gastrointestinal disorder The examiner should elicit a detailed history from the Veteran concerning any gastrointestinal and/or digestive disease problems, to include GERD. The examiner should review the claims folders, to include the Veteran's service treatment records (in particular, an August 1967 treatment note in which the Veteran complained of stomach cramps as well as reported a history of stomach cramps during service; the diagnosis was recurrent abdominal wall cramps) as well as a report of August 2011 VA examination and the subsequent September 2011 VA addendum opinion. Furthermore, the examiner should review the Board's discussion of the evidence noted in the body of the remand section, above. Thereafter, the examiner should examine the Veteran and identify any current gastrointestinal disorder. The examiner should offer an opinion as to the medical probabilities that any diagnosed gastrointestinal disorder is attributable to the Veteran's period of active service or was caused or aggravated (permanently worsened beyond its normal progression) by service-connected disability, to include PTSD. The medical basis for any conclusion reached should be thoroughly explained. If the examiner finds that he or she is unable to render an opinion without resorting to speculation, the basis for that conclusion should also be thoroughly explained. 3. After the above has been completed, undertake any additional evidentiary development deemed appropriate. Thereafter, re-adjudicate the claims remaining on appeal. (Consideration should be given to the Veteran's raised claims for service connection for hypertension and for hyperlipidemia prior to readjudication of the Veteran's claim for service connection for coronary artery disease.) If any benefit sought is denied, the Veteran and his attorney must be provided a supplemental statement of the case and given an opportunity to respond before the case is returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims remanded by the Board 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). ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs