Citation Nr: 1334716 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 07-11 930 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied claim for entitlement to service connection for vascular headaches with associated nausea and vomiting; and if so, whether service connection for a headache disability is warranted. 2. Entitlement to service connection for a skin condition, to include as due to Agent Orange exposure. 3. Entitlement to service connection for bilateral foot condition. 4. Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD). 5. Entitlement to a compensable evaluation for the service-connected hemorrhoid disability. 6. Entitlement to initial increased evaluation in excess of 30 percent prior to February 7, 2008 and in excess of 50 percent from February 7, 2008 to April 4, 2011, for the service-connected PTSD disability. 7. Entitlement to a total disability rating due to individual unemployability (TDIU) prior to April 5, 2011. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L.B. Cryan, Counsel INTRODUCTION The Veteran served on active duty in the United States Air Force from June 1968 to August 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2006, a July 2008, and a September 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office in Waco, Texas (RO). In the June 2006 rating decision, the RO awarded service connection for PTSD and assigned a 30 percent evaluation, effective from November 21, 2005. Also, in that rating decision, the RO denied the claims for service connection for skin rash and bilateral foot condition. In pertinent part of the July 2008 rating decision, the RO denied the claim for service connection for hypertension and the claim for a compensable evaluation for hemorrhoid disability. The RO also declined to reopen the previously denied claim for entitlement to service connection for vascular headaches. In the September 2009 rating decision, the RO denied entitlement to TDIU. By the way of an October 2008 rating decision, the RO increased the assigned evaluation for PTSD disability from 30 to 50 percent disabling, effective from February 7, 2008. In a June 2012 rating decision, the RO increased the assigned evaluation for PTSD disability to 100 percent disabling, effective April 5, 2011. As this is a total grant of the benefits on appeal, the claim for an increase since April 5, 2011 is no longer in appellate status or before the Board. However, the increase rating claims for PTSD disability remain pending for the periods prior to April 5, 2011. See AB v. Brown, 6 Vet. App. 35 (1993). Additionally, the grant of a 100 percent rating for PTSD renders the claim for TDIU moot for the period beginning April 5, 2011, the effective date of the total rating for PTSD disability. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) (the award of a 100 percent schedular disability rating effectively moots a claim for entitlement to a TDIU from the effective date of the 100 percent rating). See also Locklear v. Shinseki, 24 Vet. App. 311, 314, n.2 (2011). The claim for TDIU remains pending for the period prior to April 5, 2011 and will be addressed below. On his VA Form-9s, substantive appeals, dated in March 2007, September 2007, and September 2009, the Veteran indicated his desire to testify before a member of the Board at the RO. However, in several correspondences, with the most recent one dated in January 2010, the Veteran stated that he wish to withdraw those hearing requests. See 38 C.F.R. § 20.704(e) (providing that a designated representative may withdraw a hearing request). The case was remanded in November 2012 for additional development of the record. Regardless of whether the RO substantially complied with the remand instructions, the Veteran has elected to withdraw the issues of entitlement to service connection for a skin condition, to include as due to Agent Orange exposure; entitlement to service connection for bilateral foot condition; entitlement to a compensable evaluation for the service-connected hemorrhoid disability; entitlement to initial increased evaluation in excess of 30 percent prior to February 7, 2008 and in excess of 50 percent from February 7, 2008 to April 4, 2011, for the service-connected PTSD disability; and, entitlement to a total disability rating due to individual unemployability (TDIU) prior to April 5, 2011. Thus, any defect with regard to whether the RO substantially complied with the November 2012 remand instructions is harmless error with respect to these claims. Finally, the RO originally adjudicated the Veteran's claim as entitlement to service connection for vascular headaches with associated nausea and vomiting; however, recent treatment records show a diagnosis of migraine headaches. The United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Although the claim here is for a headache disability, the same concept applies. Therefore, given multiple diagnoses with regard to the Veteran's headaches, the issue is recharacterized as shown on the first page of this decision and it is acknowledged that such description includes a claim of entitlement to service connection for all currently diagnosed headache disorders. In addition to the paper claims file, there is a Virtual VA (VVA) electronic claims file associated with the Veteran's claim. The documents in the VVA file have been reviewed, and all relevant records are either duplicative of the evidence in the paper claims file or are separately identified and summarized below. The reopened claim of service connection for a headache disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In correspondence received at the Board in August 2013, and prior to the promulgation of a decision in the appeal, the Veteran indicated his request to withdraw from appellate status the issues of entitlement to service connection for a skin disorder, to include as secondary to in-service Agent Orange exposure; entitlement to service connection for a bilateral foot condition; entitlement to a compensable evaluation for the service-connected hemorrhoid disability; entitlement to initial increased evaluation in excess of 30 percent prior to February 7, 2008 and in excess of 50 percent from February 7, 2008 to April 4, 2011, for the service-connected PTSD disability; and, entitlement to a total disability rating due to individual unemployability (TDIU) prior to April 5, 2011. 2. The Veteran perfected an appeal to the Board as to the RO's August 1972 rating decision that denied service connection for headaches on a direct basis; and the August 1973 rating decision that denied service connection for headaches on the basis of aggravation. 3. In March 1974, prior to Board certification, the Veteran withdrew his appeal to the Board as to the issue of entitlement to service connection for a headache disability. 4. In unappealed September 1974, and December 1978 rating decisions, the RO did not reopen the Veteran's previously denied claim of service connection for vascular headaches associated with nausea and vomiting because new and material evidence had not been received. 5. The evidence associated with the claims file subsequent to the RO's December 1978 rating decision includes evidence that relates to an unestablished fact necessary to substantiate the claim, is neither cumulative nor redundant of evidence already of record, and raises a reasonable possibility of substantiating the claim of service connection for a headache disability. 6. The Veteran's hypertension is unrelated to service and was not caused or aggravated by a service-connected disability, including PTSD. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal by the Veteran have been met, with regard to the issues of entitlement to service connection for a skin disorder; entitlement to service connection for a bilateral foot condition; entitlement to a compensable evaluation for the service-connected hemorrhoid disability; entitlement to initial increased evaluation in excess of 30 percent prior to February 7, 2008 and in excess of 50 percent from February 7, 2008 to April 4, 2011, for the service-connected PTSD disability; and, entitlement to a total disability rating due to individual unemployability (TDIU) prior to April 5, 2011. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012). 2. The RO's August 1972, August 1973, February 1974, September 1974 and December 1978 denials of service connection for a headache disability are final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2012). 3. As pertinent evidence received since the RO's December 1978 denial is new and material, the criteria for reopening the claim for service connection for a headache disability are met. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2013). 4. The criteria for service connection of hypertension are not met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawn Claims The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. After the case was certified to the Board on appeal, but before a decision was promulgated, the Board received written notice from the Veteran in August 2013 requesting to withdraw his appeal as to the following 5 issues certified to the Board: (1) entitlement to service connection for a skin condition, to include as due to Agent Orange exposure; (2) entitlement to service connection for bilateral foot condition; (3) entitlement to a compensable evaluation for the service-connected hemorrhoid disability; (4) entitlement to initial increased evaluation in excess of 30 percent prior to February 7, 2008 and in excess of 50 percent from February 7, 2008 to April 4, 2011, for the service-connected PTSD disability; and, (5) entitlement to a total disability rating due to individual unemployability (TDIU) prior to April 5, 2011. In light of the foregoing, the appellant has withdrawn this appeal as to the issues of entitlement to service connection for a skin condition, to include as due to Agent Orange exposure; entitlement to service connection for bilateral foot condition; entitlement to a compensable evaluation for the service-connected hemorrhoid disability; entitlement to initial increased evaluation in excess of 30 percent prior to February 7, 2008 and in excess of 50 percent from February 7, 2008 to April 4, 2011, for the service-connected PTSD disability; and, entitlement to a total disability rating due to individual unemployability (TDIU) prior to April 5, 2011. Therefore, there remain no allegations of errors of fact or law for appellate consideration with respect to those issues. Accordingly, the Board does not have jurisdiction to review the these issues and they are therefore dismissed. II. Notice and Assistance Given the favorable nature of the Board's decision on the issue of whether new and material evidence has been received to reopen the previously denied claim of service connection for a headache disability, there is no prejudice to the appellant, regardless of whether VA has satisfied its duties of notification and assistance with respect to reopening the previously denied claim. In other words, despite any defect in the notice provided to the Veteran regarding new and material evidence, the matter is subsequently reopened by the Board; thus, any defect in this regard results in harmless error. See Kent v. Nicholson, 20 Vet. App. 1 (2006). With respect to the claim of service connection for hypertension, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). A February 2008 letter satisfied the duty to notify provisions, to include notice related to secondary service connection. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The letter also notified the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The claim was subsequently readjudicated, most recently in an August 2013 supplemental statement of the case. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran's service treatment records, VA medical treatment records, and private treatment records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran was asked to provide additional private records, or releases to allow VA to obtain records on his behalf, in the November 2012 Board remand and duty to assist letter. The Veteran has not indicated that there are any obtainable outstanding records pertinent to his claim of service connection for hypertension. The RO obtained the Veteran's Social Security Administration disability records, which include records of the determination, and supporting medical records 38 C.F.R. § 3.159 (c) (2). VA examinations were afforded the Veteran regarding his hypertension in June 2008 and July 2009. The June 2008 and the July 2009 examiners made all necessary clinical findings and offered requested medical opinions with supporting rationales based on sound medical principles with regard to the hypertension. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). They are adequate for adjudication purposes. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). The RO substantially complied with the remand instructions regarding the issue of service connection for hypertension by obtaining all relevant VA records and requesting authorization to obtain any additional private treatment records that would support his claim. The RO also obtained the Veteran's records related to his Social Security Disability claim and determination. The examinations provided to the Veteran after the remand are not pertinent to the Veteran's hypertension claim; thus, any defect in the examinations with regard to the hypertension claim is harmless error. No further action is necessary in this regard with respect to the issue of entitlement to service connection for hypertension. See D'Aries v. Peake, 22 Vet. App. 97, 106 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In addition to the paper claims file, there is a Virtual VA (VVA) electronic claims file associated with the Veteran's claim. The documents in the VVA file have been reviewed, and all relevant records are either duplicative of the evidence in the paper claims file or are separately identified and summarized below. III. New and Material Evidence - headache disability The Veteran seeks service connection for a headache disability, which has been previously denied by the RO. Thus, the claim must first be reopened before the Board can address the merits of the underlying service connection claim. In an August 1972 rating decision, the Veteran was denied entitlement to service connection for headaches on a direct basis. The rating decision explained that the claim was denied because headaches were not noted on the Veteran's discharge examination. The claim was subsequently re-adjudicated in an August 1973 rating decision. In that decision, the RO denied the Veteran's claim based on a finding that any pre-existing headache disability was not permanently aggravated during service. The Veteran submitted a timely Notice of Disagreement (NOD) with those decisions and the RO subsequently issued a Statement of the Case (SOC) in August 1973, and the Veteran perfected his appeal to the Board with the timely submission of a VA Form 1-9 received at the RO in October 1973. In a February 1974 rating decision, the RO confirmed and continued the denial of service connection for a headache disability and the RO issued a Supplemental Statement of the Case (SSOC) in February 1974. Before the case was certified to the Board on appeal, the Veteran requested to withdraw his appeal in a March 1974 VA Form 21-4138 (Statement in Support of Claim). As this claim was withdrawn, all of the prior rating decisions addressing the issue of service connection for vascular headaches with associated nausea and vomiting became final. In the same March 1974 VA Form 21-4138, the Veteran requested the RO to reopen the claim of service connection for a headache disability on a presumptive basis because the evidence showed treatment for headaches within the one year period following discharge from service. In an unappealed September 1974 rating decision, the RO confirmed and continued the previous denial of service connection for vascular headaches associated with nausea and vomiting on the basis of being incurred in or aggravated by service; and, because the diagnosed condition was not one that was subject to the presumption provisions. Similarly, in an unappealed December 1978 rating decision, the RO did not reopen the Veteran's previously denied claim of service connection for vascular headaches associated with nausea and vomiting because new and material evidence had not been received. The Veteran's most recent claim of service connection for headaches was received at the RO in July 2007, and the RO found that new and material evidence had not been received to reopen the previously denied claim of service connection for vascular headaches associated with nausea and vomiting in the July 2008 rating decision currently on appeal. Prior unappealed decisions are final. However, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a). When "new and material evidence" is presented or secured with respect to a previously and finally disallowed claim, VA must reopen the claim. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). New evidence means evidence not previously submitted to agency decisionmakers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2013). In order to reopen a previously and finally disallowed claim, there must be new and material evidence presented or secured since the time that the claim was finally disallowed on any basis. Evans v. Brown, 9 Vet. App. 273 (1996). The Court interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4) , which, "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). In reaching a determination on whether the claim should be reopened, the reason for the prior denial should be considered. In essence, at the time of the prior denials, the Board found that a vascular headache disability was not shown on the Veteran's discharge examination; that the Veteran's headaches began during childhood and were not aggravated by service; and, because the criteria were not met for the establishment of service connection on a presumptive basis. Pertinent evidence of record at the time of the December 1978 rating decision included service treatment records, a VA neurological examination, VA outpatient treatment records, private treatment records, and the Veteran's statement that his current headache disability began in service, or in the alternative, any preexisting headache disability was permanently aggravated in service. The above records show the following: the Veteran had headaches during service; The Veteran was treated within a year following discharge from service; the Veteran may have had a pre-existing headache disability; and continuity of symptoms since service. None of the evidence shows when the current headache disability, which now includes a diagnosis of migraine, had its onset; or whether any pre-existing headache disability was aggravated during service; and/or whether the current headache disability is secondary to or made worse by the service-connected PTSD. Since the RO's December 1978 final denial, evidence has been added to the claims file including the establishment of service connection for PTSD, and the Veteran's statement that his headache disability and gastrointestinal symptoms are related to his service-connected PTSD. Additional VA outpatient medical records and VA examinations added to the file since the December 1978 decision show a diagnosis of PTSD, a diagnosis of migraines, and raise the possibility of aggravation of a pre-existing headache disability during service. Additionally, this new evidence raises the possibility that the Veteran has a headache disability secondary to the PTSD. Further, the Veteran has stated that he did have headaches as a child, but that his headaches in service were much more severe. Given the new evidence showing a possibility of a link between the Veteran's active service and his headaches; and/or the possibility that his headaches may be secondary to the PTSD, (and, presuming the credibility of the Veteran's statements for the purpose of reopening the claim), the additional evidence is new and material. Specifically this evidence is neither cumulative nor redundant and raises a reasonable possibility of substantiating the claim, as the records suggests that the Veteran may have aggravated a pre-existing headache disability or that there may be a link between the headaches and his PTSD. Therefore, the claim for service connection for a headache disability must be reopened and re-adjudicated on the merits. III. Service Connection - hypertension Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Some chronic diseases may be presumed to have been incurred in service, if they first become manifest to a degree of ten percent or more within the applicable presumptive period. Migraine is a listed chronic disease for purposes of presumptive service connection, as an organic disease of the nervous system. 38 U.S.C.A. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). The applicable presumptive period is one year following separation from service. 38 C.F.R. § 3.307(a)(3). Insofar as the appellant presents an argument of continuity of symptomatology, the U.S. Court of Appeals for the Federal Circuit held that service connection can be based on continuity of symptomatology only with respect to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed.Cir. 2013). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). In order to establish service connection on a direct basis, the record must contain: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a) (West 2002); 38 C.F.R. § 3.303(a) (2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Service treatment records reveal no complaints of or treatment for hypertension. The Veteran's blood pressure reading on his June 1968 entrance examination was 120\70. At a July 1969 pre-deployment (to Vietnam) physical, the Veteran's blood pressure reading was 102/60. During the June 1972 discharge examination it was 120/80. These readings do not approach VA's regulatory definition of hypertension set out in 38 CFR § 4.104, Diagnostic Code 7101, note 1. These are the sole pressure readings reflected in the service records. No readings are noted with treatment of any other condition. Further, elevated blood pressure readings were not identified as such in the record and hypertension was not diagnosed. Based on these findings, hypertension was not first manifested on active duty service. In essence, the record does not reflect, and the Veteran does not assert, that hypertension had its onset in service. Rather, the Veteran maintains that his hypertension is secondary to his PTSD. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown , 7 Vet. App. 439, 448 (1995) (en banc). The first evidence in the claims file of high blood pressure readings and/or a diagnosis of hypertension comes from Veteran's VA outpatient treatment records dated in 2003. A July 2003 VA outpatient record shows that the Veteran's blood pressure was 145/88, and the assessment was hypertension. The note also indicates that the Veteran was already on hypertension medication (Metoprolol - 50 mg. daily) prior to that date. At a VA examination in June 2008, the Veteran's hypertension was described as benign, essential hypertension, well controlled on medication without complications. The examiner indicated that no large scientific studies have shown hypertension to result from PTSD, noting that the VA Normative Aging Study did not find elevation in blood pressure in the most severe PTSD cases. Thus, the examiner opined, it was unlikely that the hypertension resulted from the Veteran's PTSD. At a VA examination in July 2009, the issue of whether the Veteran's hypertension is aggravated by the service-connected PTSD was addressed. The Veteran's three blood pressure readings on the day of the exam were all in the normal range. The examiner indicated that the Veteran's hypertension was of the essential type, was well controlled with medicine and was less likely than not associated with PTSD since a review of the medical literature does not show any definite studies that PTSD is a cause of hypertension. The examiner also opined that the hypertension was not "associated" with the Veteran's service. In sum, there is no evidence of record, aside from the Veteran's own belief, that his hypertension is caused by or aggravated by the service-connected PTSD. The Veteran is not found to have the medical expertise necessary to determine the cause of his hypertension, or whether it is permanently aggravated by the PTSD. Even assuming, arguendo, that he was competent in this regard, the Veteran's statements are outweighed by the VA examiners' opinions finding no relationship or association between the Veteran's hypertension and PTSD. The examiner provided rationale for the opinions, and cited to the results medical studies to support the opinion. With regard to aggravation, the Veteran's blood pressure is controlled with medication. This is shown most recently at a May 2012 VA general medical examination. At that time, the Veteran's blood pressure was described as "controlled," and his blood pressure on examination was 103/67. Further, outpatient treatment records in Virtual VA show that the Veteran's blood pressure readings at a July 2012 VA stress test were: (0) BP:129/92 (1) BP:124/66 (2) BP: (no reading) (3) BP:137/87 (4) BP:135/88 (5) BP:131/89 A pre-test blood pressure was recorded as BP: 155/89. As such, the competent and objective evidence demonstrates that the hypertension was not caused by the PTSD, and was not aggravated by the PTSD. Although there are VA treatment records in the Veteran's virtual VA folder that show an occasional high blood pressure reading, (see e.g., January 2012 VA outpatient record noting a blood pressure reading of 152/90) the overall hypertension condition has not been shown to have permanently worsened at any time during the appeal period. According to 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1), the term "hypertension" (for the purposes of this section) means that the diastolic blood pressure is predominantly 90 mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. The Veteran's blood pressure readings to not reflect these parameters. As no permanent worsening is shown, there can be no permanent aggravation of the hypertension. The two VA medical examiners' opinions that the current hypertension is neither caused by the service-connected PTSD, nor otherwise associated with it, are entitled to great probative weight as they are based on a review of the history and a physical examination, and as a rationale based on sound medical principals was provided for the opinions. It is noted that the 2009 examiner did not specifically use the phrase, "is not aggravated by" in the opinion; however, this examiner specifically indicated that the hypertension was "less likely than not associated with the PTSD." Because the examiner found no association between the hypertension and the PTSD, then there can be no aggravation. In essence, there would have to be some association between the PTSD and the hypertension in order to consider whether one aggravates the other. As there is no competent evidence to support the Veteran's claim of service connection for hypertension, service connection is not warranted. The doctrine of reasonable doubt has been considered, but the record does not provide an approximate balance of negative and positive evidence on the merits. No reasonable basis has been identified for granting service connection for hypertension. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2013). ORDER The claim of entitlement to service connection for a skin disorder, to include as secondary to in-service Agent Orange exposure, is dismissed. The claim of entitlement to service connection for a bilateral foot condition is dismissed. The claim of entitlement to a compensable evaluation for the service-connected hemorrhoid disability is dismissed. The claim of entitlement to initial increased evaluation in excess of 30 percent prior to February 7, 2008 and in excess of 50 percent from February 7, 2008 to April 4, 2011, for the service-connected PTSD disability is dismissed. The claim of entitlement to a total disability rating due to individual unemployability (TDIU) prior to April 5, 2011 is dismissed. The previously denied claim of service connection for a headache disability is reopened. Service connection for hypertension is denied. REMAND The Veteran seeks service connection for a headache disability, variously diagnosed as vascular headache with nausea and vomiting; and, migraine. VA regulations provide that VA will assist a veteran by providing a medical examination or obtaining a medical opinion based upon review of the evidence of record if VA determines that it is necessary to decide the claim. 38 C.F.R. § 3.159(c)(4)(i) (2013). In this case, the Veteran has not been afforded VA examinations to address these claims, but as will be discussed in detail below, they are necessary in order to fairly decide the claims. See 38 C.F.R. § 3.159(c)(4) (2013); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran may have had a pre-existing headache disability which began during childhood, as shown in the records obtained shortly after discharge from service. An October 1972 VA clinical record indicates that the Veteran had onset of headaches at age 6; then he was knocked unconscious from a blow to the head when he was age 8 or 9. The Veteran reported an increase in the frequency of his headaches. What is unclear is whether the Veteran's increased headaches began during service in Vietnam, as he has stated, or whether they began after the blow to the head at age 8 or 9. It is also unclear as to whether the type of headache shown in service and after discharge from service is the same disability as the headaches during childhood. Thus, there is a question as to whether the Veteran developed a headache disability in service; or, whether any pre-existing headache disability was permanently aggravated during service beyond the natural progression of the disability. The VA treatment records dating from 1972 through the present show fairly consistent complaints of headache and the Veteran has consistently maintained that his [current] headache disability began when he was in Vietnam. In light of the foregoing, an examination is necessary to address these issues. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file, or virtual VA file, all VA medical records pertaining to the Veteran not currently of record. 2. With appropriate authorization from the Veteran, obtain and associate with the claims file all pertinent private treatment records identified by the Veteran that have not already been obtained. 3. Schedule the Veteran for a VA examination with a neurologist to determine the current nature and likely etiology of the Veteran's headaches. The claims file must be made available to and reviewed by the examiner in conjunction with the examination. The examiner should specifically indicate the current nature of all headaches, including by limited to, vascular headaches and/or migraine headaches. The examiner is asked to opine as to whether it is at least as likely as not (a probability of 50 percent or greater) that any current headache disability began in service; or is otherwise related to any disease, injury or other event in service. If not, then the examiner should opine as to whether it is at least as likely as not that any headache disability clearly and unmistakably pre-existed service; and if so, whether the headache disability was permanently aggravated (made worse) during service beyond the natural progression of the disability. The examiner must provide a complete rationale for any stated opinions. In responding to this question, the examiner should consider the Veteran's comments that his current headache disability had its onset during service in Vietnam, as he is competent to state that he has severe headaches that began during Vietnam. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 4. The Veteran must be given adequate notice of the date(s) and place(s) of any requested examination(s). A copy of all notifications, including the address where the notice was sent must be associated with the claims folder. The Veteran is to be advised that failure to report for a scheduled VA examination without good cause shown may have adverse effects on his claim. Ensure that all examinations are adequate, and if not, return the examination for clarification. 5. After completing any additional necessary development, readjudicate the issues remaining on appeal. If the disposition of any of the claims remains unfavorable, furnish the Veteran and his representative a supplemental statement of the case and afford the applicable opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs