Citation Nr: 1331412 Decision Date: 09/30/13 Archive Date: 10/02/13 DOCKET NO. 10-13 508 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to a compensable initial evaluation for recurrent tension headaches. 2. Entitlement to a compensable evaluation for residuals of a right orbit fracture. 3. Entitlement to service connection for degenerative joint disease of the left knee. 4. Entitlement to service connection for degenerative joint disease of the right knee, to include as secondary to a left knee disability. 5. Entitlement to service connection for degenerative joint disease of the left shoulder. 6. Entitlement to service connection for vision loss, to include as secondary to a service-connected right orbit fracture. 7. Entitlement to service connection for obstructive sleep apnea, to include as secondary to a service-connected right orbit fracture. 8. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities. 9. Entitlement to service connection for a low back disability, to include degenerative disc disease of the lumbosacral spine with spinal stenosis. 10. Entitlement to service connection for hypertension. 11. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD). 12. Entitlement to service connection for bilateral hearing loss. 13. Entitlement to a total rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Katz, Counsel INTRODUCTION The Veteran served on active duty from September 1966 to September 1969. These matters are before the Board of Veterans' Appeals (Board) on appeal from June 2009 and September 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office in Detroit, Michigan (RO). The Veteran presented testimony before the undersigned Veterans Law Judge (VLJ) in May 2013. A transcript of that hearing has been associated with the Veteran's claims file. In May 2013, the Veteran submitted additional evidence with a waiver of his right to have his claim readjudicated with the additional evidence. See 38 C.F.R. § 20.1304(c) (2012). Service connection for a low back disorder and hypertension were denied by a June 2009 rating decision. The Veteran did not submit a notice of disagreement with respect to those issues. In May 2010, he filed new claims for entitlement to service connection for a low back disorder and hypertension. Nevertheless, new and material evidence received prior to the expiration of the appeal will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b) (2012). In this case, the Veteran identified pertinent VA treatment records dated within one year of the unappealed June 2009 rating decision. Accordingly, the Veteran's claims for entitlement to service connection for a low back disorder and entitlement to service connection for hypertension have been pending since the June 2009 rating decision, and are properly characterized as claims for entitlement to service connection, rather than claims to reopen the issues of entitlement to service connection, as reflected on the cover page of this decision. See Bond v. Shinseki, 659 F.3d 1362, 1367-8 (Fed. Cir. 2011); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). The issues of entitlement to a compensable initial evaluation for recurrent tension headaches; entitlement to a compensable evaluation for residuals of a right orbit fracture; entitlement to service connection for degenerative joint disease of the bilateral knees; entitlement to service connection for degenerative joint disease of the left shoulder; entitlement to service connection for vision loss; entitlement to service connection for obstructive sleep apnea; entitlement to service connection for peripheral neuropathy of the bilateral lower extremities; entitlement to service connection for a low back disorder; entitlement to service connection for bilateral hearing loss; and entitlement to a TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. On May 1, 2013, prior to the promulgation of a decision in the appeal, the Veteran withdrew his appeal as to the issue of entitlement service connection for hypertension. 2. The Veteran has a current diagnosis of PTSD that is associated with an in-service stressor which is related to fear of hostile military activity. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the substantive appeal by the Veteran for the issue of entitlement to service connection for hypertension have been met. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012). 2. PTSD was incurred in active military service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.303, 3.304, 4.125 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawal of Issue 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 in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202. Withdrawal may be made by the Veteran or by his or her authorized representative. 38 C.F.R. § 20.204. By a June 2009 rating decision, the RO denied the Veteran's claim for entitlement to service connection for hypertension. Although he did not file a timely notice of disagreement, VA treatment records pertinent to his claim dated in April 2010 were received by the Board. Another rating decision denying entitlement to service connection was issued in September 2010. In October 2010, the Veteran filed a notice of disagreement, and in July 2012, he perfected his appeal. However, during a May 2013 hearing before the Board, and in a May 2013 written statement, the Veteran withdrew his appeal regarding that issue. With no allegation of error of fact or law remaining before the Board, the Board does not have jurisdiction to review the issue of entitlement to service connection for hypertension, and it is dismissed. II. PTSD Without deciding whether VA's statutory notice and development requirements have been satisfied in the present case, the Board finds that the Veteran is not prejudiced by its appellate adjudication of the issue of entitlement to service connection for a psychiatric disorder, to include PTSD, at this time. The Board's determination herein below granting service connection for this disorder represents a full grant of the benefit sought on appeal. As such, this decision poses no risk of prejudice to the Veteran. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); see also Pelegrini v. Principi, 17 Vet. App. 412 (2004). Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). 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. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection for PTSD requires (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f) (2012). A diagnosis of a mental disorder, including PTSD, must conform to the criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 38 C.F.R. § 4.125. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(f)(1). If the Veteran did not engage in combat with the enemy or if the claimed stressors are not related to combat, then the Veteran's testimony alone is not sufficient to establish the occurrence of the claimed stressors, and his testimony must be corroborated by credible supporting evidence. See Cohen v. Brown, 10 Vet. App. 128 (1997); Moreau v. Brown, 9 Vet. App. 389 (1996); Dizoglio v. Brown, 9 Vet. App. 163 (1996); Fossie v. West, 12 Vet. App. 1, 6 (1998). During the pendency of this appeal, the criteria for verifying in-service stressors were amended, effective July 13, 2010. The amendment states that If a stressor claimed by a veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f)(3). The Veteran contends that he was exposed to numerous stressors during his military service which caused his current PTSD, including fearing for his life every day during his service in Vietnam due to exposure to enemy fire. During his May 2013 hearing before the Board, in a May 2009 VA examination, and in various statements, the Veteran reported that he worked as a combat engineer in the field, based at Dak Tao, Vietnam. He explained that his base was under enemy fire on a very regular basis, and that every day he feared that he might die. He also reported that he was responsible for bringing back the bodies of about 1500 soldiers in the 173rd Airborne Division who died during the Hill 875 Massacre in 1967. He noted that he vomited from the sight of his dead comrades who died, and that he still has flashbacks when he hears a helicopter. He stated that he felt terror while performing these duties, and that he felt that he would die in Vietnam as well. The Board acknowledges that the Veteran also reported a stressor based on personal assault; however, as the Veteran's claim for entitlement to service connection for PTSD is granted herein based upon his stressors related to fear of hostile military or terrorist activity, there is no need to discuss that particular stressor. The Veteran's service treatment records and personnel records are negative for any complaints or diagnoses of a psychiatric disorder. The Veteran's service personnel records show that he had service in Vietnam from April 1967 to April 1968, and that his principal duty during his Vietnam service was security force with an Engineer Battalion. His DD Form 214 indicates his military occupational specialty was Pioneer, a position comparable to a civilian construction worker. The records reflect that the Veteran participated in the Vietnam Counter-Offensive Phases II, III, and IV, as well as the Vietnam Tet Offensive. He received various medals, including the Vietnam Service Medal with four Bronze Service Stars; the Republic of Vietnam Campaign Medal; and the National Defense Service Medal. VA treatment records from March 2009 reflect the Veteran's complaints of and treatment for depression. The Veteran reported exaggerated startle response to loud noises, and indicated that he has had those symptoms since he was a combat engineer and heard heavy artillery and mortar attacks nearby while he was constructing airstrips and building bridges. He stated that he witnessed the aftermath of mortar attacks and dead bodies being brought in body bags. The physician noted that the Veteran had been screened for PTSD but did not meet the criteria. The diagnosis was major depressive episode with melancholic features. Another March 2009 record reveals that the Veteran felt that his emotional problems were related to combat during service. The diagnosis was depression, but possible PTSD was noted in the treatment plan. In May 2009, the Veteran underwent a VA PTSD examination. The Veteran reported several traumatic experiences during his Vietnam service. He stated that he felt that he might die every day, and that one of his friends stepped on a mine and was killed in Cam Rahn Bay. He noted that he was stationed at a base where they were building an airstrip and there were about 1500 people in the 173rd Airborne Division who died. He reported that he was responsible for bringing back the bodies, and that he continues to have flashbacks whenever he hears a helicopter. He also reported that his company was mortared several times and that they were ambushed a lot. He complained of depression and agitation during service and also reported a personal assault where he was kicked in the face. The Veteran complained of symptoms including difficulty getting along with others, anger, irritability, poor impulse control, anger outbursts, sleep disturbance, nightmares, trouble connecting with others, social isolation, and lack of interest in activities once enjoyed. He also noted feeling hopeless about his future, difficulty concentrating, suspiciousness, exaggerated startle response,, and a history of suicidal thoughts. He also reported a long history of substance abuse, noting that he began using marijuana and opium when he was in Vietnam, as they helped him to calm down and deal with the situation, as he was always afraid of death. He revealed that he continued to use marijuana and alcohol to relieve stress until the mid-1990s. Mental status examination showed the Veteran to have fair grooming and hygiene. Mood was anxious and affect was normal. Speech was normal and the Veteran denied suicidal or homicidal ideation. There was no evidence of hallucinations or paranoid delusions. Thought process was organized and goal-directed. The Veteran was alert and fully oriented. Insight and judgment were fair. The VA examiner diagnosed chronic PTSD, combat related. The examiner explained that, based on the information provided by the Veteran, he met the DSM-IV criteria for PTSD which is combat-related. The examiner also noted that the Veteran's substance abuse started while he was in Vietnam, and that it was his way of coping with stress. A June 2009 VA treatment record shows that a PTSD screen was positive. The Veteran reported various psychiatric symptoms. The diagnosis was PTSD. In a June 2009 statement, M. Mitchell, a VA physician's assistant, reported that the Veteran revealed that he has continuously had problems with nightmares related to his time in Vietnam, and that he had other psychiatric symptoms such as mood swings, irritability, anger, depression, and isolation. She noted that the Veteran scored positive on a PTSD screen. In a June 2009 lay statement, K.S. explained some of the Veteran's numerous psychiatric symptoms, which she observed. She noted that the Veteran opened up to her about his experiences in Vietnam. In June 2009, the RO made a formal finding that there was not enough information to conduct a meaningful search with the U.S. Army and Joint Services Records Research Center (JSRRC), the Marine Corps, or the National Archives and Records Administration (NARA) to corroborate the Veteran's reported stressors. In a May 2010 Vet Center letter, the Veteran's counselor reported that the Veteran had been receiving treatment for PTSD symptoms since October 2009. The counselor explained the Veteran's PTSD symptoms and therapy, and stated an opinion that the Veteran's PTSD symptoms were related to his combat experiences in the Vietnam War. After a thorough review of the evidence of record, the Board concludes that service connection for PTSD is warranted. The medical evidence of record shows that the Veteran has a current diagnosis of PTSD for VA purposes. See 38 C.F.R. § 4.125. However, the RO has not made any attempt to verify any of the Veteran's reported stressors. Additionally, the evidence of record does not reveal that the Veteran engaged in combat with the enemy, as the Veteran's service personnel records give no evidence of participation in combat, and the Veteran does not allege that he engaged in combat with the enemy. Further, there is no objective evidence that the Veteran was awarded decorations, medals, badges, or commendations confirming participation in combat. Although the Veteran is not objectively shown to have participated in combat during service which would allow the Board to accept the Veteran's lay statements as conclusive evidence of a stressor's occurrence, the regulatory changes which became effective on July 13, 2010 state that the Veteran's lay testimony alone is sufficient to establish the occurrence of a claimed in-service stressor if that stressor is related to the Veteran's fear of hostile military or terrorist activity. "Fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f). As noted above, the Veteran reported various stressors related to his fear of hostile military or terrorist activity. Specifically, he reported that, as a combat engineer working in the field, his base was under enemy fire on a regular basis, and that he feared that he might die. He also reported fear and terror and confrontation with the death of others while bringing back the bodies of soldiers who died during the Hill 875 Massacre in 1967. Although the May 2009 VA examiner concluded that the Veteran's PTSD was "combat related," the stressors upon which the VA examiner's diagnosis of PTSD was based included those stressors relating to the Veteran's fear of hostile military or terrorist activity, and not actual combat with the enemy. In that regard, the only stressors suggestive of combat reported by the Veteran include fearing that he might die when his company was mortared and ambushed and being confronted with actual death of others when bringing back bodies of soldiers who died in the Hill 875 Massacre in 1967. Therefore, even though the examiner appears to have linked the Veteran's PTSD to combat, the stressors reported by the Veteran suggestive of combat do not, in fact, show that the Veteran engaged in combat with the enemy. The stressors upon which the diagnosis of PTSD is based are the stressors which are related to the Veteran's fear of hostile military or terrorist activity. Accordingly, the May 2009 VA examination is sufficient to establish that the claimed stressors reported involving fear of hostile military or terrorist activity are adequate to support a diagnosis of PTSD. Moreover, the Veteran's stressors are consistent with the places, types, and circumstances of his service, as his service personnel records reflect that he worked in construction and in the security force in support of Phases II, III, and IV of the Vietnam Counteroffensive and the Vietnam Tet Offensive. The Board finds no reason to question the credibility of the Veteran's statements regarding his exposure to artillery fire during service and his resulting fear and terror. Accordingly, in accordance with the regulatory changes made to 38 C.F.R. § 3.304(f)(3), effective July 13, 2010, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressors. Therefore, there is competent and credible evidence of record which establishes the occurrence of the Veteran's claimed stressors that relate to the Veteran's fear of hostile military or terrorist activity, as well as a VA opinion confirming that the claimed stressors are adequate to support a diagnosis of PTSD. Thus, the Board finds that the Veteran has a current diagnosis of PTSD that is associated with in-service stressors related to fear of hostile military activity. See 38 C.F.R. § 3.304(f)(3) (July 13, 2010). Applying the doctrine of reasonable doubt, the Board finds that the Veteran's PTSD is related to his active military service and therefore, service connection for PTSD is warranted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER The appeal as to the issue of entitlement to service connection for hypertension is dismissed. Entitlement to service connection for PTSD is granted. REMAND With regard to the Veteran's remaining claims, the Board concludes that additional development is necessary in order to comply with VA's duty to assist. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102 , 3.156(a), 3.159, 3.326(a). I. Initial Compensable Evaluation for Tension Headaches Entitlement to service connection for tension headaches, as a residual of traumatic brain injury, was granted by a September 2010 rating decision, and a noncompensable evaluation was assigned, effective July 17, 2009. The Veteran asserts that his headaches are worse than indicated by the assigned noncompensable evaluation. In that regard, the Veteran's testimony at the May 2013 hearing before the Board suggests that his symptoms may have worsened since his last VA examination. The Veteran testified that he had headaches approximately six times per month, and that he is immobilized from doing anything else when he has a headache. The record reflects that the Veteran was last provided with a VA examination addressing the severity of his tension headaches in June 2010, more than three years ago. To ensure that the record reflects the current severity of the Veteran's service-connected disability, the Veteran should be provided with a more contemporaneous VA examination. See 38 U.S.C.A. § 5103A (2002); 38 C.F.R. § 3.159 (2012); see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the veteran with a thorough and contemporaneous medical examination); Weggenmann v. Brown, 5 Vet. App. 281 (1993) (VA has a duty to provide an examination when there is evidence that the disability has worsened since the previous examination). The Veteran also testified during his hearing before the Board that he has had additional treatment at the VA Medical Center in Ann Arbor, including its traumatic brain injury clinic, for his headaches. Thus, the RO should ensure that all updated VA treatment records are associated with the claims file. See 38 C.F.R. § 3.159 (2012); Bell v. Derwinski, 2 Vet. App. 611 (1992). II. Compensable Evaluation for Residuals of a Right Eye Fracture During his May 2013 hearing before the Board, the Veteran testified that he had recent treatment for his residuals of a right eye disability at the VA Medical Center in Ann Arbor, and that he wished to have those records considered in determining the appropriate evaluation for his residuals of a right eye fracture. In that regard, he noted treatment as recent as December 2012 or January 2013. The Veteran's claims file reflects that the most recent VA treatment records from the Ann Arbor VAMC are dated in 2010. Accordingly, the RO must associate all updated VA treatment records pertaining to the Veteran's right eye with the claims file. Id. III. Service Connection for Vision Loss The Veteran was provided with a VA examination in May 2010 to determine the existence and etiology of any eye disorder found. The VA examiner diagnosed refractive error and presbyopia. The examiner opined that the Veteran's mild refractive error was seemingly stable since childhood and that he did not have any residual ocular complications from eye trauma that he sustained during service. Although the VA examination report reflects that the VA examiner reviewed the Veteran's claims file, the VA examiner does not appear to have considered the Veteran's service treatment records, which do not show a pre-existing refractive error at service entrance. The basis for the examiner's finding that the Veteran has had refractive error since childhood is unclear, as the Veteran has denied ocular complaints prior to service. Moreover, the service treatment records document that the Veteran underwent right eye surgery during service, but the examiner reported that it was "unknown" whether the Veteran underwent any prior eye surgeries. Also, the examiner concluded that the Veteran did not have visual problems, although refractive error was documented on examination. While refractive errors of the eyes are congenital or developmental defects and not diseases or injuries within the meaning of applicable legislation, service connection for such defects is possible if there is evidence of additional disability due to aggravation during service by a superimposed disease or injury. 38 C.F.R. §§ 3.303(c), 4.9 (2012); see VAOPGCPREC 82-90, 56 Fed. Reg. 45,711 (1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury); Sabonis v. Brown, 6 Vet. App. 426 (1994). Even though the Veteran contends that his current vision loss is related to his in-service right eye injury, the VA examiner did not provide an opinion as to whether the Veteran's vision loss was caused or aggravated by his in-service right eye injury or his service-connected residuals of a right eye fracture. Accordingly, as it does not appear that the May 2010 VA opinion was based on a thorough review of the pertinent evidence of record, the Board finds the opinion provided to be inadequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one). IV. Service Connection for Bilateral Knees, Left Shoulder, and Low Back Disorders During his May 2013 hearing before the Board, the Veteran testified that he believed that his current degenerative arthritis of the bilateral knees, left shoulder, and low back were the result of wear and tear due to the type of work that he performed during service. Specifically, he explained his belief that his arthritis was caused by heavy lifting and strain from building underground bunkers. He noted bilateral knee, back, and left shoulder pain and soreness during service and since that time, but reported that he did not seek treatment during service. The Veteran also alleged that his left knee degenerative joint disease was the result of an in-service left knee injury. He reported that, while building underground bunkers in Vietnam, a beam fell on his left leg, injuring his knee. He stated that he received treatment during service, and that he has had problems with weight bearing, giving way, pain, and weakness continuously since service. In addition to his allegations that his right knee disorder was caused by his duties during service, he contends that his current right knee arthritis is the result of altered gait from his left knee disability. Although the Veteran underwent a VA joints examination in September 2010, review of the examination report reflects that it is inadequate upon which to base an appellate decision. The VA examiner diagnosed degenerative joint disease in the left shoulder and both knees and degenerative joint and disc disease involving the lumbar spine. The examiner opined that the Veteran's low back, left shoulder, and bilateral knee disorders were not related to his active duty service based upon the lack of evidence in the service treatment records showing left shoulder, low back, and right knee complaints as well as finding that, although the service records revealed left knee complaints, there was no chronic left knee disability shown. However, the VA examiner did not address any of the Veteran's lay statements and testimony that he had symptoms during service and continuously since that time, even in the absence of objective medical evidence of chronic disabilities. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury but relied on the service medical records to provide a negative opinion). Thus, as the September 2010 VA examiner did not consider the Veteran's lay statements of in-service symptomatology and continuous symptomatology since that time, the opinion provided is inadequate, and a new VA examination must be provided with consideration of the Veteran's lay statements. Washington v. Nicholson, 19 Vet. App. 363 (2005). With regard to his back disability, the Veteran testified that he began experiencing symptoms approximately one and a half years after service discharge, and that he received treatment for his back disability at that time at the VA Medical Center in Los Angeles. As those records are not of record, the RO should obtain them and associate them with the claims file. See 38 C.F.R. § 3.159; Bell, 2 Vet. App. 611. V. Service Connection for Peripheral Neuropathy The Veteran's claim for entitlement to service connection for peripheral neuropathy is inextricably intertwined with his claim for entitlement to service connection for a low back disability, as the Veteran contends that his peripheral neuropathy is the result of a service-connected low back disorder. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Therefore, Board adjudication of the claim for entitlement to service connection for peripheral neuropathy must be deferred pending completion of the actions requested below. VI. Service Connection for Obstructive Sleep Apnea The Veteran alleges that his current obstructive sleep apnea is due to his military service. During a May 2013 hearing before the Board, the Veteran testified that he had symptoms of sleep apnea during service, including waking up in the middle of the night and not being able to breathe. He alleges that these symptoms might be related to his in-service right eye injury following an assault, which also resulted in a deviated septum. He reported that he has had these symptoms continuously since service discharge. The Veteran also contends that his current obstructive sleep apnea was caused or aggravated by his service-connected residuals of a right orbit fracture. In light of the Veteran's contentions as well as the medical evidence showing diagnoses of and treatment for obstructive sleep apnea, the Veteran should be provided with a VA examination to determine the etiology of his current obstructive sleep apnea. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). VII. Service Connection for Bilateral Hearing Loss The Veteran alleges that his current bilateral hearing loss was caused by noise exposure from artillery fire during service in Vietnam. As noted during the Veteran's May 2013 hearing before the Board, exposure to acoustic trauma during service is conceded. The Veteran underwent a VA audiological examination in June 2009 with regard to his claim. However, the opinion provided by the VA examiner is not adequate. Barr, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one); see also Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (noting that when the medical evidence of record is insufficient, in the opinion of the Board, the Board must supplement the record by seeking an advisory opinion or ordering a medical examination). In that regard, the June 2009 VA examiner diagnosed right ear mild sloping to moderate hearing loss and left ear moderate sloping to severe hearing loss. However, the examiner concluded that the Veteran's hearing loss was not related to his military service because "the discharge audiological evaluation yielded normal hearing bilaterally." However, the absence of in-service evidence of a hearing disability during service is not always fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service (as opposed to intercurrent causes). See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). As the law does not require hearing loss to be manifest during service, or at any specified time thereafter, in order to establish service connection for hearing loss, the rationale provided by the examiner is inadequate. Moreover, it does not appear that the VA examiner took into consideration the Veteran's lay statements that he had symptoms of hearing loss during service, and worsening after service discharge. Accordingly, the Veteran should be provided with a new VA examination to determine the etiology of his current bilateral hearing loss. The issue of entitlement to a TDIU has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Such issue is deemed to be part and parcel of the increased rating issues on appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009). As such, the issue must be forwarded to the RO for adjudication pior to appellate consideration by the Board. Accordingly, the case is REMANDED for the following action: 1. Obtain all VA treatment records from the VA Medical Center in Detroit, Michigan, and any associated outpatient clinics, for the prior 30 years; all records from the VA Medical Center in Ann Arbor, Michigan and any associated outpatient clinics dated from 2010 to the present; and all records from the VA Medical Center in Los Angeles dating from 1970 to the present, and associate them with the claims file. All attempts to obtain these records should be documented in the claims file. 2. Schedule the Veteran for an examination to determine the current severity of his tension headaches. The claims file and a copy of this Remand must be made available to and reviewed by the examiner in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail. Any diagnostic tests deemed necessary for an accurate assessment must be conducted. The examiner must record all pertinent medical complaints, symptoms, and clinical findings, and must review the results of any testing prior to completion of the report. A complete rationale for any opinion stated must be provided. 3. Schedule the Veteran for a new VA eye examination to determine the nature and etiology of any bilateral eye disorder found, to include vision loss. The claims file and a copy of this Remand must be made available to and reviewed by the examiner in conjunction with the examination. All necessary special studies or tests must be accomplished. After a thorough review of the Veteran's claims file, to include the Veteran's statements of record, the medical evidence including all service treatment records, and a discussion of each, the examiner must provide the following opinions: * Is it at least as likely as not (50 percent probability or greater) that any diagnosed eye disorder, to include vision loss, is related to the Veteran's active duty service? * If the Veteran is found to have an eye disorder which is a congenital or developmental defect, such as refractive error, is it at least as likely as not (50 percent probability or greater) that this congenital or developmental defect was subjected to a superimposed disease or injury during service which created additional disability, including the documented in-service right eye injury? * Is it at least as likely as not that any current eye disability, to include vision loss, was caused or aggravated by the Veteran's service-connected residuals of a right eye fracture? Aggravation is defined as a permanent worsening beyond the natural progression of the disease. In providing the requested opinions, the examiner must consider the Veteran's lay statements and testimony, and for purposes of this examination, should presume the Veteran's lay statements to be credible. The examiner must provide a complete rationale for all conclusions reached. If the examiner cannot provide the requested opinions without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. 4. Schedule the Veteran for a new VA joints examination to determine the nature and etiology of any bilateral knee, left shoulder, and back disorder found. The claims file and a copy of this Remand must be made available to and reviewed by the examiner in conjunction with the examination. All necessary special studies or tests must be accomplished. After a thorough review of the Veteran's claims file, to include the Veteran's statements and testimony of record, the medical evidence including all service treatment records, and a discussion of each, the examiner must provide the following opinions: * Is it at least as likely as not (50 percent probability or greater) that any diagnosed left knee disability is related to the Veteran's active duty service, including his documented in-service left knee injury? * Is it at least as likely as not (50 percent probability or greater) that any diagnosed right knee disability is related to the Veteran's active duty service, including wear and tear caused by the Veteran's in-service duties? * Is it at least as likely as not (50 percent probability or greater) that any diagnosed right knee disability was caused or aggravated by the Veteran's left knee disability? Aggravation is defined as a permanent worsening beyond the natural progression of the disease. * Is it at least as likely as not (50 percent probability or greater) that any diagnosed left shoulder disability is related to the Veteran's active duty service, including wear and tear caused by the Veteran's in-service duties? * Is it at least as likely as not (50 percent probability or greater) that any diagnosed low back disability is related to the Veteran's active duty service, including wear and tear caused by the Veteran's in-service duties? In providing the requested opinions, the examiner must consider the Veteran's lay statements and testimony, to include his reports of experiencing pain and soreness in his knees, back, and left shoulder during service as well as his reports of symptomatology since service discharge. For purposes of this examination, the examiner should presume the Veteran's lay statements to be credible. The examiner must provide a complete rationale for all conclusions reached. If the examiner cannot provide the requested opinions without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of his diagnosed obstructive sleep apnea. The claims file and a copy of this Remand must be made available to the examiner in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail. Following a thorough review of the claims file, to include the service and post-service treatment records and the Veteran's testimony of record, the examiner must provide the following opinions: * Is it at least as likely as not (a 50 percent probability or more) that the Veteran's obstructive sleep apnea began during service or is otherwise related to service, to include an in-service right eye injury? * Is it at least as likely as not (a 50 percent probability or more) that the Veteran's obstructive sleep apnea was caused or aggravated by his service-connected residuals of a right eye fracture? Aggravation is defined as a permanent worsening beyond the natural progression of the disease. In providing the requested opinions, the examiner must consider the Veteran's lay statements and testimony, and for purposes of this examination, should presume the Veteran's lay statements to be credible. The examiner must provide a complete rationale for all conclusions reached. If the examiner cannot provide the requested opinions without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. 6. Schedule the Veteran for a new VA audiological examination to determine the nature and etiology of any current bilateral hearing loss found. The claims file and a copy of this Remand must be made available to and reviewed by the examiner in conjunction with the examination. All necessary special studies or tests must be accomplished. After a thorough review of the Veteran's claims file, to include the Veteran's statements and testimony of record, the medical evidence including all service treatment records, and a discussion of each, the examiner must provide the following opinion: * Is it at least as likely as not (50 percent probability or greater) that any diagnosed bilateral hearing loss is related to the Veteran's conceded in-service exposure to acoustic trauma from artillery fire? In providing the requested opinion, the examiner must consider the Veteran's lay statements and testimony, to include his reports of in-service hearing loss which worsened after service discharge, and for purposes of this examination, should presume the Veteran's lay statements to be credible. The examiner must provide a complete rationale for all conclusions reached. If the examiner cannot provide the requested opinions without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. 7. Notify the Veteran that it is his responsibility to report for the examinations and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 8. When the above development has been completed, readjudicate the increased rating and service connection issues on appeal. If any benefit sought on appeal remains denied, provide an additional supplemental statement of the case to the Veteran, and afford the Veteran an adequate opportunity to respond, prior to returning those issues to the Board for appellate review. 9. Thereafter, forward the Veteran's claims folder to an appropriate VA clinician for review and request an opinion as to whether it is at least as likely as not that the service-connected disabilities, considered in combination preclude substantially gainful employment consistent with the Veteran's educational attainment and occupational experience. Rationale should be provided for the opinion proffered. 10. When the above development has been completed, adjudicate the issue of entitlement to a TDIU. If that benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran, and afford the Veteran an adequate opportunity to respond, prior to returning the issue to the Board for appellate review. The appellant 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 claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs