Citation Nr: 1533086 Decision Date: 08/04/15 Archive Date: 08/11/15 DOCKET NO. 14-28 226 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial compensable evaluation for eczematous dermatitis with onychomycosis of the feet. 2. Entitlement to an increased evaluation for posttraumatic stress disorder (PTSD), initially rated at 30 percent from February 24, 2005 to August 4, 2011, and at 50 percent thereafter. 3. Whether new and material evidence has been received to reopen a claim for service connection for hypertension, including due to Agent Orange exposure, and/or as secondary to service-connected PTSD. 4. Whether new and material evidence has been received to reopen a claim for service connection for kidney cancer, status post nephrectomy, including due to Agent Orange exposure and/or contaminated water at Camp Lejeune. 5. Entitlement to service connection for hyperaldosterone condition. 6. Entitlement to service connection for tremors. 7. Entitlement to service connection for insomnia. 8. Entitlement to service connection for sleep apnea associated with PTSD. 9. Entitlement to service connection for peripheral artery disease. 10. Entitlement to service connection for colon cancer. 11. Entitlement to service connection for incontinence. REPRESENTATION Appellant represented by: Douglas Sullivan, Esq. WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2014). 38 U.S.C.A. § 7107(a)(2) (West 2014). The Veteran served on active duty from October 1968 to July 1972. This included service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from several rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, including with regard to the initial disability ratings assigned pursuant to the grant of service connection for PTSD, as well as for eczematous dermatitis with onychomycosis of the feet. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Herein the Board recharacterizes issues of service connection for hypertension and kidney cancer that were ostensibly reopened by the RO, as petitions to reopen prior denied claims, given that whether to reopen is committed entirely to the Board's discretion. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). Moreover, the petition to reopen service connection for hypertension is amended to include secondary service connection as due to PTSD, which theory is to be reconsidered upon remand. There are additional issues regarding which the Veteran through his attorney has filed timely Notice of Disagreement (NOD), and for which a Statement of the Case (SOC) must now be provided, in particular the last four issues denoted above on the title page. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). A Board videoconference hearing was held before the undersigned Veterans Law Judge (VLJ) in June 2015, and soon thereafter additional new evidence was received accompanied by waiver of RO initial review as the appropriate Agency of Original Jurisdiction (AOJ). See 38 C.F.R. §§ 20.800, 20.1304 (2014). By February 2015 statement, the Veteran's attorney further informally raised the issue of entitlement to compensation under 38 U.S.C.A. § 1151 for residuals of inoperably and metastasized renal cell carcinoma, alleging additional disability due to negligence or otherwise faulty medical care on the part of VA. This claim under 38 U.S.C.A. § 1151 has not been adjudicated in the first instance and therefore is not before the Board. The matter is referred to the RO as the proper Agency of Original Jurisdiction (AOJ) for initial adjudication. See 38 C.F.R. § 19.9(b) (2014). Moreover, whereas by prior final RO rating decision the Veteran was denied entitlement to a total disability rating due to individual unemployability based on service-connected disability (TDIU), the Veteran's attorney again raised the issue of TDIU during the June 2015 Board hearing. It is averred that this more recent TDIU claim is "inextricably intertwined" with the claim already on appeal for increased rating for service-connected PTSD. See generally, Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Under such circumstances, the Board often may assume jurisdiction of a TDIU claim outright, absent of an appeal having been perfected in the matter. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Here however, by May 2014 final rating decision the RO already denied TDIU with direct consideration of service-connected PTSD and evidence finding psychiatric impairment not to cause unemployability, nor has substantial new evidence since come to light. The Board therefore does not deem TDIU to still be a component of an increased rating for PTSD, and instead refers the matter of a TDIU to the AOJ. In view of the remand of other issues below, it could not be decided as part of this appeal in any event. The claims for an increased evaluation for dermatological condition of the feet, reopened claims for service connection for hypertension and kidney cancer, and finally, those requiring initial issuance of a Statement of the Case are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. Through request at the June 2015 Board hearing the Veteran and his attorney withdrew from appeal the claims for service connection for hyperaldosteronism, tremors, and insomnia. 2. From the February 24, 2005 effective date of service connection through January 5, 2010, the Veteran's PTSD involved occupational and social impairment with reduced reliability and productivity. 3. From January 6, 2010, PTSD involved occupational and social impairment with deficiencies in most areas. 4. The December 2009 Board decision that denied original claims for service connection for hypertension, and for kidney cancer, both then claimed as due to exposure to Agent Orange, became final after the appellant was notified of the decision and did not appeal. 5. Since then, additional evidence has been received with presents a reasonable possibility of substantiating these claims. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal of the claims for service connection for hyperaldosterone condition, tremors, and insomnia have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2014). 2. With resolution of reasonable doubt in the Veteran's favor, the criteria are met for a 50 percent initial rating for PTSD, from February 24, 2005 to January 5, 2010. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2014). 3. With resolution of reasonable doubt in the Veteran's favor, the criteria are met for a 70 percent rating for PTSD, since January 6, 2010. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2014). 4. The December 2009 Board decision which denied service connection for hypertension, and for kidney cancer, is final. 38 U.S.C.A. §§ 7104 (West 2014); 38 C.F.R. §§ 3.104(a), 20.1100 (2014). 5. New and material evidence has been received to reopen these previously denied claims. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Claims Withdrawn on Appeal 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. In June 2015, the Veteran withdrew the appeal regarding the issues of entitlement to service connection for hyperaldosterone condition, tremors and insomnia. There remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review these claims on appeal and they are dismissed. II. Claims Under Appellate Review The Duty to Notify and Assist the Claimant The Veterans' Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103A, 5107, 5126 (West 2014), prescribes several requirements as to VA's duty to notify and assist a claimant with the evidentiary development of a pending claim for compensation or other benefits. See also 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326 (2014). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must inform the claimant of any information and evidence (1) that is necessary to substantiate the claim; (2) that the claimant is expected to provide; and (3) that VA will seek to provide on the claimant's behalf. See also Pelegrini v. Principi, 18 Vet. App. 112, 120-121 (2004). Regarding the petitions to reopen service connection presently before the Board, reopening is warranted, with remand of the underlying claims for service connection to the RO for further development and adjudication. At this time, no determination on the matter of VCAA compliance is warranted, pending further development and readjudication of the claims on the merits. As to an increased evaluation for PTSD, the requirement of VCAA notice (as distinct from concomitant duty to assist) does not apply. Where a claim for service connection has been substantiated and an initial rating and effective date assigned, the filing of a Notice of Disagreement with the RO's decision as to the assigned disability rating does not trigger additional 38 U.S.C.A. § 5103(a) notice. The claimant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to either of these "downstream elements." See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). See also Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007). This is the case here, in that the claim for service connection for the underlying disability has been substantiated, and no further notice addressing the downstream disability rating requirement is necessary. Proper action has been undertaken to comply with the duty to assist the Veteran through obtaining records of VA and private outpatient treatment, obtaining records from a disability claim with the Social Security Administration (SSA), and arranging for him to undergo VA Compensation and Pension examinations. See 38 C.F.R. §4.1 (for purpose of application of the rating schedule accurate and fully descriptive medical examinations are required with emphasis on the limitation of activity imposed by the disabling condition). The Veteran provided several personal statements. He testified at a Board hearing, during which he received proper assistance in developing his claim. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). The record as it stands includes sufficient competent evidence to decide the claim. Under these circumstances, no further action is necessary to assist the Veteran. In sum, the record reflects that the facts pertinent to the claim have been properly developed and that no further development is required to comply with the provisions of the VCAA or the implementing regulations. Accordingly, the Board will adjudicate the claim on the merits. Increased Rating for PTSD Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by diagnostic codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. The Veteran's service-connected PTSD is to be evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411 according to VA's General Rating Formula for Mental Disorders. Under that rating formula, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating may be assigned where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessed rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The symptoms and manifestations listed under the above rating formula are not requirements for a particular evaluation, but are examples providing guidance as to the type and degree of severity of these symptoms. Consideration also must be given to factors outside the rating criteria in determining the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). A veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Additionally, while symptomatology should be the primary focus when deciding entitlement to a given disability rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused the requisite occupational and social impairment. Id. Reviewing the evidence since the February 24, 2005 effective date of service connection, August 2005 private psychiatric evaluation found the Veteran irritable, withdrawn, with neat appearance but sad and fearful expression. Motor behavior was decreased. Speech was hurried. Mood and affect were liable. Sensorium showed inability to concentrate, suspiciousness, feelings of persecution, worthlessness, blame of others, and thought blocking. Judgment and insight were poor. There was difficulty falling asleep. The diagnosis was PTSD, severe. Thereafter, the evidence available is limited, and the next relevant item is the January 2010 report of private psychological evaluation, and identified symptoms of recurrent disturbing dreams and insomnia, avoidance of and anxiety response towards certain loud and disturbing sounds, avoidance of reminders of his service, hypervigilance, emotional numbness and sense of detachment, marital problems and social withdrawal. Further indicated was outburst of anger and irritability, difficulty concentrating at work and in other situations, difficulty relaxing when at home, and exaggerated startle response. Occupation was also affected as a result of the Veteran's concentration problems, and lack of tolerance for working in "team-oriented" work situations. A Global Assessment of Functioning (GAF) score was found of 50. Due to PTSD in the psychologist's view, the Veteran experienced, overall, occupational and social impairment with occasional decrease in work efficiencies and intermittent periods of inability to perform occupational tasks due to problems in concentration and mild memory impairment, due to depressed mood, anxiety, chronic sleep impairment, and mild short-term memory loss. Having undergone VA Compensation and Pension examination of October 2010, the Veteran reported experiencing nightmares related to service, three times per week, along with intrusive memories from service when he was confronted by someone in a hostile manner. He experienced psychological distress and physiological reactivity to reminders, and reported for example that when he heard a helicopter overhead he had the impulse to take cover. He avoided fireworks displays and going into the woods. He had no memory of some of the operations he had been listed as having participated in. He stated that when he returned from Vietnam, he was no longer outgoing and began avoiding others. He had no contact with his siblings. Regarding symptoms of hyperarousal, he reported difficulty with initial and middle insomnia. He could not sleep well because he was afraid something might happen. He was hypervigilant, and if heard the slightest noise while asleep he had gotten up and grabbed his shotgun. He had anger issues, and when lost his temper became very combative verbally and started yelling, cursing and arguing. He denied acting out violently, but stated in the past he had thrown things. The Veteran also reported being depressed since being deployed to Vietnam, and stated that his depression had worsened over the years, and the most recent episode had been ongoing for several years. He reported guilt that he should have accomplished more with his lift. He noted some decreased participation in his usual physical activities, though he attributed this change to medical problems. He did still enjoy learning to play the guitar, as well as photography and teaching. He reported low energy and difficulty concentrating, but he attributed the latter symptom to physical pain. He added that he felt "weighed down and hideous." He denied suicidal/homicidal ideation, intent, plan, or past attempts. However, he admitted to transient thoughts of suicide. He denied symptoms of psychosis, including auditory/visual hallucinations, delusional thoughts, or paranoid ideation. There was no history of psychiatric hospitalizations. He had undergone numerous prior sessions of psychotherapy, and found the treatment beneficial and experienced a decrease in his symptoms. He stated that he had started to feel better about himself and his ability to fit in with others in particular, but then experienced a return of symptoms due to traumatic circumstances from his personal life. He stated that he had no other periods of remission from his symptoms. He was taking one or more psychotropic medications, with some side effects present. Regarding his hygiene and adaptive daily living skills, the Veteran reported that he was able to manage self-care tasks independently. He reported that two to three days a week he would go without bathing and would wear the same shorts each day. He had recently gone a week without bathing because he was very depressed. He denied any history of illicit substance abuse or dependence. On mental status examination, the veteran presented reporting depressed and irritable mood. Affect was at times dysphoric but he presented in no acute distress and was observed laughing when describing his traumatic events. He was adequately dressed and groomed. He appeared slightly younger than his stated age of 62. He was alert and oriented to person, place, time, and situation. He was an excellent historian and was fully cooperative throughout the evaluation. Thought processes were coherent, logical, and linear. Thought content was relevant and absent of any loosening of associations or delusions. He denied suicidal/ homicidal ideation, intent, or plan. His speech was of normal rate rhythm, and volume. Eye contact, gait and posture were within normal limits and he did not exhibit any psychomotor agitation or retardation. Insight and judgment were good. Based on the examination, there was no evidence to suggest that the Veteran was not capable of managing his own benefits if awarded. The Veteran completed a PTSD symptom checklist as diagnostic testing, and the VA examiner commented that this score was inconsistent with the Veteran's self-report and presentation, suggesting a high likelihood of over reporting of symptoms. The diagnosis given was PTSD and dysthymic disorder, with GAF found of 65. The examiner further indicated in conclusion that the Veteran did meet the diagnostic criteria for PTSD. The Veteran reported clinically significant symptoms of re-experiencing, avoidance, and increased arousal. His responses on diagnostic testing were indicative of some exaggeration of symptoms and were not consistent with his self-report and presentation. He did however report clinically significant symptoms of depression that met the diagnostic criteria for dysthymic disorder and were considered also at least in part due to military service. Regarding extent of psychosocial impairment, the Veteran had reported increasing social withdrawal over the years. He had some social contacts, but primarily maintained relationships via telephone and also did not participate in celebrating major holidays. His wife reported that he lacked closeness and intimacy with her. He denied that he had ever experienced any work related problems and was working part-time as a photography professor, the part-time status being attributable to unrelated back pain. He reported that his symptoms had recently impacted his hygiene, stating that he was so depressed that he did not bathe for a week and wore the same clothes the whole time. It was highly recommended that the Veteran continue with individual psychotherapy, and adjust his dosage of psychotropic medication for maximum beneficial impact. Records of VA outpatient treatment indicate in February 2013 the Veteran reported persistent initial and middle insomnia, sleep 3-4 hours per night. He also mentioned anger, irritability and isolating himself. Objectively, general appearance was casually dressed and groomed. Interview behavior was calm, cooperative, and in no acute distress. Speech was of normal rate and rhythm. Flow of though was logical, sequential, and goal-oriented. Memory was intact to recent and remote events, as was concentration. There was no suicidal or homicidal ideation. No delusions were present. Mood was euthymic, affect was congruent to mood. Insight and judgment were intact. The assessment was PTSD, depression, with GAF of 50. The impression was that the Veteran did not appear to be in crisis at the time, and appeared to be stable for continued outpatient treatment. A psychologist's report, also from February 2013, indicated that when seen jointly with his wife, they reported the Veteran had extreme anger, nightmares every night, hypervigilance, irritability/angry outbursts, and intrusive thoughts. He did not express suicidal ideation. Objective symptoms were similar to that previously noted. When seen one month earlier by a general physician, the Veteran had mentioned that he had had thoughts of killing himself, but would not carry them out. Evaluated again in April 2013, the Veteran was alert and well-oriented, cooperative, casually dressed and normally groomed, and speech was clear and normal in rate, rhythm and volume. Mood was agitated and frustrated, and affect was congruent. Memory appeared intact. There was no evidence of psychotic symptoms. He denied suicidal ideation or homicidal ideation. The assessment was PTSD and major depressive disorder. Similar findings were observed the following month, though this time mood was euthymic and affect appropriate. VA examination of February 2014 indicated diagnosis at out of PTSD, and unspecified depressive disorder. It was not possible to differentiate what portion of each symptom attributable to each mental disorder without resorting to speculation due to simultaneous presence and variable and interactive nature of the two mental disorders in the Veteran. It was noted that depression was secondary to PTSD. The finding of overall impairment was that of occupational and social impairment with reduced reliability and productivity. As to relevant social history, the Veteran had been married for about 12 years and described his relationship with his wife as very good since she was an understanding person and could manage his anger and irritability without personalizing it. He reported not having many friends especially now that he was no longer working and spent most of his time at home. He had stopped working as a part-time professor in photography, and then as a free-lance photographer due to various cited reasons, one being that he was tired of "being in a rut," and then otherwise that did not want to lose his temper at work. Medical records cited physical ailments as the cause. Overall, the cause did not appear to be PTSD symptoms. Prior to this particular appointment the Veteran had been hospitalized for unrelated reasons, and just before the examination appointment had experienced an outburst of anger and yelled at hospital staff, but ultimately was convinced to report for the exam though he was 25 minutes late. The Veteran otherwise continued to undergo counseling for mental health issues including for PTSD. He reported sleep difficulties, sometimes limited to three to four hours per night. He stated that he had become more angry and irritable over the last couple of years than previously and could not contain his anger. Many of his PTSD triggers tended to set him off. He reported giving up many activities because of his need to avoid people or crowded places such as going to baseball games and music shows. But he was still able to enjoy other activities such as listening to music, photography, and watching movies. He reported feeling somewhat depressed frequently. He endorsed low energy and poor appetite. He denied any suicide attempt or intentions since 2010. He denied symptoms of psychosis, mania or any other significant mental health disorder. The symptoms applicable to the Veteran's PTSD diagnosis included depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work-like setting. Mental status exam revealed the Veteran was well-oriented. He was cooperative but at times irritable and angry during the exam. Speech was unremarkable. He described his mood as very upset. His affect was broad and appropriate to the content. Perceptual disturbance was denied, including hallucinations. Thought process and thought content were unremarkable. He denied any suicidal or homicidal intentions. Cognitive functioning appeared intact. Insight and judgment were good. The Veteran was capable of managing his financial affairs. According to the examiner, based on review of the record and examination of the Veteran, it was his opinion that the Veteran's PTSD and depression were somewhat worse than at the time of the last VA examination. On re-examination just a few months later in April 2014, the diagnosis at outset was PTSD and unspecified depressive disorder. It was deemed not possible to differentiate what portion of each symptom was attributable to each diagnosis because of overlap of many of the symptoms. The Veteran's condition was summarized as occupational and social impairment with reduced reliability and productivity. He reported no significant psychosocial changes since the last examination. He stated that he spend his days practicing the guitar and writing music. He also played with his two dogs, listened to music and read the newspaper online. He was last employed as a photography professor. He held that position for eight years, stating that it was the most enjoyable job he had ever had. He left the job for reasons unrelated to psychiatric condition. The Veteran at that time was engaged in mental health treatment at the VA Medical Center (VAMC) and was taking psychotropic medications. With regard to trauma related symptoms, the Veteran identified interpersonal difficulties as a primary problem. He described himself as a "hermit," though he stated he liked people. He also spoke of irritability with fits of range. A recent episode of anger was said to have caused his psychologist to consider hospitalizing him at his last session. The Veteran stated that he did not trust people, and shared with the examiner notes from previous medical encounters that he found were in error. The Veteran was found to be alert, coherent, and oriented in all spheres. Hygiene and grooming were good. Affect and mood were depressed. There was no evidence of disturbances in thought processes or thought content. He reported sleeping 4-5 hours a night with middle insomnia and twice weekly nightmares. The Veteran was found to be cooperative and responsive for the duration of the interview. There was no evidence of disturbances in cognitive functioning. The Veteran reported that he regularly used marijuana to manage problematic medical symptoms. The Veteran was found have as symptoms associated with his PTSD a depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work-like setting. He was considered capable of managing his financial affairs. Regarding occupational capacity, it was stated that the Veteran's PTSD did not preclude substantially gainful employment, namely permitting employment in a loosely supervised situation, or that requiring little interaction with the public. The Veteran had a decades long history of gainful employment in the field of photography, including eight years as an instructor on the college level, and had enjoyed this work tremendously and denied receiving any negative performance appraisals as a result of PTSD or otherwise. When reevaluated in July 2014 by VA outpatient providers, it was indicated that the Veteran was now coping with serious illness that had a possible terminal diagnosis. There was associated life stress. The Veteran's overall mental status included mood of chronic anxiety and depression, but displaying significant resilience in coping with extreme health stress. Having reviewed the above, and with application of the pertinent rating criteria to the evidence, the Board will award a partial increase in the assigned evaluation for the Veteran's service-connected PTSD, awarding a higher rating of 50 percent from the February 24, 2005 effective date of service connection through January 5, 2010, and then thereafter a 70 percent from January 6, 2010 onwards. February 24, 2005 to January 5, 2010 First, regarding the initial time period from February 24, 2005 to January 5, 2010, while mindful of limited medical evidence for rating purposes, the Board nonetheless observes that the Veteran was already presenting on mental health evaluation as irritable, withdrawn, and liable affect, with additionally, sense of suspiciousness, distracted sensorium, mood disturbance to some extent, and sleep problems. As well, the characterization of PTSD by the psychiatrist was "severe," which though is not dispositive absent corroborating symptomatology, still informs the overall depiction of mental health. Also, subsequent evaluation following this time period references prior attempts or at minimum passive thoughts of suicide, suggesting a more complex history and the likelihood of more serious symptoms. Resolving reasonable doubt in the Veteran's favor, a 50 percent rating is warranted. See 38 C.F.R. § 4.1. The above basis for partial increase having been explained, the Board does not find grounds for any higher rating, particularly in the absence of these symptoms that are constituent of a 70 percent rating: suicidal ideation; obsessed rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or similar setting); inability to establish and maintain effective relationships. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Rather, the overall assessment of the severity of PTSD is constrained by the minimal record before the Board. There is no specific ascertainable indication or report of suicidal thoughts during this time, or for that matter near continuous mood disturbance affecting independent functioning, or otherwise irritability that became manifest and documented at a later point. However, again, applying VA's doctrine of resolving reasonable doubt in the claimant's favor, an increase to 50 percent is granted. From January 6, 2010 For the remaining time period under current consideration, a 70 percent evaluation will be assigned, this in view of symptomatology that includes intermittent suicidal ideation, even if primarily just passive and occasional; impaired impulse control, with verbal outbursts at times; at times neglect of personal appearance; and general social isolation, affecting ability to interact with others outside of his relationship with spouse. The Board also notes continuing mood disturbance associated with concomitant depression, as secondary to PTSD, and substantial sleep problems. The Board does not find a 100 percent schedular rating warranted, for total occupational and social impairment, given the absence, for instance, of serious impairment in thought process or speech, persistent danger to self or others, and ability to perform activities of daily living. Nor has there been sign or symptom of delusions or hallucinations. As a result, 70 percent best approximates the disability level since January 6, 2010. Extraschedular Consideration The Board has also considered the provisions of 38 C.F.R. § 3.321(b)(1) in regard to an extraschedular evaluation. However, in this case, the record does not show that the Veteran's psychiatric disability is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. This includes regarding PTSD, and depression as secondary to that underlying condition. Additionally, the Veteran and his attorney have not identified any symptoms that are not contemplated in the rating criteria or otherwise alleged that the rating criteria are inadequate. As such, it cannot be said that the available schedular evaluations for the Veteran's PTSD is inadequate. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for service-connected disability under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Petitions to Reopen By issuance of its December 2009, the Board denied the Veteran's original claims for service connection for hypertension, and for kidney cancer. The decisional rationale was the absence of competent evidence etiologically linking either hypertension or kidney cancer to the Veteran's active military service, including to his presumed Agent Orange exposure following service in Vietnam. Also indicated at that time was that applicable regulations did not recognize either disorder as one which may be presumed service-connected due to Agent Orange exposure, per 38 C.F.R. § 3.309(e). The Veteran did not appeal the Board's decision, and the decision became final. See U.S.C.A. § 7104; 38 C.F.R. §§ 3.104(a), 20.1100. When a claim to reopen is presented, VA must first determine whether the evidence presented or secured since the last final disallowance of the claim is new and material. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a); Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing 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). 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). The Board now has before it the June 2015 medical opinion of Dr. W.B.H. which states that the Veteran's current kidney cancer syndrome is "as likely as not" related to in-service exposure to Agent Orange. Additionally, there are several prior medical statements from other treatment providers which set forth the possibility of a causal relationship between kidney cancer and Agent Orange exposure, and do the same regarding hypertension and its etiological origin. Regarding both previously denied claims, evidence has been received as to that which presents a reasonable possibility of substantiating the previously deficient element of causation. The claims are therefore reopened, pending the further development requested by remand below. ORDER The claim of service connection for hyperaldosterone condition is dismissed. The claim of service connection for tremors is dismissed. The claim of service connection for insomnia is dismissed. An initial evaluation of 50 percent for PTSD from February 24, 2005 to January 5, 2010 is granted, subject to the law and regulations governing the payment of VA compensation. A 70 percent evaluation for PTSD since January 6, 2010 is granted, subject to the law and regulations governing the payment of VA compensation. New and material evidence having been received, the claim for service connection for hypertension is reopened; the claim on appeal to this extent is granted. New and material evidence having been received, the claim for service connection for kidney cancer is reopened; the claim on appeal to this extent is granted. REMAND The Board remands the underlying claims for service connection for hypertension and kidney cancer to the RO for de novo reconsideration, and for further development. The aforementioned June 2015 opinion of Dr. W.B.H posits that kidney cancer is attributable to in-service Agent Orange exposure, but the underlying rationale of the opinion is never stated, and, particularly given that kidney cancer has never been presumptively linked to exposure to Agent Orange under VA law, some additional statement of reasoning is needed to substantiate the opinion proffered. The remaining medical assessments that indicate mere possible linkage between kidney cancer and Agent Orange, and the same regarding hypertension, are not definitive. See e.g., Tirpak v. Derwinski, 2 Vet. App. 609 (1992) (medical professional's use of equivocal terms such as "may" or "may not" was too speculative to constitute a definitive opinion on issue of causation). Consequently, VA Compensation and Pension examination is warranted on the matter of causation, regarding both disorders. Future consideration of both claims should encompass all avenues of recovery, including whether hypertension is secondary to existing service-connected PTSD. This further includes a relationship, if any, between kidney cancer, and the Veteran's averred having consumed contaminated water during service. As to the evaluation for eczematous dermatitis with onychomycosis of the feet, the most recent VA Compensation and Pension examination report from January 2014 (as documented within the Veteran's supplemental "Virtual VA" electronic file). Upon this report, a summary of medical history provides as follows: "[The Veteran] states he was awarded a settlement on this case previously but the VA refused to pay (there is no evidence of this claim)." Whether the Veteran filed any other compensation claim in this case related to his dermatological condition, with VA or otherwise, and including the disposition, must be ascertained. For the claims for service connection for sleep apnea associated with PTSD, peripheral artery disease, colon cancer, and incontinence, which were decided and denied by May 2014 RO rating decision, the Veteran has filed a timely Notice of Disagreement on these claims, requiring AOJ issuance of a Statement of the Case as the next stage in the appellate process. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999); Holland v. Gober, 10 Vet. App. 433, 437 (1997). Accordingly, these claims are REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Contact the Veteran and request that he identify any prior claim for compensation, filed with VA or otherwise, in connection with the instant claim of higher rating for eczematous dermatitis with onychomycosis of the feet (consistent with what he identified on January 2014 VA examination of the feet), and provided such additional claim is confirmed, request that he provide any and all available documentation of the same. 2. Schedule appropriate VA examination(s) with an endocrinologist and/or other specialists. The claims folder must be provided to and reviewed by the examiner(s) in conjunction with the examination(s). Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail. Regarding the Veteran's condition of kidney cancer, the examiner is requested to provide a comprehensive opinion as to whether it is at least as likely as not (50 percent or greater probability) that kidney cancer is etiologically related to the Veteran's presumed in-service exposure to Agent Orange in Vietnam, taking into account prior medical opinions that have addressed this subject. This includes a June 2015 VA physician's statement which provided a finding on causation supporting the claim, but which unfortunately did not have a clear medical basis. Also note, as relevant, that a January 2014 VA medical opinion has already considered but ruled out the likelihood that the kidney cancer is attributable to the Veteran's having had exposure to contaminated water at Camp Lejeune. Reconciliation of all opinions should be attempted or rationale set out as to why that is not possible. An appropriate examiner is requested to then provide a similar opinion as to whether it is at least as likely as not that hypertension is etiologically related to the Veteran's service or service-connected disability, on the following grounds: 1) Is hypertension causally related to the Veteran's presumed in-service exposure to Agent Orange in Vietnam, taking into account all prior medical opinions that have addressed this subject? Consideration should be expressly indicated as to a prior study undertaken by the Institute of Medicine, published in 2007, reporting that there was "limited or suggestive evidence of an association" between herbicide exposure and hypertension. See Veterans and Agent Orange: Update 2006 (2007). 2) Is hypertension secondarily related to the Veteran's service-connected PTSD, including as a consequence of anxiety symptomatology, this based on initial incurrence of hypertension due to PTSD, and/or chronic aggravation (i.e., a permanent worsening) due to PTSD? The examiner should include in the examination report the rationale for any opinion expressed. 3. Then review the claims file. If the directives specified in this remand have not been implemented, appropriate corrective action should be undertaken before readjudication. Stegall v. West, 11 Vet. App. 268 (1998). 4. Thereafter, readjudicate the claims remaining on appeal, in light of all additional evidence received to include receipt of any additional relevant medical evidence addressing the subject of causation due to exposure to contaminated water at Camp Lejeune should take into account the development procedures specified under VBA Training Letter 11-03 (April 27, 2011). Thereafter, if any benefit sought on appeal is not granted, the Veteran and his attorney should be furnished with a Supplemental Statement of the Case (SSOC) and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. 5. The AOJ shall issue a Statement of the Case addressing the issues of service connection for sleep apnea associated with PTSD, peripheral artery disease, colon cancer, and incontinence. Only if the Veteran or his attorney submits a timely Substantive Appeal addressing these issues should they be 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). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claims, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs