Citation Nr: 1752495 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 09-15 567A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a higher rating for vascular dementia, to include posttraumatic stress disorder (PTSD) with depression, rated as 30 percent disabling prior to September 25, 2008, 50 percent disabling from September 25, 2008 to June 19, 2014, and 100 percent disabling thereafter. 2. Entitlement to an initial compensable rating for hypertension. 3. Entitlement to service connection for diabetes mellitus, to include as due to exposure to a herbicidal agent. 4. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected hypertension and/or vascular dementia. 5. Entitlement to service connection for cardiomyopathy with coronary artery disease (CAD), to include as due to exposure to a herbicidal agent or secondary to service-connected vascular dementia. 6. Entitlement to service connection for peripheral neuropathy of the legs, to include as due to radiation exposure, exposure to a herbicidal agent, or secondary to a service-connected disability. 7. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected vascular dementia. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from July 1963 to July 1967. This case comes before the Board of Veterans' Appeals (Board) on appeal from July 2006, July 2008, and September 2009 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The issues of entitlement to service connection for cardiomyopathy with CAD, peripheral neuropathy of the legs, and sleep apnea are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's PTSD manifests impairment in most areas without total social and occupational impairment. 2. The Veteran's hypertension requires continuous medication for control; he does not have a history of diastolic pressure predominantly 100 or more; he does not currently have diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more. 3. The Veteran was not exposed to herbicidal agents during active duty service. 4. Diabetes mellitus was demonstrated years after service and is not etiologically related to a disease or injury in service, including exposure to a herbicidal agent. 5. The Veteran's erectile dysfunction was incurred secondary to service-connected hypertension. CONCLUSIONS OF LAW 1. The criteria for a rating of 70 percent, but not higher, for PTSD throughout the claims period are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411-9305 (2017). 2. The criteria for an initial compensable rating for hypertension are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7101. 3. Diabetes mellitus was not incurred in or aggravated by active service, nor may its incurrence or aggravation be presumed. 38 U.S.C. §§ 1110, 1112, 1116, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. 4. Service connection for erectile dysfunction as secondary to service-connected hypertension is warranted. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Increased Rating Claims Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability ratings. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Staged ratings are also appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Vascular Dementia and PTSD Service connection for PTSD was granted in a July 2006 rating decision with an initial 30 percent evaluation assigned effective June 20, 2005. An increased 50 percent evaluation was granted effective September 25, 2008 in the September 2009 rating decision on appeal. In March 2015, the Veteran's disability was recharacterized as vascular dementia including PTSD and a total schedular (100 percent rating) was assigned effective June 20, 2014. As the Veteran is in receipt of the highest possible schedular rating from June 20, 2014, the decision below focuses on the appropriate rating for the period prior to this date. The Veteran's vascular dementia and PTSD is currently rated as 30 percent disabling prior to September 25, 2008 and 50 percent disabling from September 25, 2008 to June 19, 2014. These ratings were assigned under Diagnostic Code 9411, in accordance with the General Rating Formula for Mental Disorders (General Rating Formula). See 38 C.F.R. § 4.130. When the disability was recharacterized to include vascular dementia in March 2015, the diagnostic code was also changed to 9411-9305, but is still rated in accordance with the General Rating Formula. Under the General Rating Formula, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine actives; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A maximum 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The Board finds that an initial rating of 70 percent, but not higher, is warranted for the Veteran's PTSD (now vascular dementia) throughout the period prior to June 20, 2014. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). Regarding the Veteran's specific symptoms, VA treatment records and examination reports document consistent findings of a depressed mood, intrusive thoughts, paranoid thinking, chronic sleep impairment with nightmares, angry outbursts, mood swings, and intermittent suicidal thinking without intent. The Veteran also experienced consistent cognitive difficulties throughout the claims period, to include concentration problems and deficits with word recall, that gradually worsened to the level contemplated by the 100 percent rating on June 20, 2014. The July 2006, February 2008, July 2009, and November 2011 VA examiners identified moderate symptoms and impairment associated with the Veteran's PTSD, but the service-connected condition clearly manifested deficiencies in all areas of the Veteran's life. The Board finds these symptoms are of similar severity, frequency, and duration as those contemplated by a 70 percent initial rating and an increased rating is warranted throughout the applicable period. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The Board has considered whether a total schedular rating is warranted at any time during the claims period. The Veteran does not endorse any of the symptoms listed in the criteria for a 100 percent evaluation, and the symptoms he does experience are not of similar severity, frequency, and duration as those associated with a total rating. For example, the Veteran has reported intermittent suicidal thoughts during the claims period, but he is not in persistent danger of hurting himself and has consistently denied any active suicidal ideation. The Veteran's focus on his in-service trauma (the death of a pilot in December 1965 when a plane and atomic bomb rolled off the USS TICONDEROGA) and perceived cover-up by the Navy have been characterized by various VA examiners as obsessive, paranoid, and deluded, but he has never endorsed actual hallucinations or delusions. The Board therefore finds that he does not manifest persistent delusions or hallucinations or grossly inappropriate behavior. Furthermore, the Veteran's cognitive problems during this period were limited to issues with recurrent word recall and difficulties with concentration; he clearly did not manifest cognitive problems that most nearly approximated disorientation to time or place, memory loss for names of close relatives, his own occupation, or his own name prior to June 20, 2014 and the assignment of a 100 percent schedular rating for vascular dementia. With respect to occupational and social functioning, the Veteran has also not experienced total impairment due to PTSD. While he stopped working as a truck driving instructor in 2005, VA treatment records show that the Veteran retired from his employment due to a combination of physical and mental health problems. The Veteran has also remained married to his wife of over 50 years, and stated during the February 2008 VA examination that she was supportive and understanding of his psychiatric and cognitive conditions. The Veteran has few close friends, but reported throughout the claims period that he maintained social contacts with other veterans at the local American Legion club and had a close friend with whom he went out at least once a week. The Veteran clearly isolated himself from others throughout the claims period, but it is equally clear that he was capable of forming and maintaining some social relationships. Thus, the Veteran's PTSD symptoms are not of similar severity, frequency, or duration as those contemplated by a total schedular rating and total occupational and social impairment is not demonstrated. The Board has considered whether there is any other schedular basis for granting a higher rating other than that discussed above, but has found none. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the award of a rating higher than that assigned above. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Hypertension Service connection for hypertension was awarded in the July 2008 rating decision on appeal. An initial noncompensable (0 percent) evaluation was assigned effective April 8, 2008. The Veteran contends that a compensable rating is warranted as his hypertension requires continuous medication for control and has manifested several acute events of elevated blood pressure readings. The Veteran's hypertension is rated as noncompensably disabling under Diagnostic Code 7101 pertaining to hypertensive vascular disease. This diagnostic code does not provide for a noncompensable rating, therefore the initial evaluation was assigned in accordance with 38 C.F.R. § 4.31 (providing that when a diagnostic code does not provide for a zero percent evaluation, a zero percent evaluation shall be assigned if the compensable requirements are not met). Under Diagnostic Code 7101, a 10 percent rating is applicable if diastolic pressure is predominantly 100 or more, or systolic pressure is predominantly 160 or more, or the minimum evaluation for an individual with a history of diastolic pressure of predominantly 100 or more who requires continuous medication to control blood pressure. A 20 percent evaluation is warranted if diastolic pressure is predominantly 110 or more or systolic pressure is predominantly 200 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. The Board finds that the Veteran's hypertension does not more nearly approximate the criteria associated with a 10 percent rating. Although the disability requires control with continuous medication, the Veteran's blood pressure readings have not more nearly approximated a history or current findings of diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more. Blood pressure readings upon VA examinations in November 2011 and November 2014 showed diastolic and systolic readings below the levels contemplated by a compensable 10 percent evaluation. The Veteran's blood pressure was most elevated in February 2008, when it measured to 159/82, and in August 2012, when it measured to 146/96. These findings are clearly below the criteria for a 10 percent evaluation which requires systolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more. Although the Veteran contends that his blood pressure would measure much higher without the use of daily medication, Diagnostic Code 7101 contemplates the effects of hypertensive medication and rating the disability with consideration of the Veteran's medication is appropriate. Cf. Jones v. Shinseki, 26 Vet. App. 56, 61 (2012) (finding that the plain language of Diagnostic Code 7101 contemplates the effects of hypertensive medication). The medical and lay evidence establishes that the Veteran's hypertension responds well to medication and there is no evidence of functional impairment associated with the service-connected condition. In his November 2008 notice of disagreement, the Veteran reported that his blood pressure was very elevated in December 2003, when it was measured to 220/130. This finding is dated outside the claim period, as service connection was not established prior to April 8, 2008, and it cannot support the claim for a higher rating. During the applicable claims period, the Veteran's blood pressure readings did not approximate the criteria associated with a compensable rating, and it is therefore clear that the current noncompensable evaluation is appropriate under Diagnostic Code 7101. The Board has considered whether there is any other schedular basis for granting a higher rating, but has found none. Also, manifestations warranting a higher rating are not objectively shown at any time during the appellate period; hence, "staged" ratings are not warranted. The Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim seeking a compensable rating for hypertension. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Service Connection Claims Diabetes Mellitus The Veteran contends that service connection is warranted for diabetes mellitus as it was incurred due to exposure to a herbicide agent during his active duty service in the waters surrounding the Republic of Vietnam. He specifically contends that he was exposed to herbicides while the naval vessel, the USS TICONDEROGA, was located in the harbor waters of Vietnam. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The record establishes the first element of service connection-a current disability. The Veteran's private physician diagnosed diabetes mellitus in July 2004 based on a laboratory findings of elevated sugar levels. The Veteran has continued to receive VA and private treatment for diabetes throughout the claims period and a current disability is demonstrated. Service treatment records are negative for complaints or treatment related to diabetes and no abnormalities were noted at the June 1967 separation examination. Laboratory testing performed in connection with the separation examination also showed that the Veteran's urine tested negative for sugar. Thus, service records do not indicate the incurrence of a physical injury or signs or symptoms of diabetes during active duty. The Veteran contends he was exposed to an herbicidal agent during his period of active duty service aboard the USS TICONDEROGA which operated in the waters outside of Vietnam. The Veteran therefore contends that service connection is warranted on a presumptive or direct basis. Turning first to his contentions regarding service connection on a presumptive basis, a veteran who, during active military service, served in Vietnam during the period beginning in January 1962 and ending in May 1975, is presumed to have been exposed to herbicides. 38 C.F.R. §§ 3.307, 3.309. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307. The presumption requires that the veteran actually stepped foot on land in Vietnam. Haas v. Peake, 525 F.3d 1168 (2008); VAOPGCPREC 27-97. In other words, for purposes of applying the presumption of exposure to herbicides under 38 C.F.R. § 3.307 (a)(6)(iii), the service member must have actually been present at some point on the landmass or the inland waters of Vietnam during the Vietnam conflict. In the case before the Board, the Veteran does not contend that he ever "stepped foot" on land in Vietnam; rather, he contends that he was exposed to herbicides while serving aboard the USS TICONDEROGA which was present in the official waters of Vietnam. In a July 2005 statement, the Veteran reported that he was present in the "harbor waters" of Vietnam. Information received from the National Personnel Records Center (NPRC) in February 2006 establishes that the USS TICONDERGOA was present in the official waters of Vietnam on numerous occasions throughout the Veteran's active duty service, but the NPRC was not able to confirm whether the Veteran had any in-country service. The Board must therefore determine whether the Veteran's service in the official waters of Vietnam constitutes his presence in the inland waterways of Vietnam. What constitutes "inland waterways" was not defined in Haas and is not defined in VA regulations. Thus, the Board has historically referred to the VA Adjudication Procedure Manual M-21 (Manual) for interpretive guidance. The Manual maintains that inland waterways include rivers, canals, estuaries, and delta areas, such as those on which the Vietnam "brown water" Navy operated. VA Adjudication Procedure Manual M21-1MR, pt. IV, sub. Pt. ii, ch. 2, § C.10.k. The Manual clearly states that service aboard a ship that merely anchored in an open deep-water harbor, such as Da Nang, Vung Tau, or Cam Ranh Bay, along the Vietnam coast does not constitute inland waterway service to establish presumptive exposure to herbicides. Id. Any such anchorage is considered to be in "blue water" that does not provide for a presumption of herbicide exposure. Id. After review of an Institute of Medicine (IOM) report, ''Blue Water Navy Vietnam Veterans and Agent Orange Exposure," the Secretary of VA determined that the evidence available at that time did not support establishing a presumption of exposure to herbicides for Blue Water Navy Vietnam Veterans. See 77 Fed. Reg. 76170 (Dec. 26, 2012 ). In order for the presumption of exposure to Agent Orange to extend to a Blue Water Navy veteran, development must provide evidence that the veteran's ship operated temporarily on the inland waterways of Vietnam or that the Veteran's ship docked to the shore or a pier. In claims based on docking, a lay statement that the Veteran personally went ashore must be provided. Although evidence that a veteran's ship docked, along with a statement of going ashore, is sufficient for the presumption of herbicide exposure, service aboard a ship that anchored temporarily in an open deep water harbor or port is generally not considered sufficient. M21-1 IV.ii.2.C.3.e In recent years, VA amended its process for determining whether a waterway was deemed offshore or inland in response to The United States Court of Appeals for Veterans Claims' (Court) decision in Gray v. McDonald, 27 Vet. App. 313 (2015) (finding that VA's interpretation of 38 C.F.R. § 3.307(a)(6)(iii), designating Da Nang Harbor as an offshore, rather than an inland, waterway was inconsistent with the purpose of the regulation and did not reflect the VA's fair and considered judgment). In particular, the Court could not discern any reason as to why, in VA's determination, certain bodies of water such as Quy Nhon Bay and Ganh Rai Bay, were brown water, but Vung Tau Harbor, Da Nang Harbor, and Cam Ranh Bay, were blue water. The Court stated that VA's old policy of where to draw the line between inland waterways and offshore waters was arbitrary and, thus, not entitled to deference because some harbors and bays were considered to be offshore waters (e.g. Da Nang Harbor) while others were considered inland waterways (e.g., Ganh Rai Bay). The Gray Court did not state that Da Nang Harbor was part of the inland waterways, merely that the line VA drew was flawed. Subsequent to the Court's decision in Gray, VA updated its policy to state that service aboard a ship that anchored in a deep-water costal harbor, such as Da Nang, Vung Tau, Qui Nhon, Ganh Rai Bay, or Cam Ranh Bay, along the Republic of Vietnam coast, does not constitute inland waterway service or qualify as docking to the shore and is not sufficient to establish presumptive exposure to herbicides, unless the evidence of record confirms the Veteran went ashore during anchorage. VA Adjudication Manual M21-1 IV.ii.2.C.3.m. All harbors and bays are considered offshore, while all rivers and deltas are considered inland. Da Nang Harbor, along with Nha Trang Harbor, Qui Nhon Bay Harbor, Cam Ranh Bay Harbor, Vung Tau Harbor, and Ganh Rai Bay, are specifically considered offshore waters of the Republic of Vietnam. VA Adjudication Manual M21-1 IV.ii.1.H.2.c. In light of the foregoing, service connection may be presumed for residuals of exposure to an herbicidal agent by showing two elements. First, the Veteran must show that he served in the Republic of Vietnam during the Vietnam era. 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6). Second, the Veteran must be diagnosed with one of the specific diseases listed in 38 C.F.R. § 3.309(e). In this case, the evidence does not establish that the Veteran was exposed to an herbicidal agent such as Agent Orange. The Veteran does not report that the USS TICONDERGOA entered a deep-water coastal harbor, docked at shore, or otherwise entered the inland waterways of Vietnam. Rather, he contends that his service along the coast of the country, specifically in the Gulf of Tonkin, is sufficient to establish presumptive exposure to herbicides. The Board disagrees. In February 2006, the NPRC found that there was no record the Veteran was exposed to herbicides and his own statements place the USS TICONDEROGA well outside the inland waterways of Vietnam. In support of his claim, the Veteran submitted copies of the deck log from the USS TICONDEROGA dated on November 22, 1965. The deck log states that the ship was "steaming off the eastern coast of [Vietnam]" and the coordinates for the ship's position place it far from the coast of Vietnam in the Gulf of Tonkin. Additionally, as noted above, the Veteran does not contend that he set foot in Vietnam or docked at the shore. The weight of the evidence therefore establishes that Veteran did not serve in any capacity in Vietnam, and service connection on the basis of the presumptions afforded herbicide exposed veterans is not warranted. 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6). Diabetes is also subject to presumptive service connection as a chronic disease. 38 U.S.C. § 1112(a); 38 C.F.R. §§ 3.307, 3.309(a). The record is clear, however, that the Veteran's diabetes was initially identified many years after service. The service treatment records are negative for evidence of diabetes and laboratory testing during active duty service is negative for abnormal sugar levels. The Veteran first manifested elevated blood sugar levels in 2004, more than 35years after service, while undergoing treatment by a private physician, and was diagnosed with diabetes. As there is no showing of diabetes in service or to a compensable degree in the year after service, presumptive service connection for diabetes mellitus as a chronic disease is not warranted. Service connection is still possible in this case if the record demonstrates the Veteran's direct exposure to a herbicidal agent and a link between that exposure and diabetes , i.e., exposure that is not based on the regulatory presumptions of 38 C.F.R. § 3.307. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (when the evidence does not warrant presumptive service connection, an appellant is not precluded from establishing service connection with proof of direct causation). However, in this case, there is simply no medical or lay evidence establishing that the Veteran was exposed to a herbicidal agent during active duty service. The Board has also considered whether there is any other evidence of a link between the Veteran's diabetes and an incident of active duty service. He has not alleged any other service injuries to account for his diabetes and service records are negative for any findings or symptoms of the disease. There is also no lay or medical evidence of diabetes until decades after the Veteran's separation from service. Finally, the record is negative for any competent medical evidence in support of the claim, to include any statements from the Veteran's treating physicians. The Board must conclude that the preponderance of the evidence is against the claim and service connection for diabetes mellitus is not warranted. 38 U.S.C. § 5107(b). Erectile Dysfunction The Veteran contends that service connection is warranted for erectile dysfunction as secondary to service-connected PTSD or hypertension. Treatment records and a June 2009 VA examination document findings of erectile dysfunction. The VA examiner provided an opinion against service connection for erectile dysfunction as secondary to PTSD and its medications, but found that the Veteran's erectile dysfunction started after an aortic aneurysm repair in 2005. A November 2011 VA examiner found that the aortic aneurysm repair was itself due to hypertension. The Board also notes that the Veteran is service-connected for other vascular deficiencies related to hypertension, including vascular dementia. The Board will therefore resolve any doubt in favor of the Veteran and find that service connection is warranted for erectile dysfunction as secondary to service-connected hypertension. ORDER Entitlement to a 70 percent rating, but not higher, for vascular dementia to include PTSD with depression prior to June 20, 2014 is granted. Entitlement to an initial compensable rating for hypertension is denied. Entitlement to service connection for diabetes mellitus is denied. Entitlement to service connection for erectile dysfunction is granted. REMAND The Board finds that additional development is necessary before a decision may be rendered with respect to the other issues on appeal. Specifically, the Veteran (through his fiduciary or representative) must be contacted and asked to identify his private physicians and provide medical releases to allow VA to obtain records from the identified health care providers on his behalf. Additional VA medical opinions are also required under VA's duty to assist to determine the nature and etiology of the disabilities on appeal. Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's records of VA treatment for the period beginning August 28, 2016. 2. Contact the Veteran (via his fiduciary and/or representative) and ask that he identify all private physicians who have treated the disabilities on appeal. Provide medical release forms and ask that he execute them to allow VA to obtain treatment records from any identified private physicians, to include his private neurologist and vascular surgeon, identified in the VA treatment records as Drs. Weiss and Weyman, respectively. If valid medical release forms are received, obtain treatment records from the private doctors identified by the Veteran. All efforts to obtain these records must be documented in the claims file. 3. After completion of the above, provide the claims file to an appropriate examiner to determine the nature and etiology of the claimed heart disability and sleep apnea. After reviewing the claims file, the examiner should determine the following: a) Whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent), that the Veteran's cardiomyopathy with CAD is caused or aggravated by service-connected hypertension and/or vascular dementia with PTSD. The Veteran was diagnosed with cardiomyopathy and CAD in April 1999 when he underwent a cardiac catheterization and five-vessel aortocoronary bypass grafting at a private hospital. In May 2005, a private psychologist opined that the Veteran's cardiovascular disorders were "appreciably influenced" by his psychiatric symptoms including anger and emotional stress. The Veteran has also provided copies of several articles and abstracts noting that veterans with PTSD are at a greater risk of heart disease. The examiner must address the May 2005 private opinion and treatise evidence in the medical opinion report. b) Whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent), that the Veteran's obstructive sleep apnea is caused or aggravated by service-connected vascular dementia with PTSD. The Veteran has provided articles in support of his claim that indicate an association between PTSD-related sleep impairment and sleep apnea. A full rationale and explanation must accompany all medical opinions. The examiner must address the aggravation aspect of the secondary service connection claims. 4. After completion of the above, readjudicate the issues on appeal. If the benefits sought are not fully granted, issue a SSOC before returning the case to the Board, if otherwise in order. 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). 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. §§ 5109B, 7112 (2012). ______________________________________________ M. H. Hawley Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs