Citation Nr: 1539746 Decision Date: 09/16/15 Archive Date: 09/24/15 DOCKET NO. 13-34 130A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for a lumbar strain disability. 2. Entitlement to service connection for hypertension, to include as due to service-connected disability. 3. Entitlement to service connection for a heart condition. 4. Entitlement to service connection for diabetes mellitus. 5. Entitlement to service connection for erectile dysfunction, to include as due to service-connected disability. 6. Entitlement to service connection for obstructive sleep apnea, to include as due to service-connected disability. 7. Entitlement to service connection for a thyroid disorder. 8. Entitlement to service connection for an acquired psychiatric disorder, separate from posttraumatic stress disorder (PSTD). 9. Entitlement to a compensable rating for a bilateral hearing loss disability. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Pelican, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1969 to April 1973. The Veteran had service in the Republic of Vietnam from April 1970 to April 1971. This case comes before the Board of Veterans' Appeals (the Board) from an August 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this case should take into consideration the existence of these electronic records. The record reflects that after the final Supplemental Statement of the Case (SSOC) additional relevant evidence was added to the record. No subsequent SSOC was issued, but this is not necessary because the Veteran submitted a waiver of initial review of the evidence by the agency of original jurisdiction in accordance with 38 C.F.R. § 20.1304 (2015). The issues of entitlement to service connection for hypertension, a heart disorder, diabetes mellitus, erectile dysfunction, obstructive sleep apnea, a thyroid disability, and an acquired psychiatric disorder separate from PTSD are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the period prior to November 17, 2014, the Veteran's lumbar strain disability was manifested by flexion no less than 85 degrees, with less movement than normal and pain on movement, and reports of painful flare-ups that caused him to be unable to move. The Veteran was not shown to have forward flexion limited to 30 degrees or less, ankylosis of the thoracolumbar spine, or intervertebral disc syndrome productive of incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. 2. From November 17, 2014, the Veteran's lumbar strain disability was manifested by flexion to 20 degrees, with less movement than normal weakened movement, pain on movement, and interference with sitting, standing, and / or weight bearing, as well as flare-ups that caused him to have difficulty moving while performing work duties as a mechanic. Intervertebral disc syndrome productive of incapacitating episodes having a total duration of at least 6 weeks during the past 12 months or ankylosis of the thoracolumbar spine have not been shown. 3. There is no objective evidence of neurological symptoms or abnormalities associated with the service-connected back disability at any point during the appeal. CONCLUSIONS OF LAW 1. For the period prior to November 17, 2014, the criteria for a rating in excess of 10 percent for the Veteran's lumbar strain disability have not been met or approximated. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5235-5243 (2015). 2. From November 17, 2014, the criteria for a rating of 40 percent, but no higher, for the Veteran's lumbar strain disability have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5235-5243 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (explaining that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Duties to Notify and Assist The VCAA requires VA to assist a claimant at the time he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of the evidence that is necessary, or would be of assistance, in substantiating their claims, and provide notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b)(1) (2015); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006). The appeal for a higher initial disability rating for the service-connected lumbar strain disability arises from a disagreement with the initial evaluation following the grant of service connection. The Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. VA's duty to assist under the VCAA includes helping the claimant obtain service treatment records and other pertinent records, as well as performing an examination or obtaining a medical opinion when one is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c) (2015). Here, the Veteran's service treatment records, VA medical records, and Social Security Disability records are in the claims file. He has not identified any other records or evidence that remains outstanding. Thus, the duty to obtain relevant records on the Veteran's behalf is satisfied. See 38 C.F.R. § 3.159(c) (2015). With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2015). The RO provided the Veteran QTC examination in June 2013 and a VA examination in November 2014. The examination reports are thorough and supported by the other evidence of record. The examination reports discussed the clinical findings and the Veteran's reported history as necessary to rate the disability under the applicable rating criteria. The examination reports also discussed the impact of the lumbar strain disability on the Veteran's daily living. They are, therefore, adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (noting that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2015). The Veteran declined the opportunity to present testimony before a Veterans' Law Judge. The Veteran has been accorded the opportunity to present evidence and argument in support of his claim. Thus, the Board finds that VA has satisfied its duties to inform and assist the Veteran at every stage of this case, and may proceed to the merits of the Veteran's claim. Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2015). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2015). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). Where a Veteran appeals the initial rating assigned for a disability, evidence contemporaneous with the claim and the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Id. In determining the applicable disability rating, pertinent regulations do not require that all cases show all findings specified by the Rating Schedule; rather, it is expected in all cases that the findings be sufficiently characteristic as to identify the disease and the resulting disability, and above all, to coordinate the impairment of function with the rating. 38 C.F.R. § 4.21 (2015). Therefore, with respect to the claim at issue herein, the Board will consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. 38 C.F.R. § 4.40 (2015). Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss in light of 38 C.F.R. § 4.40 (2015), taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14 (2015). The provisions of 38 C.F.R. § 4.40 (2015) and 38 C.F.R. § 4.45 (2015), however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. The rating schedule is also intended to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2015). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Related considerations include instability of station, disturbance of locomotion, and interference with sitting, standing and weight-bearing. 38 C.F.R. § 4.45 (2015). Under the General Rating Formula, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, disabilities are evaluated as follows: Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm or guarding not resulting in an abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height (10 percent); Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent); Forward flexion of the thoracolumbar spine to 30 degrees or less; or with favorable ankylosis of the entire thoracolumbar spine (40 percent); Unfavorable ankylosis of the entire thoracolumbar spine (50 percent); Unfavorable ankylosis of the entire spine (100 percent); 38 C.F.R. § 4.71a, General Rating Formula (2015). When evaluating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. Id. at Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. Normal combined range of motion of the thoracolumbar spine is 240 degrees. Normal ranges of motion for each component of spinal motion provided are the maximum usable for calculating the combined range of motion. Id. at Note (2) (2015). Analysis The Veteran was afforded a QTC examination in June 2013. He reported flare-ups that caused him to be unable to move; however frequency or severity of the flare-ups was not noted. Range of motion testing showed flexion to 85 degrees, without painful motion; extension to 15 degrees with painful motion at 15 degrees; right lateral flexion to 20 degrees with painful motion at 20 degrees; left lateral flexion to 20 degrees with painful motion at 20 degrees; right lateral rotation to 20 degrees without painful motion, and left lateral rotation to 20 degrees without painful motion. Repetitive testing was performed with no additional limitation of motion. The examiner noted the Veteran's functional loss included less movement, pain on movement, weakness, fatigability, and / or incoordination, as well as other (scoliosis). No localized tenderness or pain to palpation was observed, nor was guarding or muscle spasms. Muscle strength and reflex examinations were normal. Straight leg raising was negative bilaterally. No radiculopathy or other neurological abnormalities were observed. Intervertebral disc syndrome was not diagnosed. No assistive devices were noted to be used by the Veteran for ambulation. The examiner stated that the lumbar strain did not affect the Veteran's ability to work. According to a November 17, 2014 VA examination report, the Veteran reported flare-ups that made him unable to move during his job as a motor mechanic. Range of motion testing showed flexion to 60 degrees, with painful motion at 30 degrees; extension to 15 degrees with painful motion at 0 degrees; right lateral flexion to 15 degrees with painful motion at 0 degrees; left lateral flexion to 15 degrees with painful motion at 0 degrees; right lateral rotation to 15 degrees with painful motion at 5 degrees; and left lateral rotation to 15 degrees with painful motion at 5 degrees. The Veteran was unable to complete repetitive testing; it was noted that movements were too painful. The examiner stated that the Veteran's range of motion loss during pain on use or flare-ups was 20 degrees flexion and 5 degrees each of extension, left and right lateral flexion, and left and right rotation. The examiner noted the Veteran's functional impairment included less movement than normal, weakened movement, pain on movement, and interference with sitting, standing, and / or weightbearing. Localized tenderness or pain to palpation was observed, and described as paraspinous muscle tenderness. No guarding was noted. Muscle strength testing showed full strength ankle plantar flexion, ankle dorsiflexion, and great toe extension, and 4/5 of the hip and knee. Reflex examination was normal. Sensory examination showed upper anterior thigh (L2), thigh and knee (L3/4), and foot / toes (L5) were normal bilaterally, and that the lower leg / ankle (L4/L5/S1) was normal on the left side and decreased on the right side. Straight leg raising was negative bilaterally. No radiculopathy or other neurological abnormalities were observed. Intervertebral disc syndrome was not diagnosed. No assistive devices were noted to be in use. Additionally, the examiner stated that the Veteran was restricted from working as a mechanic because of an inability to bend and straighten up. For the period prior to November 17, 2014, the Board finds that the Veteran's symptoms do not warrant a rating in excess of 10 percent. The June 2013 QTC examination report indicated the Veteran had flexion to 85 degrees, which is on par with the 10 percent rating assigned for that period. Additionally, although the Veteran had painful movement, upon repetitive testing he had no reduction in his range of motion. Additionally, muscle spasms or guarding were not shown. Treatment records do not contradict these findings. Beginning November 17, 2014, the evidence of record supports a rating of 40 percent. The Board notes that the Veteran's initial range of motion results were on par with a 20 percent rating. However, the examiner stated that the Veteran's degree of range of motion loss during pain on use or flare-ups was 20 degrees flexion with 5 degrees of extension, left and right lateral flexion, and left and right lateral rotation, which is consistent with a 40 percent rating. VA regulations provide that the provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare-ups. 38 C.F.R. § 4.14 (2015). Here, because the Veteran experiences greater limitation of motion due to flare-ups, his back disability warrants a 40 percent rating from November 17, 2014 forward. The Board notes that the November 2014 VA examination report indicated the Veteran had active movement against some resistance in his bilateral hips and knees, and decreased sensation in his right lower leg and ankle. However, the examiner did not attribute these symptoms to the Veteran's service-connected lumbar strain. Moreover, the examiner noted that the Veteran did not exhibit evidence of radiculopathy or any other objective neurological abnormalities. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243, Note (1) (2015). Accordingly, a separate rating on this basis is not warranted. Lastly, at no point during the appeal period has the Veteran been shown to have unfavorable ankylosis of the thoracolumbar spine. Accordingly, a rating in excess of 40 percent is not warranted at any point during the appeal period. Extraschedular Considerations The Board has also considered whether the Veteran is entitled to referral for compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors, which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2015). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Director, Compensation Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not suggest an exceptional disability picture for which the available schedular evaluation for the service-connected disability may be inadequate. The Board notes that the Veteran's lumbar strain disability is manifested by subjective complaints of pain, weakness, fatigue, lack of endurance, impairment of work functions, and difficulty sitting, standing, walking, as well as objective findings of limitation of movement to 20 degrees flexion, less movement than normal. These findings are contemplated by the rating criteria. Moreover, as to the second Thun element, the evidence does not suggest that any of the "related factors" are present. Specifically, the Veteran's lumbar strain disability has not been shown to result in frequent hospitalizations at any point. Moreover, the Board found no evidence record indicating the Veteran missed work due to his service-connected lumbar strain disability. The Board also notes that a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 762 F.3d 1362 (2014). The Veteran has at no point during the current appeal indicated that he believes the assigned schedular rating for his lumbar strain disability and other service-connected disabilities to be inadequate or that the schedular criteria do not adequately describe or reflect his symptomatology. Therefore, referral for consideration of an extraschedular evaluation on this basis is not warranted. As a final matter, entitlement to a total disability rating based on individual unemployability (TDIU) has been effect for the entire appeal period; therefore, the Board need not address is herein. (CONTINUED ON NEXT PAGE) ORDER For the period prior to November 17, 2014, entitlement to a rating in excess of 10 percent for service-connected lumbar strain is denied. From November 17, 2014, entitlement to a rating of 40 percent, but no higher, for service-connected lumbar strain is granted, subject to regulations applicable to the payment of monetary benefits. REMAND The Veteran has not been afforded VA examinations to assess the nature and etiology of his claimed hypertension, heart condition, diabetes mellitus, erectile dysfunction, obstructive sleep apnea, and thyroid disorder. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service; and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. The third element, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. Id. at 83. As to the first McLendon element, the Veteran's records show he has diagnoses of hypertension and hypothyroidism, and is in receipt of treatment for erectile dysfunction. Moreover, a February 2014 correspondence noted that the Veteran had a diagnosis of diabetes mellitus; however, VA medical records cannot confirm that diagnosis. Additionally, a June 2014 VA medical record from Dr. Rafiq indicated that the Veteran was to undergo exercise testing to rule out coronary artery disease. Furthermore, the Veteran submitted private treatment records indicating he would undergo a sleep study to determine if he had a diagnosis of sleep apnea; however, no study is of record. Regarding the second and third McLendon elements and the hypertension, erectile dysfunction, and obstructive sleep apnea claims, the Veteran asserts they may be due to his PTSD, for which he is service-connected. He also asserts that his heart condition, diabetes mellitus, and thyroid condition are due to exposure to toxic herbicides while he served in the Republic of Vietnam. Given the Veteran's service in the Republic of Vietnam, exposure to toxic herbicides is presumed. Thus, given the lack of sufficient medical expertise to decide the hypertension, erectile dysfunction, and hyperthyroidism, the Board finds a remand for VA examinations is warranted. Furthermore, given the uncertainty regarding current diagnoses of a heart condition and diabetes mellitus, the Board finds that further development of those claims is warranted before affording the Veteran a VA examination. With respect to the hypertension claim, the Institute of Medicine's 2006 report, as well as subsequent reports in 2010 and 2012 confirm that there is "limited or suggestive evidence of an association between exposure to [Agent Orange] and hypertension..." See VETERANS AND AGENT ORANGE: UPDATE 2006, INSTITUTE OF MEDICINE 557-60 (2007); VETERANS AND AGENT ORANGE: UPDATE 2010, INSTITUTE OF MEDICINE 694 (2011), VETERANS AND AGENT ORANGE: UPDATE 2012, INSTITUTE OF MEDICINE 862-63 (2014). The examiner should address these findings, and provide an opinion as to whether, based on the Veteran's presumed exposure to Agent Orange during service, it is at least as likely as not that his exposure caused or resulted in his currently diagnosed hypertension. Separately, the Veteran seeks service connection for an acquired psychiatric disorder, other than PTSD. The Veteran's medical records indicate he has diagnoses of depression, anxiety disorder not otherwise specified (NOS), partner relational conflict, panic disorder with agoraphobia, and social phobia. The January 2014 QTC examination and the November 2014 PTSD disability benefits questionnaire (DBQ) indicate the only diagnosis the Veteran has is PTSD; however, neither examiner commented on the other diagnoses mentioned above. Accordingly, an addendum opinion is necessary to determine if the Veteran's other diagnosed psychiatric disorders are part and parcel of the service-connected PTSD or separate psychiatric conditions. Lastly, the Veteran's claim for an increased rating for a bilateral hearing loss disability was denied in a February 2013 rating decision. The Veteran filed a timely Notice of Disagreement with the decision a week later. As the AOJ has not issued a Statement of the Case with respect to this claim, the Board is obligated to remand it. Manlincon v. West, 12 Vet. App. 238 (1999); 38 C.F.R. § 19.29 (2015). Accordingly, the case is REMANDED for the following actions: 1. Issue the Veteran a statement of the case on the issue of entitlement to an increased rating for bilateral hearing loss, based on the February 2013 rating decision and February 2013 notice of disagreement. Inform the Veteran that the claim will be returned to the Board only if he timely submits a substantive appeal, VA Form 9, indicating his continued intent to appeal the decision. 2. Obtain any outstanding VA treatment and evaluation records relating to the Veteran's claimed disabilities, including records from September 2012 to present. All records secured should be associated with the claims file. 3. Request that the Veteran provide or identify any documentation of pertinent private (non-VA) medical care he received for his claimed disabilities not already of record, to include any records relating to sleep studies, heart conditions, and diabetes mellitus. After obtaining any necessary contact information and authorization from the Veteran, obtain copies of any outstanding treatment records from any provider identified by the Veteran. If, after making reasonable efforts to obtain records identified by the Veteran; and if the AOJ is unable to secure such records, the AOJ must notify the Veteran and (a) identify the specific records the AOJ is unable to obtain; (b) briefly explain the efforts that the AOJ made to obtain those records; (c) describe any further action to be taken by the AOJ with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. All records secured should be associated with the claims file. 4. Next, schedule the Veteran for VA examinations by appropriate examiners. The examiner or examiners should review the Veteran's claims file in conjunction with the examination. Any indicated studies or diagnostic tests should be performed. Following physical examination of the Veteran and review of his pertinent medical history and lay statements, the examiner should provide an opinion on the following: a) Whether it is at least as likely as not (a probability of 50 percent or greater) that hypertension is related to service, to include exposure to toxic herbicides. Note that the lack of documented treatment in service, while probative, cannot serve as the sole basis for a negative finding. The Veteran's lay contentions must be considered and weighed in making the determination as to whether a nexus exists between service and the currently diagnosed hypertension, and alternatively the exposure to herbicides. Likewise, the mere fact that a presumption has not been established for hypertension is not dispositive of the issue of nexus. Consideration must still be given to the exposure, and to the NAS study indicating that there is "limited or suggestive evidence of an association between hypertension and [Agent Orange]." b) Whether it is at least as likely as not (a probability of 50 percent or greater) that hypertension is caused by service-connected PTSD. c) Whether it is at least as likely as not (a probability of 50 percent or greater) that hypertension is aggravated (i.e., permanently worsened) by service-connected PTSD. d) Whether it is at least as likely as not (a probability of 50 percent or greater) that any diagnosed heart condition is related to service, to include exposure to toxic herbicides. e) Whether the Veteran has a current diagnosis of diabetes mellitus. f) Whether it is at least as likely as not (a probability of 50 percent or greater) that erectile dysfunction is related to service, to include exposure to toxic herbicides. g) Whether it is at least as likely as not (a probability of 50 percent or greater) that erectile dysfunction is caused by service-connected disability (including PTSD, lumbar strain, bilateral hearing loss, and tinnitus) or medications to treat such conditions. h) Whether it is at least as likely as not (a probability of 50 percent or greater) that erectile dysfunction is aggravated (i.e., permanently worsened) by service-connected disability (including PTSD, lumbar strain, bilateral hearing loss, and tinnitus) or medications to treat such conditions. i) Whether it is at least as likely as not (a probability of 50 percent or greater) that any diagnosed obstructive sleep apnea is related to service, to include exposure to toxic herbicides. j) Whether it is at least as likely as not (a probability of 50 percent or greater) that obstructive sleep apnea is caused by service-connected PTSD. k) Whether it is at least as likely as not (a probability of 50 percent or greater) that obstructive sleep apnea is aggravated (i.e., permanently worsened) by service-connected PTSD. i) Identify any diagnosed thyroid condition present since June 2010. j) Whether it is at least as likely as not (a probability of 50 percent or greater) that any diagnosed thyroid condition is related to service, to include exposure to toxic herbicides. If aggravation is found for any of the above claimed disabilities, the examiner should address the following medical issues: (1) the baseline manifestations of the Veteran's claimed disability found prior to aggravation; and (2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disability. In formulating the opinions, the term "at least as likely as not" does not mean "within the realm of possibility." Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against. The underlying reasons for any opinion expressed must be provided. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2011). 5. Return the claims file to the author of the November 2014 VA psychiatric examination report. If the requested examiner is no longer available, another examiner should be asked to review the claims file and answer the questions posed below. Alternatively, if the examiner determines that another examination would be helpful, the Veteran should be scheduled for a new examination. The examination report must reflect that review of the claims folder occurred. Based on the review of the Veteran's claims file, the examiner is asked to provide an opinion on the following: a) Identify any acquired psychiatric disorder, other than PTSD, diagnosed from March 2012 forward. b) Whether it is at least as likely as not (a probability of 50 percent or greater) that any diagnosed acquired psychiatric disorder (other than PTSD) is a symptom of PTSD, or is a separate and distinct psychiatric disorder. c) For any currently diagnosed psychiatric disorder that is separate and distinct from PTSD, whether it is at least as likely as not (a probability of 50 percent or greater) that it is related to service. d) For any currently diagnosed psychiatric disorder that is separate and distinct from PTSD, whether it is at least as likely as not (a probability of 50 percent or greater) that it is caused by the service-connected PTSD. e) For any currently diagnosed psychiatric disorder that is separate and distinct from PTSD, whether it is at least as likely as not (a probability of 50 percent or greater) that it is aggravated (permanently worsened beyond the natural progression) by the service-connected PTSD. A rationale for any opinion offered is requested. 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. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2011). 6. Ensure completion of the foregoing and any other development deemed necessary, and then readjudicate the Veteran's claims. If any claim remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case and an opportunity to respond. 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). 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). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs