Citation Nr: 1751384 Decision Date: 11/09/17 Archive Date: 11/17/17 DOCKET NO. 17-04 506 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and anxiety disorder. 2. Entitlement to service connection for obstructive sleep apnea, to include as secondary to an acquired psychiatric disorder. 3. Entitlement to service connection for hypertension. 4. Entitlement to an initial compensable rating for bilateral pterygium. 5. Entitlement to an initial rating in excess of 70 percent for bilateral hearing loss. 6. Entitlement to an initial rating in excess of 10 percent for tinnitus. 7. Entitlement to an effective date prior to May 8, 2012 for the award of service connection for bilateral hearing loss. 8. Entitlement to an effective date prior to May 8, 2012 for the award of service connection for tinnitus. 9. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: J. Michael Woods, Attorney ATTORNEY FOR THE BOARD R. Behlen, Associate Counsel INTRODUCTION The appellant served on active duty in the Army from October 1963 to September 1965 and from November 1965 to November 1968. These matters are before the Board of Veterans' Appeals (Board) from September 2013, April 2014, March 2015, and January 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the September 2013 rating decision denied service connection for PTSD, while the April 2014 rating decision determined that new and material evidence had not been received to reopen the claim of service connection for PTSD. Here, the appellant's Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, which was received in September 2013, upon which he stated that he was unable to secure and follow a substantially gainful occupation, in part due to PTSD, was treated as a petition to reopen his claim of service connection for PTSD, even though it was received within one year of the September 2013 rating decision and that decision had not yet become final. 38 C.F.R. § 3.156(b). Additionally, the appellant's July 2014 notice of disagreement (NOD) was received within one year of the September 2013 rating decision and expressed disagreement with the decisions in both the September 2013 and April 2014 rating decisions. Therefore, the Board finds that the appellant's NOD was with regard to the original denial of service connection for PTSD in the September 2013 rating decision. Thus, the issue of entitlement to service connection for PTSD, now characterized as an acquired psychiatric disorder, is properly on appeal. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of entitlement to service connection for an acquired psychiatric disorder, entitlement to service connection for obstructive sleep apnea, entitlement to increased ratings for bilateral hearing loss and tinnitus, entitlement to earlier effective dates for the awards of service connection for bilateral hearing loss and tinnitus, and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Hypertension did not have its inception during the appellant's active service or within the applicable presumptive period, and the most probative evidence indicates that hypertension is not causally related to active service or any incident therein. 2. The appellant's bilateral pterygium is manifested by findings of acuity of 20/40 or better bilaterally for corrected distance and near vision. The appellant does not have active chronic conjunctivitis, a visual field defect, contraction or loss of a visual field, or scotoma. There are no characteristics of disfigurement, nor is there evidence of any other symptomatology. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 2. The criteria for entitlement to an initial compensable rating for bilateral pterygium have not been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.79, Diagnostic Codes 6018, 6034, 6066 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Neither the appellant nor his attorney has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Applicable Law A. Standard of Proof The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). "It is in recognition of our debt to our veterans that society has [determined that,] [b]y tradition and by statute, the benefit of the doubt belongs to the veteran." See Gilbert, 1 Vet. App. at 54. B. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. § 1110. "To establish a right to compensation for a present disability, a Veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'-the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including hypertension, arthritis, and other organic diseases of the nervous system, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). i. Herbicide agents In addition, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that such veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii). If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain enumerated diseases shall be service connected if the requirements of 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C. § 1113; 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). The enumerated diseases which are deemed to be associated with herbicide agent exposure are AL amyloidosis; chloracne or other acneform disease consistent with chloracne; type 2 diabetes; Hodgkin's disease; ischemic heart disease; chronic B-cell leukemias; multiple myeloma; non-Hodgkin's lymphoma; Parkinson's disease; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); and certain soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). Id. VA's Secretary has determined that there is no positive association between exposure to herbicide agents and any other condition for which he has not specifically determined a presumption of service connection is warranted. See Determinations Concerning Illnesses Discussed in National Academy of Sciences Report: Veterans and Agent Orange: Update 2012, 79 Fed. Reg. 20,308 (Apr. 11, 2014). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and early onset peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). Despite the presumptive regulations, a claimant may establish service connection based on exposure to Agent Orange with proof of actual direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Brock v. Brown, 10 Vet. App. 155 (1997). C. Increased Evaluations Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if that disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the initial rating assigned following an award of service connection, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous. . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. Pterygium is evaluated under Diagnostic Code (DC) 6034, which indicates that evaluations should be done based on visual impairment, disfigurement (DC 7800), conjunctivitis (DC 6018), etc., depending on the particular findings. 38 C.F.R. § 4.79. DC 6018 provides that active chronic conjunctivitis should be provided a 10 percent rating with objective findings, such as red, thick conjunctivae, mucous secretion, etc.). Inactive conjunctivitis is to be evaluated based on residuals, such as visual impairment and disfigurement (DC 7800). 38 C.F.R. § 4.79. The appellant's bilateral pterygium has been rated for residuals based on visual impairment under DC 6066. DC 6066 directs that a 10 percent rating be assigned for impairment of central visual acuity in the following situations: (1) when the corrected visual acuity is 20/50 in one eye and 20/40 in the other eye; (2) when vision in both eyes is correctable to 20/50; (3) when vision in one eye is correctable to 20/70 and vision in the other eye is correctable to 20/40; or (4) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/40. 38 C.F.R. § 4.79, DC 6066. Higher evaluations are warranted for poorer vision. III. Analysis A. Entitlement to service connection for hypertension. A February 1968 Dental Patient History shows that the appellant denied having ever had high blood pressure and stated that no physician ever told him he had heart trouble. The October 1968 separation examination was essentially normal, save for notation of a growth in the eyes which had been removed in August 1968. Examination was negative for heart-related observations, symptoms, or complaints. Blood pressure was measured at 128/80 during such examination. In his October 1968 Report of Medical History, the appellant denied having or having ever had palpitation or pounding heart or high or low blood pressure. Such was also denied on his September 1965 Report of Medical History at the end of his first period of service. March 2003, July 2003 and September 2003 VA treatment records reflect the Veteran had hypertension and was receiving treatment for the condition. An August 2011 clinical note states that the appellant had a history of hypertension for four to five years, and was taking medication for such. A May 2012 statement from Dr. J.A.D. notes that the appellant had hypertension by history. However, blood pressure remained well-controlled. Blood pressure was noted to be at goal in April 2012. However, no opinion regarding the etiology of the appellant's hypertension was offered by Dr. J.A.D. The record on appeal establishes that hypertension was not present during the appellant's active service or manifest to a compensable degree within one year of separation. Service treatment records are negative for hypertension-related symptomatology or complaints; and his October 1968 separation examination was negative for heart-related symptoms or complaints. Rather, the evidence of record indicates that the appellant's hypertension is of a more recent onset. Although the exact date of onset is unclear, the earliest record of treatment for hypertension is from March 2003, which is about 35 years following separation. The Veteran's service records reflect that he served in Vietnam during the period prescribed by regulation wherein exposure to herbicide agents is presumed. However, the record on appeal contains no indication that any medical professional has related the appellant's post-service hypertension to his active service or any incident therein, including exposure to herbicide agents. As set forth above, VA regulations provide that, if a veteran was exposed to an herbicide agent during active military, naval, or air service, certain enumerated diseases shall be service connected if the requirements of 38 U.S.C. § 1116, 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C. § 1113; 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). The enumerated diseases, however, do not include hypertension. See 38 C.F.R. § 3.309(e). Although hypertension is not amongst the delineated diseases associated with herbicide agent exposure, service connection for claimed residuals of exposure to herbicide agents may be established with evidence of actual causation. 38 C.F.R. § 3.309(e); Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange). As set forth above, however, the record contains no evidence of a link between hypertension and the appellant's active service or any incident therein, including exposure to Agent Orange. The Board observes that neither the appellant nor his attorney has contended that the appellant developed hypertension as a result of exposure to herbicide agents, including Agent Orange. Rather, the appellant has simply claimed entitlement to service connection for hypertension, originally characterized as high blood pressure. This is merely a conclusory generalized statement that the appellant believes his recently-developed hypertension is related to his active service. See Waters v. Shinseki, 601 F.3d 1274 , 1278 (Fed. Cir. 2010) (holding that a veteran's mere conclusory generalized lay statement that a service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide a VA examination). The appellant's attorney is reminded that it is a claimant's responsibility to support a claim for VA benefits, including submitting or specifically identifying relevant evidence and alleging specific errors of fact of law. See 38 U.S.C. §§ 5107(a), 7105(d)(5). An appellant's attorney is expected to present arguments he or she deems material and relevant to the clients' cases. See, e.g., Andrews v. Nicholson, 421 F.3d 1278, 1282 (Fed. Cir. 2005) (pro se pleadings, not those of counsel, are entitled to a sympathetic reading). In summary, the Board finds that the most probative evidence shows that the appellant's current hypertension did not have its onset during active service, did not manifest to a compensable degree within one year of service separation, and is not causally related to his active service or any incident therein, including exposure to Agent Orange. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). B. Entitlement to an initial compensable rating for bilateral pterygium. The appellant was afforded a VA examination in February 2015 for his bilateral pterygium. The claims file was reviewed. His uncorrected distance visual acuity was 20/100 in each eye. Uncorrected near vision was 20/70 bilaterally. Corrected distance and near vision were each 20/40 or better bilaterally. The appellant did not have a difference equal to two or more lines on the Snellen test type chart or its equivalent between distance and near corrected vision, with near vision being worse. Pupil diameter was 4 mm. bilaterally; and pupils were round and reactive to light. There was no afferent pupillary defect. There was no anatomical loss, light perception only, extremely poor vision, or blindness of either eye. There was no corneal irregularity that resulted in severe irregular astigmatism. There was no diplopia (double vision). Tonometry was performed using Goldmann applanation; and pressure was 15 bilaterally. Slit lamp and external eye examination was normal bilaterally for lids, lashes, conjunctiva/sclera, anterior chamber, iris, and lens. Fundus was normal bilaterally. The appellant did not have a visual field defect, or condition that may result in such. Visual field testing was not performed. There was no contraction or loss of a visual field. There was no scotoma. The appellant was not legally blind. The appellant had a corneal condition. He had not undergone a corneal transplant. He did not have keratoconus. The appellant had pterygium in the cornea bilaterally. There were no other corneal conditions that may result in an irregular cornea. There was no decrease in visual acuity or other visual impairment. There was no scarring or disfigurement. There were no incapacitating episodes in the past 12 months. The optometrist opined that the appellant's pterygium did not impact his ability to work. There were no other conditions, pertinent physical findings, complications, signs, or symptoms. The Board finds that the February 2015 VA medical opinion is entitled to great probative weight as it is based upon a review of the claims file and an examination of the appellant. There is no competent evidence of record which suggests that the severity of the appellant's bilateral pterygium warrants an initial compensable rating for any portion of the period on appeal. The evidence does not indicate the Veteran has objective findings of active conjunctivitis, so a 10 percent rating under DC 6018 is not appropriate. The evidence of record establishes that the appellant's bilateral pterygium is manifested by findings of acuity of 20/40 or better bilaterally for corrected distance and near vision. There is no evidence, nor do the appellant or his attorney contend, that the appellant has a visual field defect, contraction or loss of a visual field, scotoma, characteristics of disfigurement, or any other symptomatology. Rather, the competent medical evidence of record establishes that the appellant's bilateral pterygium is asymptomatic. The Board has considered the applicability of other diagnostic codes for diseases of the eye and diagnostic codes for scars. 38 C.F.R. §§ 4.79, 4.118. However, no other potentially applicable diagnostic code would afford the appellant an initial compensable rating, or a compensable rating for any portion of the period on appeal. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). As noted above, the evidence establishes that the appellant's bilateral pterygium is asymptomatic. Thus, the appellant does not meet the criteria for an initial compensable rating for any of the diagnostic codes for diseases of the eye. See 38 C.F.R. § 4.79, DCs 6000-6091. With respect to diagnostic codes for scars, the February 2015 VA examiner observed that there was no scarring or disfigurement. Thus, an initial compensable rating under the rating criteria for scars is not warranted. See 38 C.F.R. § 4.118, DCs 7800-7805. The Board observes that the appellant's attorney has pointed to no other potentially applicable diagnostic code. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for hypertension is denied. Entitlement to an initial compensable rating for bilateral pterygium is denied. REMAND Although the Board regrets the delay, remand for further development of the issues remaining on appeal is required. A. Psychiatric Disorder Given the evidence of record and the appellant's contentions, the Board has expanded the appellant's claim of service connection for PTSD to an acquired psychiatric disorder, to include PTSD and anxiety disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009) (holding that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by a claimant's description of the claim, reported symptoms, and the other information of record). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). The requirements for establishing an in-service stressor are delineated in 38 C.F.R. § 3.304(f)(1)-(5). In pertinent part, the regulation provides that if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). In this case, the record reflects that the appellant reported that during his service in Vietnam he had to ride shotgun on guard duty; and, although nothing ever happened, he was on a high state of alert. He also reported that he and his comrades "were expecting trouble every day" after a jeep was shot up, although the appellant had been at the compound at the time of the actual incident. In a buddy statement received in April 2017, G.G., who served with the appellant, reported that the two were shot at on runways during takeoffs and landings, and subject to ambush, while delivering classified materials. The Veteran's DD Form 214 reflects that his military occupational specialty was communications specialist. The August 2013 VA examiner determined that the Veteran's stressors were related to the fear of hostile military or terrorist activity. The August 2013 VA examiner concluded that the appellant did not meet the full criteria for a diagnosis of PTSD under the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) or exhibit any other mental disorder that conformed to DSM-IV criteria. The appellant was noted to never have been treated for or diagnosed with PTSD or any mental health disorder. The Board notes that a mental disorder Disability Benefits Questionnaire (DBQ) was completed by Dr. H.H.G., a private psychologist, in March 2015. The claims file was reviewed. He was diagnosed with anxiety disorder, not otherwise specified, under DSM-5 criteria. Dr. H.H.G. opined that it more likely than not began during his active service and is aggravated by his tinnitus. Dr. H.H.G. opined that the appellant "cannot sustain the stress from a competitive work environment and cannot be expected to engage in gainful employment due to his anxiety disorder." Dr. H.H.G. observed that there was no mental health diagnosis rendered during the appellant's August 2013 VA examination, but did not offer an opinion as to why anxiety disorder, or any other mental health disorder, had not been diagnosed previously while Dr. H.H.G. opined that anxiety disorder began during the appellant's active service in the 1960s. It is unclear whether Dr. H.H.G. examined the appellant in person or simply conducted a telephonic interview. Since that August 2013 VA examination was conducted, however, VA amended 38 C.F.R. § 4.125(a) to indicate that a diagnosis of a mental disorder, to include PTSD, must conform to the standards set in the DSM-5. The amendments are applicable to the appellant's claim. See 38 C.F.R. § 4.125; 79 Fed. Reg. 45,093, 45,094-096 (Aug. 4, 2014); 80 Fed. Reg. 14,308 (Mar. 19, 2015) (final) (providing that for claims that were initially certified for appeal to the Board, the Court of Appeals for Veterans Claims (CAVC), or the U.S. Court of Appeals for the Federal Circuit prior to August 4, 2014, DSM-IV will apply. For all applications for benefits received by VA or pending before the AOJ on or after August 4, 2014, DSM-5 will apply). As the appellant's claim was first certified for appeal in February 2017, DSM-5 applies to his claim. As noted, the appellant was provided a VA examination in August 2013, in which the examiner used DSM-IV and opined that the appellant did not have a current diagnosis of PTSD or any other mental disorder. Thus, a remand is required to provide the appellant with a VA psychiatric examination that uses DSM-5, in accordance with current VA regulations. B. Bilateral Hearing Loss and Tinnitus A January 2017 rating decision awarded service connection for bilateral hearing loss, evaluated as 70 percent disabling, and for tinnitus, evaluated as 10 percent disabling. Both awards were made effective May 8, 2012. VA received the Veteran's NOD in February 2017 which disagreed with the ratings and effective dates assigned for the awards. The filing of a NOD confers jurisdiction on the Board and the next step is for the Agency of Original Jurisdiction (AOJ) to issue an SOC. See Manlincon v. West, 12 Vet. App. 238 (1999). Although the NOD was recently filed, the claims being appealed are inextricably intertwined with the TDIU claim that is being remanded, as explained below. Therefore, issuance of an SOC must be completed prior to adjudication of the TDIU claim. C. TDIU On his September 2013 Form 21-8940, the appellant contended that he is unable to secure or follow a substantially gainful occupation due to PTSD, incapacitating tinnitus, and incapacitating hearing loss. He reported last working full-time in 1987, which was when he became too disabled to work. The appellant reported that, with respect to hearing loss, he experiences communication problems and feels like he lost more than one job due to poor hearing. He also reported that his tinnitus is incapacitating and makes it hard to concentrate. As the appellant has filed an NOD with regard to the initial 10 percent rating assigned for tinnitus and the initial 70 percent rating assigned for bilateral hearing loss, the resolution of such claims may have an impact on the appellant's claim of entitlement to TDIU. Further, Dr. H.H.G., the private psychologist, opined that the appellant is unable to work due to a psychiatric disorder. Thus, the issues of entitlement to service connection for an acquired psychiatric disorder and entitlement to initial increased ratings for tinnitus and hearing loss are inextricably intertwined with the issue of entitlement to TDIU. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review meaningless and a waste of judicial resources, the two claims are inextricably intertwined). D. Obstructive Sleep Apnea Similarly, in his April 2017 brief, the appellant's attorney argues that the appellant's diagnosed obstructive sleep apnea was caused or aggravated by a psychiatric disorder. Thus, it, too, is inextricably intertwined with the claim of entitlement to service connection for an acquired psychiatric disorder. See Harris, 1 Vet. App. at 183. Accordingly, the case is REMANDED for the following actions: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Associate any updated VA medical records with the claims file from August 2013 to the present. 2. Issue an appropriate statement of the case addressing the issues of earlier effective dates for the award of service connection for bilateral hearing loss and tinnitus and increased ratings for bilateral hearing loss and tinnitus. The Veteran and his attorney should be advised of the time afforded for perfecting an appeal in these matters, and given opportunity to do so. If that occurs, these matters should also be returned to the Board for appellate review. 3. After completing the development requested in item 1, provide the appellant with an appropriate examination to determine the nature and etiology of any current psychiatric disorder. Access to the appellant's electronic VA claims file should be made available to the examiner for review in connection with the examination. After reviewing the record and examining the appellant, the examiner should delineate all current mental disorders exhibited by the appellant, if any. Diagnoses should be rendered in accordance with DSM-5. The examiner is asked to provide opinions on the following: A) If PTSD is diagnosed, then is it at least as likely as not (50% or greater probability) that any of the claimed stressors caused the Veteran's PTSD. B) For any other mental disorder that is diagnosed, then is it at least as likely as not that any psychiatric disorder identified is causally related to the appellant's active service or any incident therein? C) For any mental disorder diagnosed, is it at least as likely as not that it was i) caused or ii) aggravated (i.e., any increase in severity beyond the natural progression of the condition) by service-connected bilateral hearing loss or tinnitus? The examiner is asked to specifically consider: (1) the private March 2015 diagnosis of anxiety disorder, unspecified, under DSM-5 criteria; (2) the August 2013 VA examination report; and (3) lay statements submitted by the Veteran, his family, and his friends and service comrades regarding his alleged stressors and observed symptomatology. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide any requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 4. After completing the above actions, and any other development deemed necessary, readjudicate the claims of service connection for a psychiatric disorder, service connection for obstructive sleep apnea, and entitlement to TDIU. If any claim remains denied, a Supplemental Statement of the Case must be provided to the appellant and his attorney. After the appellant and his attorney have had the appropriate opportunity to respond, the appeal must be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ M. Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs