Citation Nr: 1630197 Decision Date: 07/28/16 Archive Date: 08/04/16 DOCKET NO. 14-26 685 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an effective date prior to January 24, 2013 for the assignment of a 100 percent rating for the service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD. 3. Entitlement to service connection for a skin disorder manifested by recurrent boils as secondary to Methicillin resistant Staphylococcus aureus (MRSA). 4. Entitlement to service connection for erectile dysfunction (ED) to include as secondary to medications prescribed for service-connected disabilities. 5. Entitlement to an initial disability rating in excess of 10 percent for the service-connected gastroesophageal reflux disease (GERD). 6. Entitlement to a total disability rating prior to January 24, 2013 based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD L. B. Cryan, Counsel INTRODUCTION The Veteran served on active duty from May 1989 to September 1992. This case is before the Board of Veterans' Appeals (Board) on appeal from April 2013 and June 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In the April 2013 rating decision, the RO, in pertinent part, granted service connection for GERD, and assigned an initial 10 percent rating, effective from February 22, 2012; granted an increased disability rating from 50 percent to 100 percent for the service-connected PTSD, effective from February 11, 2013; and, denied service connection for MRSA boils, sleep apnea and ED. In a May 2013 Notice of Disagreement (NOD), the Veteran disagreed with the initial 10 percent rating assigned for the service-connected GERD; disagreed with the effective date for the assignment of a 100 percent rating for the service-connected PTSD; and disagreed with the denial of service connection for MRSA boils, sleep apnea, and ED. In a June 2014 rating decision, the RO found that a clear and unmistakable error (CUE) had been made regarding the effective date of the 100 percent rating for PTSD, and thereby assigned an earlier effective date of January 24, 2013 for the assignment of the 100 percent rating for the service-connected PTSD. The RO also issued a Statement of the Case (SOC) as to the issues of service connection for GERD, MRSA, ED, and entitlement to a TDIU, which had since been raised by the record. The Veteran perfected his appeal as to these issues in July 2014. Regarding the earlier effective date issue, the Veteran subsequently responded with another NOD in July 2014, asserting that an effective date prior to January 24, 2013 is warranted for the assignment of a 100 percent rating for PTSD. The RO issued an SOC addressing the earlier effective date issue in March 2015, and the Veteran perfected his appeal as to that issue in April 2015. Then, in a June 2015 rating decision, the RO reduced the 100 percent rating for PTSD to 70 percent, effective from September 1, 2015. The Veteran submitted an NOD disagreeing with the rating reduction in August 2015; and, in an October 2015 rating decision, the RO restored 100 percent disability rating for the PTSD, effective from September 1, 2015, the same day that the reduction was made effective, thereby nullifying the rating reduction. The Veteran was provided notice of this action in November 2015, and it was explained that because his benefits were fully restored, no further action would be taken on the August 2015 NOD. With respect to the claim for a TDIU, as indicated above, a June 2014 rating decision granted an effective date of January 24, 2013 for the assignment of a 100 percent rating for PTSD. Because a 100 percent schedular rating for PTSD for the period beginning on January 24, 2013 is granted, there remains no rating period since January 24, 2013 where the schedular rating is "less than total," as required for consideration of a TDIU. See 38 C.F.R. § 4.16(a). For this reason, the issue of entitlement to a TDIU since January 24, 2013 is now rendered moot. The question of whether the Veteran is entitled to an award of TDIU is rendered moot as of January 24, 2013 by the grant of a 100 percent ("total") schedular rating for PTSD, leaving no question of law or fact to decide regarding the TDIU issue. 38 U.S.C.A. §§ 7104, 7105; 38 C.F.R. §§ 4.14, 4.16. The Board acknowledges that a TDIU claim can be granted despite the existence of a schedular total rating for the purpose of establishing entitlement to SMC under 38 U.S.C.A. §1114(s). In Bradley v. Peake, 22 Vet. App. 280 (2008), the Court held that 38 U.S.C.A. § 1114(s) does not limit "a service-connected disability rated as total" to only a schedular rating of 100%, and 38 C.F.R. § 3.350(i) permits a TDIU rating based on a single disability to satisfy the statutory requirement of a total rating. When a Veteran is awarded TDIU based on a single disability and receives schedular disability ratings for other conditions, SMC based on the statutory housebound criteria may be awarded so long as the same disability is not counted twice, i.e., as a basis for TDIU and as a separate disability rated 60 percent or more disabling. See 75 Fed. Reg. 11,229, 11,230, Summary of Precedent Opinions of the VA General Counsel (March 10, 2010) (withdrawing VAOPGCPREC 6-1999 in light of Bradley, 22 Vet. App. at 280). Later, in Buie v. Shinseki, 24 Vet. App. 242 (2010), the Court held that VA was required to assess all of the claimant's disabilities to determine whether entitlement to SMC under 38 U.S.C.A. § 1114(s) is established whenever a veteran with a total disability rating is subsequently awarded service connection for any additional disability or disabilities even in the absence of an express claim for SMC. As distinguished from the facts in Bradley and Buie, the contention during the course of this appeal was that the Veteran's service-connected PTSD alone renders him unemployable. The 100 percent schedular rating awarded for the period beginning January 24, 2013 specifically contemplates total unemployability (i.e., total occupational impairment) due to PTSD. The Veteran has not contended, and the evidence does not otherwise show, that any service-connected disability other than PTSD, either alone or in combination with the other service-connected disabilities, is of such a severity so as to preclude substantially gainful employment. Thus, the issue of entitlement to a TDIU from January 24, 2013 forward is rendered moot. Moreover, pursuant to this decision, the Board has assigned a separate 60 percent rating for the Veteran's service-connected GERD from March 9, 2015, but not earlier. As such, the statutory criteria for an award of special monthly compensation (SMC) at the housebound rate are met as of March 9, 2015, but not earlier. See 38 U.S.C.A. § 1114(s). The Board will consider the issue of entitlement to a TDIU prior to January 24, 2013. As noted below, the Board is granting entitlement to a TDIU effective from February 22, 2012 to January 24, 2013. Finally, in a January 2013 VA examination of the skin, the examiner noted that the Veteran had recurrent bilateral tinea pedis (Athlete's Foot), that was first noted in service in 1991, and again in 1992. The examiner opined that it was more likely than not related to service. In addition, a private doctor, J.A., MD also noted in a November 2014 memorandum that the Veteran had a history of tinea pedis during service. As such, the matter is referred to the RO to provide a VA claim form to the Veteran so that he may file a claim of service connection for bilateral tinea pedis if he so chooses. This appeal was processed using the Virtual Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The issue(s) of service connection for sleep apnea, ED, MRSA boils, and entitlement to a TDIU prior to February 22, 2012, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In a December 2011decision, the Board granted an increased rating from 30 percent to 50 percent for the service-connected PTSD, effective from July 6, 2004; and, denied a disability rating in excess of 50 percent; the Veteran did not appeal that decision to the United States Court of Appeals for Veterans Claims (CAVC or Court). 2. Between December 2011 and January 24, 2013, no claim, formal or informal was received requesting an increased rating for the service-connected PTSD. 3. On February 24, 2013, the RO received a claim for an increased rating for the service-connected PTSD, and, in an April 2013 rating decision, the RO granted an increased rating to 100 percent for the service-connected PTSD, effective from February 11, 2013. 4. In a June 2014 rating decision, the RO assigned an earlier effective date of January 24, 2013 for the assignment of the 100 percent rating for the service-connected PTSD. 5. An increase in the severity of the Veteran's service-connected PTSD was not factually ascertainable within the one year prior to the date on which his most recent claim for increase was received, January 24, 2013. 6. Since the effective date of service connection, and prior to March 9, 2015, the Veteran's service-connected GERD was manifested by persistently recurrent epigastric distress, with dysphagia (with esophageal stricture/spasm, status post esophageal dilation), heartburn, regurgitation, and substernal gas pain, with transient nausea and vomiting; these symptoms, in resolving all doubt in the Veteran's favor, more nearly approximate an overall disability picture productive of considerable impairment of health. 7. Since March 9, 2015, the evidence has shown a co-existing gastrointestinal (GI) bleed, peptic ulcer disease and blood loss anemia, accompanied by pain, hematemesis and melena or other symptom combination productive of definite or severe impairment of health. 8. For the period on appeal extending from March 9, 2015, the Veteran is in receipt of a single service-connected disability rated as 100 percent and additional service-connected disabilities independently rated at 60 percent, separate and distinct from the 100 percent service-connected disability, and involve different anatomical segments or bodily systems, to warrant SMC at the housebound rate. 9. From February 22, 2012 to January 24, 2013, the Veteran's PTSD was rated as 50 percent disabling; his GERD, pursuant to this decision, was rated as 30 percent disabling; tinnitus was rated as 10 percent disabling, and his hearing loss was rated as noncompensable. 10. From February 22, 2012 to January 24, 2013, the Veteran has one disability rated as 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent; and, during that time period, the Veteran's PTSD, as likely as not, precluded the Veteran from obtaining or maintaining substantially gainful employment consistent with his educational background and work history. CONCLUSIONS OF LAW 1. The Board's December 2011 decision is final. 38 U.S.C.A. § 7104 (West 2014). 2. The criteria for entitlement to an effective date prior to January 24, 2013, for the assignment of a 100 percent rating for the service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5110 (West 2014); 38 C.F.R. §§ 3.1, 3.151, 3.155, 3.400 (2015); 38 C.F.R. § § 3.155, 3.157 (prior to September 25, 2014). 3. The criteria for the assignment of an initial disability rating of 30 percent, but not higher, for the service-connected GERD have been more nearly approximated since the effective date of service connection (February 22, 2012), and prior to March 12, 2015. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.7, 4.20, 4.113, 4.114, Diagnostic Codes 7203, 7204, 7304, 7305, 7306, 7307, 7346 (2015). 4. Since March 12, 2015, the criteria for the assignment of a 60 percent rating, but not higher, for the service-connected GERD are more nearly approximated. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.7, 4.20, 4.113, 4.114, Diagnostic Codes 7203, 7204, 7304, 7305, 7306, 7307, 7346 (2015). 5. The criteria for SMC at the housebound rate have been met for the appeal period extending from March 9, 2015. 38 U.S.C.A. § 1114(s) (West 2014); 38 C.F.R. § 3.350(i) (2015). 6. The criteria for entitlement to a TDIU were met from February 22, 2012 to January 24, 2013. 38 U.S.C.A. §§ 1155 , 5107 (West 2014); 38 C.F.R. §§ 3.102 , 3.340, 3.341, 4.16 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist At the outset, VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). By correspondence dated in February 2013, VA notified the Veteran of the information needed to substantiate and complete his claims, to include notice of the information that he was responsible for providing, the evidence VA would attempt to obtain, and how VA assigns disability ratings and effective dates of awards. It is not alleged that notice was less than adequate. The earlier effective date issue and the claim for a higher initial disability rating for the service-connected GERD, both on appeal, arise from the disagreement with the assignment of the effective date following the grant of an increased rating for PTSD, and disagreement with the initial rating assigned following the grant of service connection for GERD. Courts have held that once a claim 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). The Board notes that the records pertinent to the Veteran's earlier effective date claim and increased rating claim have been obtained. The Veteran has been accorded ample opportunity to present evidence and argument in support of the appeal and he has done so. Regarding the GERD, the Veteran was afforded a VA examination in January 2013. This examination is adequate because the examiner discussed the Veteran's medical history, described his disabilities and associated symptoms in detail, and supported all conclusions with analyses based on objective testing and observations. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran has not asserted that his GERD has worsened during the course of the appeal. Thus, a new examination is not necessary due to the passage of time. Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007). After the Veteran's substantive appeal was filed in July 2014, the Veteran submitted additional private treatment records which are pertinent to his claim for a higher initial rating for the service-connected GERD. It is noted that these records were submitted after the statement of the case and were not accompanied by a waiver of AOJ consideration. However, Section 501 of the Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law (PL) 112-154, amends 38 U.S.C. § 7105 by adding new paragraph (e). Under 38 U.S.C. § 7105(e), if the claimant or the claimant's representative submits new evidence with or after a substantive appeal received on or after February 2, 2013, then it is subject to initial review by the Board, unless the Veteran explicitly requests AOJ consideration. In the present case, the Veteran's Substantive Appeal was received in 2014; therefore the new 38 U.S.C. § 7105(e) is applicable to the present appeal. As the Veteran did not explicitly request that the AOJ review the additional evidence, the evidence is properly before the Board for initial review. In sum, the Board is satisfied that the originating agency properly processed the Veteran's effective date claim and increased rating claim after providing the required notice and the duty to notify and assist has been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993). Accordingly, the Board will address the merits of these claims. II. Earlier Effective Date for 100 Rating for PTSD The Veteran seeks an earlier effective date for the assignment of a 100 percent rating for his service-connected PTSD. Before the issue on appeal of entitlement to an earlier effective date for the assignment of a 100 percent rating for the service-connected PTSD can be addressed, the issue as to the finality of a prior Board decision must first be addressed. Service connection for PTSD was granted pursuant to a September 2007 rating decision. An initial 10 percent rating was assigned, effective from July 6, 2004. The Veteran appealed the initial rating assigned; and, in a September 2008 rating decision, the RO increased the initial 10 percent rating to 30 percent, effective from July 6, 2004, the effective date of service connection. The Veteran continued with his appeal, and in a June 2009 rating decision, the RO further increased the PTSD rating to 50 percent, effective from February 16, 2009. As this increase was not a full grant of benefits sought on appeal, the issue remained pending. In a December 2011 decision, the Board found that the service-connected PTSD had been manifested by symptoms that more nearly approximated the criteria for the assignment of a 50 percent disability rating since the effective date of service connection. Therefore, the Board granted an increase in the initial 30 percent rating to 50 percent prior to February 16, 2009, but found that at no time did the PTSD warrant a rating higher than 50 percent. In a January 2012 rating decision, the RO effectuated the Board's decision and assigned a 50 percent rating effective from July 6, 2004, the effective date of service connection. Notably, the Veteran did not appeal the Board's December 2011 decision that denied entitlement to a disability rating higher than 50 percent for PTSD. Board decisions are final when issued, unless the Board Chairman orders reconsideration. 38 C.F.R. § 20.1100(a) (2015). Reconsideration of the December 2011 decision has not been ordered. As such, the December 2011 Board decision is final U.S.C.A. § 7104 (West 2014); 38 C.F.R. § 20.1100 (2015). The next communication regarding the Veteran's PTSD came from an informal claim for an increased rating, received at the RO on February 24, 2013. In general, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a) (West 2014); 38 C.F.R. § 3.400 (2015). An exception to that rule applies, however, under circumstances where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation. In such an instance, the law provides that the effective date of the award "shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." 38 U.S.C.A. § 5110(b)(2) (West 2014); see also 38 C.F.R. § 3.400(o)(2) (2015); Harper v. Brown, 10 Vet. App. 125 (1997). In a June 2014 rating decision, the RO assigned a 100 percent rating for the service-connected PTSD, effective from January 24, 2013, the date of the Veteran's most recent claim for increase. Thus, the earliest possible effective date for the assignment of the 100 percent rating is January 24, 2013 unless the above exception applies. Here, though, an increase in disability is not factually ascertainable within the one year period prior to the January 24, 2013 claim for increase because the evidence of record does not support a finding of increased disability during that time period. Consequently, there is no basis on which to assign an effective date prior to January 24, 2013 for the assignment of a 100 percent rating for the service-connected PTSD. The Veteran's attorney asserts that the Veteran filed an increased rating for PTSD on February 22, 2012. See July 2014 NOD. However, this assertion is not supported by the record. The record reflects that on February 22, 2012, the Veteran requested service connection for ED, GERD, sleep apnea, and MRSA boils. Although the Veteran asserted at that time that the ED, GERD, and sleep apnea could be related to, or secondary to, his service-connected PTSD, there is nothing in the Veteran's statements that could be construed as an informal claim for an increased rating for the service connected PTSD. Likewise, an increased rating claim cannot be inferred based on the evidence of record at that time. Moreover, the Veteran did not suggest in the February 2012 claim that his PTSD had worsened. Likewise, the accompanying cover letter from the Veteran's attorney only refers to claims for service connection for ED, GERD, a sleep disorder, and MRSA boils, and does not mention PTSD. In summary, the December 2011 Board decision is final, and the first evidence of an increase in disability with regard to the Veteran's PTSD comes from his January 24, 2013 claim for an increased rating. Thus, the earliest possible effective date for the assignment of the 100 percent rating is January 24, 2013, and there is no basis for assignment of a compensable rating effective any earlier than January 24, 2013. 38 C.F.R. § 3.400(o). III. Increased Rating - GERD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. Staged ratings must be considered, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). See also Fenderson v. West, 12 Vet. App. 119, 126 (1999) (applying this concept to initial ratings). In this case, as noted below, the Board finds that staged ratings are appropriate. It is the Board's responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board will consider not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. The VA examiner in January 2013 reviewed the entire record, noting that the Veteran underwent a July 2008 endoscopy which revealed mild Schatzki's ring. The examiner also noted the Veteran's esophageal stricture and the dilation treatment for that condition in 2005 and 2008, which helped. Outpatient treatment in February 2009 notes that the Veteran's Omeprazole was "not working" as he was still reporting heartburn and gas. The VA examination report from January 2013 notes the Veteran's continued complaints of heartburn and trouble getting food down his esophagus. His episodes are usually kept under control by taking omeprazole, Tums and forced vomiting and that the really bad ones have only been one or two times per year. The examiner also noted the Veteran's reports that he felt he needed another dilation due to esophageal stricture. The examiner specifically indicated that the Veteran had an esophageal stricture, described as mild in degree. The examiner indicated that the Veteran's GERD was manifested by symptoms of persistently recurring epigastric distress, pyrosis (heartburn), regurgitation, and transient nausea and vomiting, occurring on average only two times per year and lasting less than one day. The examiner indicated that the GERD condition did not impact his ability to work; however, the examiner did also note the additional symptom of mild esophageal stricture and/or spasm of the esophagus (cardiospasm) necessitating recurrent dilation. The examiner based the above findings on the Veteran's reported history, a clinical examination of the Veteran, and a complete review of the record including the medical evidence of record. The Veteran's service-connected GERD is rated by analogy under 38 C.F.R. § 4.114, Diagnostic Code 7346 which evaluates hiatal hernia. 38 C.F.R. § 4.114. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Under Diagnostic Code 7346, the maximum rating of 60 percent is warranted for symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is assigned for two or more symptoms associated with the 30 percent rating, but of less severity. 38 C.F.R. § 4.114 , Diagnostic Code 7346. Here, the Veteran's GERD is manifested by persistently recurring epigastric distress with dysphagia, pyrosis, regurgitation, and gas; however, the January 2013 examination report also noted that the Veteran had mild esophageal stricture necessitating occasional dilation. Esophageal stricture and cardiospasm are rated under 38 C.F.R. § 4.118, Diagnostic Codes 7303 and 7204, respectively. Under Diagnostic Code 7203, moderate stricture of the esophagus is rated at 30 percent. Severe esophageal stricture, permitting liquids only, warrants a 50 percent rating, and a maximum schedular rating of 80 percent is warranted for esophageal stricture permitting passage of liquids only, with marked impairment of general health. Under Diagnostic Code 7204, spasm of the esophagus (cardiospasm), if not amenable to dilation, is to be rated as for the degree of obstruction (stricture). Here, the examiner in January 2013 indicated that the Veteran's stricture was mild. However, and more significantly, the regulations pertaining to the Schedule of Ratings of the Digestive System at 38 C.F.R. § 4.114 provide that ratings under Diagnostic Codes 7301 to 7329, inclusive 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other; rather, a single rating will be assigned under the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. This is because there are diseases of the digestive system, particularly within the abdomen, which while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle related to pyramiding as outlined in § 4.14. 38 C.F.R. § 4.113. Here, the Veteran's symptoms associated with the service-connected GERD prior to March 2015, include persistently recurring epigastric distress with dysphagia, pyrosis, regurgitation, and gas, with only transient nausea and vomiting on average of twice per year. This overall disability picture does not, in and of itself, result in considerable impairment of health. The Veteran reports that his nausea and vomiting only occur a couple of times per year, and therefore should not be considered a symptom that is "persistently recurring." Also, prior to March 12, 2015, the Veteran did not report more serious symptoms of material weight loss, hematemesis, or melena; and, anemia was not shown. The Veteran takes medications which helped to control his symptoms; and, the Veteran's Social Security Administration Records do not support a finding of "considerable impairment of health" due to his GERD symptoms. These records show that the Veteran was too disabled to work due to his PTSD and back conditions. Based on the foregoing GERD symptoms, and without consideration of the esophageal stricture (for which Diagnostic Code 7203 applies), considerable impairment of health is not shown based on the Veteran's self-reported history and the findings on the January 2013 VA examination report. The Veteran reported in 2009 that his medication was not working, but then reported in January 2013 that his GERD symptoms were controlled with medication most of the time. Therefore the predominant GERD symptoms prior to March 9, 2015 do not, in and of themselves, warrant a rating in excess of 10 percent under Diagnostic Code 7346. However, the Board must also consider the Veteran's co-existing abdominal condition of mild esophageal stricture when determining the proper disability rating to assign. According to 38 C.F.R. § 4.113, the Veteran's esophageal stricture cannot necessarily be disassociated from the service-connected GERD, and dysphagia (trouble swallowing) is a symptom listed under the criteria at Diagnostic Code 7346; and, esophageal stricture (which is associated with trouble swallowing) is rated under Diagnostic Code 7203. Therefore, this is a situation where co-existing abdominal conditions, if rated separately, would result in pyramiding, in violation of 38 C.F.R. § 4.14. As such, according to 38 C.F.R. §§ 4.113, 4.114, a single evaluation is to be assigned based on the predominant disability (GERD), which is then elevated to the next higher evaluation given the severity of the Veteran's co-existing condition. See also, Mittleider v. West, 11 Vet. App. 181, 182 (1998) (When it is not possible to separate the effects of service-connected and non-service-connected disabilities, such effects should be attributed to the service-connected condition.) Therefore, the 10 percent rating under Diagnostic Code 7346 is elevated to the next higher rating of 30 percent under Diagnostic Code 7346 to reflect consideration of the co-existing abdominal conditions. When considered together, elevation to the next higher rating is warranted as the overall disability picture becomes more severe than was represented by the 10 percent rating under Diagnostic Code 7346. As these symptoms have been present since the effective date of service connection, the criteria for the assignment of this 30 percent rating have been met or approximated since the effective date of service connection. Prior to March 9, 2015, the Veteran's GERD did not result in severe impairment of health. The record did not indicate the presence of material weight loss, hematemesis, melena anemia, severe pain, or vomiting more than occasionally. Additionally, the Veteran's esophageal stricture did not prevent the Veteran from consuming solid foods. Thus, a rating in excess of 30 percent for the service-connected GERD is not warranted prior to March 9, 2015. Beginning on March 9, 2015, the record reflects that the Veteran developed additional co-existing abdominal conditions. On March 9, 2015, the Veteran was admitted to a private hospital with for a gastrointestinal bleed. The March 9, 2015 admitting diagnosis was GI bleeding and abdominal pain. The Veteran underwent testing, including an EGD, and this revealed esophagitis, esophageal stricture and was dilated, and stomach ulcer. He presented on admission with nausea and hematemesis (vomiting blood). Although the Veteran's hematemesis resolved prior to discharge on March 12, 2015, these records show an overall worsening of the digestive system. At the time of admission on March 9, 2015, the Veteran reported that one day previously, he developed purple colored emesis multiple times, black stool (melena), and severe abdominal pain. His symptoms appeared abruptly and he had not been previously treated for a GI bleed; however, a previous history of hematemesis and melena was noted. According to the discharge summary of March 12, 2015, the Veteran's symptoms appeared to be associated with gastric ulcers and esophageal stricture; and significantly, the criteria under Diagnostic Code 7346 also include the same symptoms. Thus, separate ratings are not assignable for GERD, esophageal stricture and gastric ulcer because these disabilities produce a common disability picture. To rate them separately, would violate the rule against pyramiding, and no medical professional has suggested that the symptoms from the Veteran's GI bleed can be satisfactorily disassociated from the overall service-connected disability picture in this case. Under Diagnostic Code 7305, a 40 percent rating is warranted for moderately severe duodenal ulcer; less than severe but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four times or more a year. A 60 percent rating is warranted for duodenal ulcer that is severe; pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7305. Under Diagnostic Code 7306, a 100 percent rating is assigned for gastrojejunal ulcers that are pronounced, manifested by symptoms of periodic or continuous pain unrelieved by standard ulcer therapy with periodic vomiting, recurring melena or hematemesis, and weight loss, which are totally incapacitating. A 60 percent rating is assigned for severe gastrojejunal ulcers manifested by the same symptoms as required for the 100 percent rating, but with less pronounced or continuous symptoms, which are productive of definite impairment of health. Id. A 40 percent rating is assigned for moderately severe ulcers, with intercurrent episodes of abdominal pain at least once a month partially or completely relieved by ulcer therapy, mild and transient episodes of vomiting or melena. Although the Veteran was discharged on March 12, 2015 with improved symptoms, the evidence of record shows an overall worsening of disability which included gastric ulcers and symptomatic esophageal stricture. Thus, with consideration of all of the Veteran's gastrointestinal symptoms, and resolution of all doubt in the Veteran's favor, elevation to the next higher, 60 percent rating is warranted beginning on March 9, 2015 as a result of additional co-existing conditions that worsen the overall disability picture. At that point, the Veteran's overall digestive system disability picture was manifested by symptoms more nearly approximating the criteria for the assignment of a 60 percent rating under Diagnostic Code 7346. The Veteran had pain, vomiting, hematemesis, melena, anemia, with other symptoms of esophageal stricture causing regurgitation, heartburn, and dysphagia, and severe abdominal pain due to a GI bleed, all of which more nearly approximates an overall disability picture productive of severe impairment of health. A rating in excess of 60 percent is not warranted. Although the Veteran required hospitalization for his symptoms in March 2015, these records do not suggest that his symptoms on admission remained severe enough at the time of discharge to suggest total incapacitation for an extended period of time. Although the Veteran's GI bleed was causing anemia, there is no indication that the anemia was permanent or severe. Furthermore, the Veteran has not since reported significant weight loss or symptoms that are continuous, and he has not provided any additional medical evidence to suggest that the Veteran's condition at discharge subsequently deteriorated to the point that he has become completely and permanently incapacitated due to the GERD. Thus, when considered together, the Veteran's symptoms are productive of definite and severe impairment of health, but they are not pronounced based on the criteria for rating hiatal hernia and ulcers under Diagnostic Codes 7305, 7306, and 7346. Thus, when the predominant disability picture is considered, along with an elevation to the next higher evaluation, the assignment of a 60 percent rating, but no higher, is warranted since March 9, 2015. The outcome is the same whether the Veteran's disability picture is rated under Diagnostic Codes pertaining to ulcers, or under the Diagnostic Code 7346 pertaining to hiatal hernia. See 38 C.F.R. § 4.114, Diagnostic Codes 7305, 7306. In other words, when all co-existing abdominal issues are considered together, the overall disability picture is elevated to symptoms resulting in "definite impairment of health" which corresponds to the assignment of a 60 percent rating under Diagnostic Code 7305 or 7306. IV. Increased Ratings - Extraschedular & SMC Additionally, the Board has considered whether referral for consideration of an extraschedular rating is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of this VA regulation, for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of his disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the evidence does not show such an exceptional disability picture that the available schedular rating for the service-connected gastrointestinal disability is inadequate. A comparison between the level of severity and symptomatology of this disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. See Diagnostic Code 7346. There is no evidence in the record of related symptoms of and/or impairment not encompassed by the criteria for the respective schedular rating assigned. Therefore, those criteria are not inadequate, and referral for extraschedular consideration is not warranted. 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111 (2008). In addition, there is no indication of governing norms such as frequent hospitalizations or "marked interference" with employment, above and beyond that contemplated in the rating criteria. 38 U.S.C.A. § 1155 (West 2014) (Disability evaluations are determined by the application of a schedule of ratings, which is based on average industrial impairment). According to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be entitled to "consideration [under 38 C.F.R. § 3.321(b) ] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." Referral for an extraschedular rating under 38 C.F.R. § 3.321(b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when the "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities. However, the Board is cognizant of VA's duty to maximize benefits. See Bradley, 22 Vet. App. at 280 . Relevant to this appeal, a claim for increased disability compensation may include the "inferred issue" of entitlement to SMC even where the Veteran has not expressly placed entitlement to SMC at issue. Akles, 1 Vet. App. at 121; See Buie, 24 Vet. App. at 242. SMC at the housebound rate is payable where a veteran has a single service-connected disability rated as 100 percent and: (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or, (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). Here, for the appeal period extending from March 9, 2015, the Veteran is in receipt of a single service-connected disability rated as 100 percent and additional service-connected disabilities independently rated at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, to warrant SMC at the housebound rate. The criteria for SMC at the housebound rate have been met since March 9, 2015. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). The Veteran has not asserted, and the evidence of record does not suggest, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. There is thus neither allegation nor indication that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. V. TDIU Finally, the Veteran asserts that a TDIU is warranted. As noted above, the Veteran is in receipt of a 100 percent schedular rating for PTSD effective from January 24, 2013. This rating contemplates total occupational impairment, and the Veteran has consistently maintained that his unemployability is related to his PTSD. Records obtained from the Social Security Administration (SSA) show that the Veteran last worked in 2011, and he was in receipt of SSA disability benefits due to his psychiatric disorder and a non-service-connected back disability. In light of the Veteran's contentions, which are supported by the records obtained from SSA, the Board need not consider whether a TDIU is warranted on and after January 24, 2013 because to award a TDIU from January 24, 2013 forward would be duplicative as the 100 percent rating for PTSD already contemplates the Veteran's total occupational impairment as of that date. Because the assignment of a TDIU would be wholly based on unemployability due to PTSD, it would not provide a basis upon which to grant SMC at the housebound rate under 38 U.S.C.A. § 1114(s) prior to March 9, 2015. In other words, a TDIU based solely on PTSD would not provide an independently ratable disability of 60 percent or more. Regarding the time period prior to January 24, 2013, the record reflects that the Veteran last worked in 2011. In a September 2014 memorandum, the Veteran's private treating doctor wrote that the Veteran, who had severe debilitating psychiatric difficulties due to his service-connected PTSD, had been a patient for over 4 years; and, that the Veteran had not been able to work since 2011 as a result of chronic, debilitating impairment and was not employable due to the severity of his symptoms. SSA records also show that the Veteran was deemed unemployable as of January 2011 due to his psychiatric disability as well as a non-service-connected back condition. To establish entitlement to a TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to a veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). VA regulations establish objective and subjective standards for an award of TDIU. When a veteran's schedular rating is less than total (for a single or combination of disabilities), a total rating may nonetheless be assigned where a veteran has a single service-connected disability that is rated as 60 percent disabling or more; or when there are two or more disabilities, at least one disability is rated at 40 percent or more, and any additional disabilities result in a combined rating of 70 percent or more, and the disabled person is unable to secure or follow a substantially gainful occupation. For the purpose of one 60 percent disability, or one 40 percent disability in combination, disabilities resulting from common etiology will be considered as one disability. See 38 C.F.R. § 4.16(a). Prior to this decision, the Veteran did not meet the schedular threshold percentage requirements for consideration of a TDIU on a schedular basis prior to January 24, 2013 because although his PTSD was rated as 50 percent disabling, his GERD was only rated at 10 percent; and, when considered along with his ratings for tinnitus and hearing loss, did not combine to at least 70 percent. However, pursuant to this decision, the Veteran now meets the schedular threshold percentage requirements for consideration of a TDIU on a schedular basis as of February 22, 2012, because the Board has granted an initial disability rating of 30 percent for the service-connected GERD, effective from February 22, 2012. Thus, the Veteran's service-connected disabilities are now rated as follows from February 22, 2012 to January 24, 2013: PTSD rated as 50 percent disabling, GERD rated as 30 percent disabling, tinnitus rated as 10 percent disabling, and hearing loss rated as noncompensable. Accordingly, from February 22, 2012 to January 24, 2013, the Veteran has one disability rating at least 40 percent disabling with sufficient additional disability to bring the combined rating to 70 percent. See Combined Ratings Table at 38 C.F.R. § 4.25. Therefore, the remaining question is whether the Veteran is precluded from obtaining or maintaining gainful employment consistent with his education and work history during that time period. Here, the Veteran's February 2013 VA Form 21-8940 (TDIU claim form) shows that the Veteran worked as a VA security officer from 2006 to 2011. He had a high school education and no additional training. Given that the Veteran's treating mental health provider, P.M., MD, opined in a September 2014 memorandum, that the Veteran could no longer work after January 2011 as a result of his severe psychiatric condition, the Board finds that a TDIU is warranted on a schedular basis from February 22, 2012 to January 24, 2013. The effective date of the TDIU is based on the effective date of the 30 percent rating for GERD because that is the first date on which the Veteran met the schedular threshold percentage under 38 C.F.R. § 4.16(a). Given these findings, the Board concludes that the Veteran is unemployable due to his service-connected disabilities effective from February 22, 2012. All doubt has been held in the Veteran's favor. See Gilbert, 1 Vet. App. 49, 53-56 (1990). The issue of entitlement to a TDIU prior to February 22, 2012 is addressed in the remand below. ORDER An effective date prior to January 24, 2013, for the assignment of a 100 percent rating for the service-connected PTSD is denied. An initial disability rating of 30 percent, but not higher, for the service-connected GERD is granted prior to March 9, 2015, subject to the laws and regulations governing the payment of monetary benefits. A 60 percent rating, but not higher, is granted for the service-connected GERD beginning on March 9, 2015, subject to the laws and regulations governing the payment of monetary benefits. SMC at the housebound rate is granted effective from March 9, 2015. 38 U.S.C.A. § 1114(s) (West 2014); 38 C.F.R. § 3.350(i) (2015). Entitlement to TDIU is granted from February 22, 2012 to January 24, 2013, subject to the law and regulations regarding the award of monetary benefits. REMAND The Veteran seeks service connection for sleep apnea, ED, and MRSA-related boils. Additional development with regard to these issues is necessary. Regarding ED, the VA examiner in January 2013 indicated that it appeared the Veteran met the criteria for a diagnosis of ED, but could not provide an opinion as to the etiology of the ED. Although the VA examiner indicated that the ED did not appear to be related to medications taken for service-connected disabilities, the examiner did not consider whether the Veteran's ED is caused by, or otherwise related to his service-connected PTSD. In other words, the examiner did not opine as to the likelihood that the Veteran's service-connected PTSD symptoms cause or aggravate (permanently worsen beyond natural progression) the ED. Another examination is therefore necessary to decide the claim. Regarding the sleep apnea, the Veteran initially filed a claim of service connection for sleep problems. At that time, he felt his sleep problem was related to his PTSD. See January 2009 Decision Review Office (DRO) hearing transcript, p. 14. The RO denied the Veteran's claim in a June 2008 rating decision. The RO noted that even though the Veteran reported trouble sleeping on his discharge examination in September 1992, the Veteran did not have a sleep disorder diagnosed in service, or currently. The Veteran did not appeal that determination. In February 2012, the Veteran submitted a new claim, but specifically claimed service connection for sleep apnea, a specific disorder separate and apart from his PTSD. Thus, this is a new claim and not a claim to reopen. The Veteran has a current diagnosis of sleep apnea. See November 2014 private sleep study (nocturnal polysomnogram). The sleep study report noted "associated co-morbid conditions including anxiety/depression." Because the Veteran reported trouble sleeping in service, and he has a current diagnosis of sleep apnea, he should be afforded a VA examination to determine the likelihood that his sleep apnea had its onset during service and/or whether his sleep apnea is related to his PTSD. VA must provide a medical examination when there is evidence of (1) a current disability, (2) an in-service event, injury, or disease, (3) some indication that the claimed disability may be associated with the established event, injury, or disease, and (4) insufficient competent evidence of record for VA to make a decision. McClendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A(d)(2) (West 2014); 38 C.F.R. § 3.159(c)(4)(i) (2015). The third prong, which requires evidence that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McClendon, 20 Vet. App. at 83. Regarding the Veteran's claim of service connection for MRSA-related boils, the Veteran was examined for this condition in January 2013. The examiner found no boils present at the time of the examination, and opined that his MRSA boils, including abscesses and anal/perineal fistula, were less than likely permanently aggravated or a result of any event and/or condition that occurred in service. The examiner noted that the Veteran did have pediculosis and athlete's foot in service, but they are not related to any bacterial infection that occurred after service. The examiner found that the MRSA infection contracted after service was more likely than not related to exposure to a source after service. The examiner pointed out that the first incision and drainage took place in 2004, many years after service, and the examiner opined that MRSA, being such an aggressive bacteria, would have more than likely have already been evidence much more proximate the time of service had the Veteran contracted the infection during service. The examiner indicated that the Veteran's skin conditions or abscesses, fistulas, and boils were not the type of skin lesions that developed without the bacteria's presence; and, although the Veteran reported having some skin lesions in service, it is very less than likely any were related or caused by MRSA because that would have been evidence due to the MRSA's aggressive behavior. By contrast, the Veteran's private dermatologist, Dr. J.A., MD, noted in a November 2014 memorandum that he was treated for tinea pedis, tinea cruris, and Furunculosis. Dr. J.A. further noted that the Veteran had a history of severe tinea pedis and tinea cruris of the groin during his military service in 1990, which then caused a MRSA bacterial infection, with subsequent recurring episodes of Furunculosis. Dr. J.A. opined that the Veteran has been a carrier of MRSA bacteria since that time. In essence, the VA examiner found that the MRSA infection first occurred several years following discharge from service, but the private doctor indicated that the MRSA had its onset during service. Although a September 1989 STR shows treatment for possible poison ivy/contact dermatitis in the groin area; and, a September 1991 STR notes fluid filled blisters on both feet, there is no indication that MRSA was involved. Nonetheless, given this finding of in-service contact dermatitis and blisters in service, another examination is necessary to reconcile the two opinions. In addition, the Veteran submitted an article from the "Science Daily" online publication from May 2009 suggesting a link between MRSA and common foot conditions. Given that the Veteran had a in-service history of tinea pedis and foot blisters, the examiner should address this evidence. Finally, the Veteran's schedular disability rating does not meet the percentage requirements set forth in 38 C.F.R. § 4.16(a) for consideration of a TDIU prior to February 22, 2012, but the Veteran maintains that he was unemployable due to PTSD as of January 2011. Prior to February 22, 2012, the Veteran's combined disability rating is less than 70 percent and the Veteran did not have a single disability rated at 60 percent or higher. Thus, the schedular threshold percentage requirements for consideration of a TDIU on a schedular basis were not met prior to February 22, 2012. Nevertheless, the Veteran may still warrant entitlement to a TDIU if the evidence shows that his service-connected disabilities preclude him from securing or following substantially gainful employment. 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16. In this case, the Veteran's combined service-connected disability rating at the time he became unemployed in January 2011 was 60 percent. PTSD was rated as 50 percent disabling, tinnitus was rated as 10 percent disabling, and hearing loss was rated as noncompensable. Although the Veteran has pending claims of service connection which are being remanded, those claims were filed on February 22, 2012, and, pursuant to this decision, the criteria for entitlement to a TDIU have been established as of that date. Thus, deferral of the TDIU issue pending resolution of the pending claims would not alter the outcome with respect to entitlement to a TDIU on a schedular basis prior to February 22, 2012. However, where the percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the veteran's background including his employment and educational history. 38 C.F.R. §§ 3.321(b), 4.16(b). Appropriate cases must be referred to the Director of the VA Compensation and Pension Service for such extraschedular consideration. Bowling v. Principi, 15 Vet. App. 1 (2001). Here, the evidence shows that the Veteran may have been unemployable prior to February 22, 2012 due to his PTSD. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the electronic claims file all outstanding VA records dated from November 2012. 2. With appropriate authorization, obtain and associate with the electronic claims file all outstanding private medical records identified by his as pertinent to his claims of service connection for sleep apnea, ED, and MRSA boils. 3. After completion of the above directives, schedule the Veteran for a VA dermatology examination by a physician with appropriate expertise to determine the nature and etiology of the Veteran's MRSA boils. The entire record must be reviewed by the examiner. All appropriate tests and studies should be conducted and clinical findings should be reported in detail. Based on the examination results and the review of the entire electronic record, including a copy of this remand, the examiner should provide an opinion as to whether the Veteran has a current disability manifested by recurrent MRSA-related skin boils, and if so, whether such disorder, at least as likely as not (a probability of 50 percent or greater began in or is related to an injury or disease incurred during active service. Even if the examiner finds that the Veteran does not have an active boil at the time of the examination, the examiner should consider the Veteran's self-reported history as to the timing, frequency and severity of his outbreaks as well as the treatment records since service showing treatment for this condition. The examiner is asked to reconcile the opinion of the VA examiner in January 2013 with the private dermatologist's opinion from November 2014. In this regard, if the examiner finds that the Veteran's MRSA infection is unrelated to service and/or the Veteran's recurrent boils, then the examiner should nonetheless address whether the Veteran's current disability manifested by boils, as likely as not, had its onset during service; or, whether the Veteran's boils are made permanently worse (aggravated) by a service-connected disability. Please provide a complete rationale for all opinions provided. 4. Schedule the Veteran for a VA examination by a physician with appropriate expertise to determine the nature and etiology of the Veteran's ED and sleep apnea. The entire record must be reviewed by the examiner. All appropriate tests and studies should be conducted and clinical findings should be reported in detail. a. Based on the examination results and the review of the entire electronic record, including a copy of this remand, the examiner should provide an opinion as to whether the Veteran has a current disability manifested by ED, and if so, whether such disorder, at least as likely as not (a probability of 50 percent or greater began in or is related to an injury or disease incurred during active service, including whether it is, as likely as not, caused or aggravated (made permanently worse) by the service-connected PTSD and/or other service-connected disability and/or whether it is caused by or aggravated by any medications prescribed for any of the Veteran's service-connected disabilities. Please provide a complete explanation for the opinion. b. Based on the examination results and the review of the entire electronic record, including a copy of this remand, the examiner should provide an opinion as to whether the Veteran's currently diagnosed sleep apnea, at least as likely as not (a probability of 50 percent or greater began in or is related to an injury or disease incurred during active service, including whether it is, as likely as not, caused or aggravated (made permanently worse) by the service-connected PTSD and/or other service-connected disability and/or whether it is caused by or aggravated by any medications prescribed for any of the Veteran's service-connected disabilities. The examiner should also opine as to whether the Veteran's sleep apnea was caused or aggravated by his reported history of exposure to smoke from burn pits and inhaled irritants/toxins during service. In this regard, the examiner is directed to the December 2014 memorandum from a private pulmonologist, Dr. F.G., who noted the Veteran's self-reported history of in-service exposure to smoke from burn pits and inhaled irritants/toxins. Please provide a complete explanation for the opinions. The examiner is also 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. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. After any additional development deemed appropriate has been conducted, readjudicate the claim for entitlement to a TDIU prior to February 22, 2012. If the claim remains denied, refer it to the appropriate department officials under 38 C.F.R. § 4.16(b) for extraschedular consideration. 6. Readjudicate the Veteran's claims for entitlement to service connection for MRSA-related boils, ED and sleep apnea. If any action taken is adverse to the Veteran, including the claim of entitlement to a TDIU prior to February 22, 2012, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs