Citation Nr: 1622865 Decision Date: 06/07/16 Archive Date: 06/21/16 DOCKET NO. 12-33 543 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to November 30, 2011, and in excess of 50 percent thereafter. 2. Entitlement to service connection for a sleep disorder, to include as secondary to service-connected PTSD. 3. Entitlement to service connection for a heart disability, to include as secondary to service-connected PTSD. 4. Entitlement to a total disability rating due to individual unemployability (TDIU). REPRESENTATION Appellant represented by: Calvin D. Hansen, Attorney ATTORNEY FOR THE BOARD S. Spitzer, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1970 to February 1972. This appeal comes before the Board of Veterans' Appeals (Board) from October 2011 and February 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). A September 2012 rating decision increased the rating for the Veteran's service-connected PTSD to 50 percent from November 30, 2011. In February 2015, the Board remanded the current issues for further evidentiary development. The case is once again before the Board. The issue of entitlement to service connection for a sleep disorder is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to November 30, 2011, the Veteran's PTSD was manifested by 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). 2. From November 30, 2011, the Veteran's PTSD was not manifested by occupational and social impairment with deficiencies in most areas. 3. A heart murmur was noted on the Veteran's service entrance examination. 4. The Veteran's pre-existing heart murmur was not aggravated during military service. 5. Coronary artery disease (CAD) has increased in severity beyond natural progression due to service-connected PTSD. 6. Resolving all doubt in the Veteran's favor, the competent and credible evidence of record demonstrates that his service-connected disabilities preclude him from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. For the period prior to November 30, 2011, the criteria for a rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). 2. For the period from November 30, 2011, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). 3. The criteria for service connection for CAD by aggravation have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1153, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.306, 3.307, 3.309, 3.310 (2015). 4. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.19 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act Under the Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist a claimant in the development of a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2015). Compliant VCAA notice was provided for the Veteran's PTSD and heart claims in June 2011 and for his claim for TDIU in December 2012. The case was last readjudicated in October 2015. In addition, the Board finds that the duty to assist a claimant has been satisfied. The Veteran's service treatment records (STRs) are on file, as are various post-service medical records, VA examination reports, and lay statements. The Board also notes that the actions requested in the prior remand have been undertaken to the extent possible. In March 2015, a letter requesting clarification of the Veteran's employment information was sent to his prior employer and a response was received. Additionally, VA examinations were conducted and VA opinions and updated VA treatment records were obtained. While the Veteran did not undergo an evaluation by a VA vocational specialist to ascertain the effect of his service-connected disabilities on employment, such error is harmless inasmuch as the Veteran's claim for TDIU is granted. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Analysis The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. Increased Rating for PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history; reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PTSD is currently rated as 30 percent disabling prior to November 30 2011, and as 50 percent disabling thereafter, under the criteria of 38 C.F.R. § 4.130, Diagnostic Code 9411. The relevant rating criteria are as follows. A 30 percent rating is assigned 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; mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned 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- 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 is assigned for 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; obsessional 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned for 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. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on social and occupational impairment rather than solely on the examiner's assessment of the level of disability at the moment of examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder the rating agency will consider the level of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Court has held that the use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Another factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition (DSM-IV)); see also Richard v. Brown, 9 Vet. App. 266 (1996). A GAF score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech at times illogical, obscure, or irrelevant), or where there is major impairment in several areas such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A GAF score of 41 to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 indicates moderate symptoms (e.g., flattened affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). A GAF score of 61 to 70 indicates some mild symptomatology (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or social functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. After review of the evidence of record, the Board finds that a higher evaluation for PTSD is not warranted for either period under review. During the period prior to November 30, 2011, the medical evidence of record reflects that the Veteran's PTSD was manifested by symptoms that included depressed mood and affect, isolation, trouble sleeping, hypervigilance, anger, nightmares, anxiety, and a guarded manner. VA clinicians noted that the Veteran was well groomed and dressed appropriately, with an anxious or depressed mood and affect. There was no evidence of auditory or visual hallucinations. A July 2011 VA psychologist examined the Veteran and noted that the Veteran reported seeing his son, daughter, and grandchildren seldom, but that he will speak with his daughter and brother once every two weeks. The examiner noted that the Veteran was employed until 2011 as a store stocker working 25 to 30 hours per month, and that the Veteran stated that he retired because of eligibility for retirement due to age or duration of work. During the examination, the Veteran was found to have an irritable attitude, was neatly groomed and dressed, spoke with rapid speech, and had a restricted affect and anxious mood. The Veteran was oriented times three. The Veteran was found not to be suffering from delusions, hallucinations, or suicidal or homicidal ideation. The Veteran described difficulty falling asleep, hypervigilance, outbursts of anger, and experiencing nightmares two to three times per week. The examiner opined that the Veteran's PTSD would lead to intermittent periods of inability to perform occupational tasks with associate decrease in work efficiency. The examiner found that the Veteran had no deficiencies in judgment, thinking, family relations, work or mood, and did not have reduced reliability. The examiner assigned a GAF score of 50. The Board finds that the Veteran's PTSD prior to November 30, 2011 most closely approximates the currently assigned 30 percent rating. In that regard, the Veteran did not demonstrate the symptoms associated with higher ratings during that time period, nor did he demonstrate other symptoms of similar severity, frequency, and duration. While the Veteran reported during VA treatment in November 2011 that he "didn't care if he died," this was found to be only passive suicidal ideation. Additionally, the Veteran denied suicidal thoughts during other VA treatment sessions during this period. Furthermore, while the Veteran reported limited social relationships during his private treatment sessions and VA examination, the record reflects that he was employed in 2011. Moreover, the symptoms the Veteran described during VA treatment and to the VA examiner, including depressed mood and anxiety are contemplated by the 30 percent rating criteria. While some of the Veteran's symptoms during that time period are not specifically enumerated in those criteria, the Board finds that the Veteran's overall mental health picture, as evidenced during VA treatment and during the VA examination, is in keeping with a 30 percent rating. Turing to the period from November 30, 2011, medical evidence of record reflects that the Veteran's PTSD was manifested by symptoms that included blunted/flat affect, disturbances of motivation and mood, goal-directed and responsive speech, logical thought processes with adequate insight, passive suicidal thoughts, isolation, anxiety, and sleep impairment. During a private psychological evaluation in December 2011, the Veteran reported living alone, and that he feels anxiety around others and avoids social interaction whenever possible. The Veteran stated that he spends most of his time home alone, and is occasionally visited by his daughter or brother. He stated that he retired in 2005. He also reported occasional alcohol use with infrequent binging when feeling very tense or frustrated, and experiencing nightmares. The Veteran stated that he experienced suicidal ideation in the form of passive thoughts such as "I didn't care if I woke up again," but denied attempts. The examiner reported that the Veteran was appropriately dressed and groomed and oriented times three. The Veteran was intense and agitated, but showed appropriate humor. Speech was goal-directed and responsive, with no evidence of hallucinations or delusions. Thought form was organized and insight was fair to good. The Veteran was described as having average reasoning and computational abilities, and concentration, attention, and social comprehension were described as average. The examiner opined that the Veteran has a chronic sleep impairment and considerable difficulty with social functioning, and assigned a GAF score of 53. In January 2013, a VA psychologist examined the Veteran and found that the Veteran's symptoms were productive of occupational and social impairment with reduced reliability and productivity. The Veteran again reported that he lives alone and does not engage in social activities, and has only occasional contact with his brother and daughter. He stated that he last worked in September or October 2012 but stopped since he injured his right arm. The Veteran again described nightmares. The examiner noted that the Veteran was dressed appropriately and oriented in all spheres with concentration intact. The examiner noted symptoms of depressed mood, anxiety, flattened affect, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. The examiner also opined that the Veteran is not unemployable due to his service-connected disabilities, including PTSD. A GAF score of 50 was assigned. In June 2015, the Veteran was afforded another VA examination. The psychiatrist found that the Veteran's symptoms were productive of occupational and social impairment with reduced reliability and productivity. The Veteran reported no changes in his social history. The psychiatrist reported the Veteran as experiencing the same symptoms noted on the January 2013 examination report. During the examination, the Veteran denied any psychotic symptoms or suicidal ideation, his mood was euthymic and his affect was anxious. The Veteran was fully oriented with his memory intact and displayed improved insight and judgment. The psychiatrist reported a GAF score of 59. The Board finds that the Veteran's PTSD from November 30, 2011 most closely approximates the currently assigned 50 percent rating. In that regard, the Veteran did not demonstrate the symptoms associated with higher ratings during this time period, nor did he demonstrate other symptoms of similar severity, frequency, and duration. Although treating VA clinicians and the December 2011 private psychologist have noted passive suicidal ideation, the Veteran denied attempts and denied suicidal ideation during the June 2015 VA examination. Furthermore, the Veteran reported working until October 2012, and engaging in social activities, including attending his grandson's basketball game in February 2014 and fishing with his daughter in May 2013, July 2014, and June 2015. Moreover, the symptoms noted by the VA examiners, including blunted affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships are contemplated by the 50 percent rating criteria. While some of the Veteran's symptoms during this time period are not specifically enumerated in those criteria, the Board finds that the Veteran's overall mental health picture, as evidenced during VA treatment and during the VA and private examinations, is in keeping with a 50 percent rating. The Board has also considered the GAF scores assigned during this period. While VA clinicians from July 2012 to January 2013 assigned GAF scores ranging from 43 to 48, accompanying increased symptoms were not reported. Significantly, the first GAF score reported during this period (50, recorded November 2011) and the last reported score (59, reported June 2015) shows that, despite fluctuations, the functional disability resulting from the Veteran's psychiatric disorder was fairly stable and indicative of moderate impairment. With respect to both time periods, the Board has considered the Veteran's assertions as to his symptomatology and the severity of his condition, but, to the extent he believes he is entitled to higher ratings during those time periods, concludes that the findings during medical evaluations are more probative than the Veteran's lay assertions to that effect. Accordingly, the preponderance of the evidence is against the Veteran's claim, and an evaluation in excess of 30 percent for PTSD prior to November 30, 2011, and in excess of 50 percent thereafter, is denied. The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability pictures as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2015); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the established schedular criteria are inadequate to describe the severity and symptoms of the claimant's disability. See Thun v. Peake, 22 Vet. App. 111, 118 (2008). Here, the rating criteria for psychiatric disability reasonably describe the Veteran's disability level and symptomatology and provide for additional or more severe symptoms than currently shown by the evidence. Indeed, the rating criteria specifically contemplate occupational and social impairment. The Board notes that it has considered all psychiatric symptomology in determining his functional impairment, not just the symptoms listed in the rating criteria. See Mauerhan, 16 Vet. App. 436. In short, the Veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun, 22 Vet. App. at 115. Consequently, referral of his increased rating claim for extraschedular consideration is not warranted. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). B. Service Connection for Heart Disability Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013) (holding that only conditions listed as chronic diseases in 38 C.F.R. § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b)). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Moreover, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and cardiovascular disease becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2015). Under the governing criteria, every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by service. 38 U.S.C.A. § 1111. A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153 (West 2014); 38 C.F.R. § 3.306 (2015). If a pre-existing disorder is "noted" on entering service, in accordance with 38 U.S.C.A. § 1153, the veteran has the burden of showing an increase in disability during service. If the veteran meets that burden and shows that an increase in disability occurred, the burden then shifts to the government to show that any increase was due to the natural progress of the disease. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306; Green v. Derwinski, 1 Vet. App. 320 (1991). "Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered 'aggravation in service' unless the underlying condition, as contrasted to symptoms, is worsened." See Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Additionally, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2015). Service connection may also be established for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310(b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened. Davis v. Principi, 276 F.3d 1341, 1346-47 (Fed. Cir. 2002). The Veteran claims that his current heart condition was caused by his service-connected PTSD. As an initial matter, the Board notes that the Veteran has been diagnosed during the course of the appeal with coronary artery disease (CAD). Accordingly, the first criterion for establishing service connection has been met. The question then becomes whether this condition is related to service, to include the Veteran's service-connected PTSD. The Veteran's October 1969 induction examination notes a heart murmur, chest pains and a normal electrocardiogram (EKG). In March 1970, the Veteran again complained of chest pains, and a chest x-ray was normal. A February 1972 chest x-ray was also negative, as was the Veteran's February 1972 separation examination. The first post-service treatment record for CAD is from December 2003; VA treatment records note stenting at the right coronary artery. In September 2004, the Veteran presented for VA primary care and reported experiencing brief episodes of shortness of breath which were associated with his CAD. During that primary care session, the Veteran reported experiencing depression, but did not think that it was a problem and did not require treatment at that time. PTSD was first noted in a positive screen in August 2007. In November 2008, the Veteran was diagnosed with PTSD. VA treatment records are devoid of reports of or treatment for heart murmurs and/or congestive heart failure (CHF). In July 2011, the Veteran underwent a VA heart examination in connection with this claim. The examiner reported diagnosis of ischemic heart disease status post myocardial infarction (MI) in 2003. The July 2011 VA psychologist added that the available research on PTSD does not support a causative or aggravating relationship to a heart condition. In March 2012, the Veteran's private cardiologist, Dr. Fruehling, provided an opinion that the Veteran's PTSD is one of several contributing factors for CAD, along with hypertension and hyperlipidemia. He noted that the Veteran's PTSD is not the only causal factor for CAD, and added that the Veteran's last stress test was in August 2011, and was normal with no evidence of ischemia or significant infarction. In August 2012, a VA general practitioner examined the Veteran and noted that 2004 treatment records reflected the Veteran's reports that his depression was not severe, and that the Veteran was not assessed with PTSD until 2008. Therefore, he opined that the evidence does not support PTSD as a risk factor for the Veteran's heart disease based on the lack of severity of his PTSD. A VA psychologist subsequently reviewed this opinion and opined that it was supported by clinical research. In accordance with the Board's February 2015 remand instructions, the Veteran was again afforded a VA examination in June 2015. A VA physiatrist opined that it was unlikely that the heart murmur noted on the Veteran's entrance examination increased in severity during service, because a heart murmur was not heard during the present examination or documented by the March 2012 private cardiologist, and the Veteran's medical records do not document heart valve disease or CHF. He added that the Veteran's March 1970 report of chest pains was unlikely to be cardiac in nature, given that the Veteran was 20 years old at the time of this report. Addressing aggravation due to PTSD, he opined that it is more likely than not that PTSD aggravated the Veteran's CAD because hypertension (a risk factor for CAD) is elevated in patients with PTSD, and that recent studies have found that PTSD increases the risk of CAD. In July 2015, a VA cardiologist noted that, in addition to PTSD, the Veteran's risk factors included hyperlipidemia, male gender and tobacco abuse. Given the 2003 MI, the examiner opined that the Veteran's heart disability was not likely to have been caused by PTSD, but it is likely that the Veteran's PTSD aggravated his CAD, as it is a risk factor for CAD and the Veteran has significant PTSD. In September 2015, another VA examiner reviewed the Veteran's claims file, including the June 2015 examination report and July 2015 opinion. That examiner stated that the Veteran's CAD would have occurred regardless of mental health issues due to the other noted risk factors. Therefore, the Veteran's baseline heart disease would be commensurate with his previous symptoms, and it cannot be determined how much any mental health disease worsened the CAD beyond normal progression, as there is no current manner in which to determine this. After review of the record, the Board finds that service connection for a heart disability is not warranted. The preponderance of the probative evidence indicates that the Veteran's pre-existing heart murmur was not aggravated by service, and that his current CAD is not related to service and was not caused or aggravated by his service-connected PTSD. At the outset, the Board notes that because a heart murmur was noted on entrance, the burden shifts to the Veteran to show that his heart murmur worsened during service. 38 U.S.C.A. § 1153. However, the Veteran's STRs are devoid of complaints of or treatment for a heart murmur or CHF during service, and the Veteran's separation examination was negative for heart conditions. Additionally, the only medical opinion of record addressing the question of whether the Veteran's heart murmur was aggravated by service is against the claim. The June 2015 VA physiatrist reviewed the Veteran's claims file, examined him, and provided an explanation for his conclusion. That conclusion is supported by the in-service and post-service medical records which do not document heart murmurs or CHF, to include VA and private examination reports. Additionally, the examiner noted that the Veteran's in-service complaints of chest pain were unlikely to be cardiac related and provided a rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Turning to the question of whether the Veteran's current CAD is related to service, the Board notes that the probative evidence does not reflect that a heart condition was present in service or within one year following discharge from service. Indeed, the Veteran did not have a diagnosed heart condition until several decades after service. The Veteran has not asserted that his CAD occurred in service, or that he was diagnosed with CAD within a year following discharge from service; rather, he asserts that his CAD is related to his service-connected PTSD. Therefore, the Board now addresses the question of whether there is a causal relationship between the Veteran's CAD and his service-connected PTSD. Regarding the medical opinions of record, the Board finds the medical opinion provided by the September 2015 VA examiner to be the most probative on the question of whether the Veteran's CAD is related to his PTSD. The examiner reviewed the Veteran's entire claims file, including the previous examination reports, and provided adequate explanations for his conclusions. His conclusions are supported by the evidence of record, including the March 2012 private cardiologist's opinion, which notes that the Veteran has many contributing factors for CAD, and that PTSD is not the sole causal factor. His conclusion is also supported by the occurrence of the only myocardial infarction of record occurring in 2003, the Veteran's September 2004 report that his depression was under control at that time and the first reported positive screen for PTSD in August 2007. Moreover, the evidence does not indicate that the Veteran's CAD has worsened due to his PTSD. As noted by the private cardiologist, the August 2011 stress test was found to be normal while the Veteran had a GAF score of 50 during this time period. See Nieves-Rodriguez v. Peake, supra. However, the March 2012 private, and June 2015 and July 2015 VA opinions state that the Veteran's CAD was aggravated by PTSD. Although the September 2015 VA opinion is to the contrary, the Board finds the evidence in its entirety is in equipoise as to this question and thus service connection for CAD on the basis of aggravation is in order. The benefit of the doubt has been resolved in the Veteran's favor. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1153, 5107; 38 C.F.R. §§ 3.303, 3.306, 3.307, 3.309, 3.310. III. TDIU The Veteran asserts that he is unemployable as a result of his service-connected disabilities, which are bilateral hearing loss, PTSD, and tinnitus. VA will grant a TDIU when the evidence shows that a Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. TDIU benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there is only one such disability, it must be rated at least 60 percent disabling to qualify for TDIU benefits; if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). In determining whether an appellant is entitled to a total disability rating based upon individual unemployability, neither the appellant's nonservice-connected disabilities nor advancing age may be considered. 38 C.F.R. §§ 3.341(a), 4.19. Factors to be considered are the Veteran's education, employment history, and vocational attainment. See Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). At the outset, the Board notes that the Veteran meets the schedular requirements for a TDIU. Service connection has been established for bilateral hearing loss, rated as 70 percent disabling; PTSD rated as 50 percent disabling; and tinnitus rated as 10 percent disabling. The Veteran's combined schedular rating is 90 percent. As above, service connection has been granted for CAD. The record reflects that the Veteran has a high school education and worked as a machinery operator for a farm equipment company for 33 years until 2005, and then worked part-time as a liquor store stocker from 2007 to 2012. During VA treatment in September 2010, the Veteran stated that he was "fired" due to physically contacting a customer. The Veteran's supervisor at the liquor store submitted a statement explaining that the Veteran's termination was due to his difficulty hearing customers. The July 2011 VA psychologist found that the Veteran's PTSD would not cause total occupational and social impairment. As noted previously, the January 2013 VA psychologist opined that the Veteran's PTSD, either by itself or in conjunction with other service-connected disabilities does not render the Veteran unable to secure or maintain substantially gainful employment. Immediately following that psychological examination, the Veteran underwent a VA audiological examination. The examiner opined that despite the Veteran's poor word recognition scores (40 percent right ear/38 percent left ear), much of his speech range is in the normal-moderate-severe range, and therefore could function at tasks that did not involve required hearing levels. The June 2015 VA physiatrist opined that the Veteran's PTSD prevents him from securing a substantially gainful occupation, as he struggles with anxiety, gets upset easily, and struggles not to react violently. The Veteran also submitted a statement from his general practitioner who opined that the Veteran is unable to secure or maintain employment based on his medical problems. After reviewing the evidence of record and resolving all doubt in the Veteran's favor, the Board finds that he is unable to secure and follow a substantially gainful occupation by reason of his service-connected disabilities. See Gilbert, 1 Vet. App. 54. In making that determination, the Board has considered the Veteran's limited education, his employment history, and his level of disability due to his bilateral hearing loss, PTSD, CAD, and tinnitus. Specifically, the Board notes the examination findings that the Veteran gets upset easily and struggles not to react violently are consistent with the Veteran's statement made during treatment that he was fired for a physical altercation with a customer. In conjunction with his employer's statement that the Veteran was terminated for difficulty hearing customers, the Board finds that the combined effect of his service-connected disabilities makes it unlikely that the Veteran could secure or follow a substantially gainful occupation consistent with his educational level and occupational experience. The Board acknowledges the various negative opinions provided by VA examiners; those opinions did not consider the combined effects of the Veteran's hearing loss and PTSD. Moreover, applicable regulations place responsibility for the ultimate TDIU determination on VA, not a medical examiner. Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). Additionally, while the Veteran has stated at times that he was fired as a stocker due to an arm injury, the Board finds his statements made during VA treatment and the explanation from his employer to be more probative evidence of the reason for his termination. Accordingly, the Board finds that the competent evidence, when considered as a whole, is at least in equipoise with respect to the issue of whether the Veteran is unemployable due to the effects of his service-connected disabilities. Therefore, entitlement to a TDIU is granted. ORDER For the period prior to November 30, 2011, an evaluation in excess of 30 percent for PTSD is denied. For the period from November 30, 2011, an evaluation in excess of 50 percent for PTSD is denied. Entitlement to service connection for CAD is granted. A total disability rating based on individual unemployability is granted, subject to the applicable laws and regulations governing the payment of monetary benefits. REMAND While further delay is regrettable, the Board finds that additional development is necessary for the sleep disorder claim. As noted previously by the Board, the Veteran's VA treatment records contain a February 2009 notation of sleep disorders and a November 2011 assessment of possible sleep apnea. As the 2011 and 2013 VA examiners did not consider or address these treatment records, the Board remanded for another VA examination to assess the nature of any sleep disorder. In response, the Veteran underwent a psychiatric examination in June 2015. The psychiatrist opined that the medical evidence does not support a primary sleep disorder, but noted that that the Veteran has not had a sleep study. A remand by the Board confers on the Veteran, as a matter of law, the right to compliance with the remand. Stegall v. West, 11 Vet. App. 268 (1998). Thus, the Board finds that the Veteran should be afforded a VA sleep apnea examination prior to adjudication of his claim. Relevant ongoing medical records should also be requested. 38 U.S.C.A. § 5103A(c) (West 2014); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following actions: 1. Obtain VA treatment records dating from October 2015 to the present. If the requested records are unavailable, the claims file should be annotated as such and the Veteran and his representative notified of such. 2. After associating all available records requested above with the claims file, schedule the Veteran for a VA sleep apnea examination. All indicated tests should be conducted and the results reported. Following review of the claims file and examination of the Veteran, the examiner should diagnose any sleep disorders. If the examiner finds that the Veteran does not have a sleep disorder distinct from PTSD, the examiner should explain why. For any diagnosed sleep disorder, the examiner should respond to the following: (a) Is it at least as likely as not (50 percent probability or greater) that the sleep disorder is causally related to service? Please explain why or why not. (b) If the sleep disorder is not related to service, is it at least as likely as not that the sleep disorder was caused by his service-connected PTSD? Please explain why or why not. (c) If the sleep disorder was not caused by the service-connected PTSD, is it at least as likely as not that the sleep disorder has been permanently worsened beyond normal progression (aggravated) by his service-connected PTSD? Please explain why or why not. If the examiner finds a sleep disorder that is aggravated by a service-connected disability, he/she should attempt to quantify the degree of aggravation beyond the baseline level of the sleep disorder. A rationale for any opinion expressed should be set forth. If the examiner cannot provide an opinion without resorting to speculation, he/she should explain why the opinion cannot be provided (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). 3. After completing the requested actions, and any additional action deemed warranted, the AOJ should readjudicate the claim on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. 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 2014). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs