Citation Nr: 1752468 Decision Date: 11/15/17 Archive Date: 11/22/17 DOCKET NO. 13-00 509A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to a disability rating in excess of 60 percent from November 1, 2013 to June 30, 2015 for status post robotic prostatectomy due to prostate cancer with residual urinary incontinence and frequency, to include whether the initial staged rating was appropriate. 2. Entitlement to a disability rating in excess of 40 percent from July 1, 2015 for status post robotic prostatectomy due to prostate cancer with residual urinary incontinence and frequency, to include whether a reduction from 60 percent to 40 percent was proper. 3. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to February 14, 2017. 4. Entitlement to special monthly compensation (SMC) at the housebound rate from November 1, 2013. 5. Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD. REPRESENTATION Veteran represented by: Douglas E. Sullivan, Esq. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Delhauer, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1971 to March 1974. These matters come before the Board of Veterans' Appeals (Board) on appeal from October 2009, April 2012, September 2013, and March 2015 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In an October 2013 notice of disagreement, the Veteran's attorney expressed disagreement with the September 2013 rating decision, stating that the disability rating for the Veteran's prostate cancer should not be reduced. The September 2013 rating decision granted service connection for prostate cancer with a 100 percent evaluation effective March 1, 2013, and assigned a 60 percent evaluation from November 1, 2013. As the September 2013 rating decision granted entitlement to service connection for prostate cancer, the staged ratings assigned for that disability were not a reduction in any compensation received by the Veteran prior to that decision, and therefore it is not a formal reduction issue for which the notice provisions of 38 C.F.R. § 3.105(e) are applicable. See Tatum v. Shinseki, 24 Vet. App. 139, 143 (2010). As the Veteran has indicated disagreement with the initial staged ratings assigned, the Board has characterized the issue as stated on the title page. Further, in a December 2014 rating decision, during the pendency of the appeal, the RO proposed to reduce the disability rating for the Veteran's status post robotic prostatectomy due to prostate cancer with residual urinary incontinence and frequency from 60 percent disabling to 40 percent disabling. In a March 2015 rating decision, the RO reduced the Veteran's rating to 40 percent, effective July 1, 2015. In July 2015, the Veteran's representative indicated disagreement with the reduction. As the Veteran continues to seek an increased disability rating for his prostate cancer for the entire appeal period, the Board finds the issue of entitlement to a disability rating in excess of 40 percent, to include the propriety of the reduction, is also currently before the Board, as characterized on the title page. In August 2012, a hearing was held before a Decision Review Officer (DRO) at the RO. In May 2015, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. Transcripts of these hearings are associated with the evidentiary record. In July 2015, the Board remanded these matters for further development. In a May 2017 rating decision, the Agency of Original Jurisdiction (AOJ) granted a 100 percent disability rating for the Veteran's service-connected posttraumatic stress disorder (PTSD), effective February 14, 2017. As the Veteran has not been granted the maximum benefit allowed for the entire appeal period, the claim is still active as characterized on the title page. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board must consider entitlement to special monthly compensation (SMC) when raised. Akles v. Derwinski, 1 Vet. App. 118 (1991). The issue of entitlement to SMC at the "statutory housebound" rate under the provisions of 38 U.S.C. § 1114(s) has been raised by the rating issues before the Board, and accordingly, the Board finds the issue is also on appeal. In the May 2017 rating decision, the AOJ also granted entitlement to service connection for bilateral cataracts. As this decision represents a full grant of the benefit sought, the issue of service connection for a bilateral eye disability is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Since the issuance of the May 2017 supplemental statement of the case, the Veteran's attorney submitted additional VA treatment records in June 2017, along with a signed waiver of consideration of this additional evidence by the AOJ. The issue of service connection for sleep apnea is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. The AOJ did not provide the Veteran the requisite VA examination following cessation of medical treatment for his prostate cancer. 2. In a December 2014 rating decision, the AOJ proposed to reduce the Veteran's rating for status post robotic prostatectomy due to prostate cancer from 60 percent to 40 percent disabling. No response from the Veteran to the December 2014 notice letter and proposed rating decision was received by VA. 3. In a March 2015 rating decision, the AOJ reduced the Veteran's rating for status post robotic prostatectomy due to prostate cancer to 40 percent disabling, effective July 1, 2015. At the time of the reduction, the 60 percent rating had been in effect for less than five years, and resulted in a decreased combined disability rating. 4. At the time of the March 2015 rating decision, improvement in the Veteran's residuals of prostate cancer under the ordinary conditions of life had not been demonstrated. 5. The Veteran's prostate cancer has remained in constant remission since an April 2013 prostatectomy, and renal dysfunction has not been shown to be a residual of the prostate cancer. 6. Prior to February 14, 2017, there is an approximate balance of positive and negative evidence as to whether the Veteran's PTSD was manifested by symptoms resulting in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. However, total occupational and social impairment was not shown. 7. Based on the Board's award of a 100 percent disability rating for the service-connected prostate cancer up to November 3, 2014, the Veteran had a single service-connected disability rated at 100 percent plus additional service-connected disabilities having a combined rating of 60 percent from March 1, 2013 to November 3, 2014. CONCLUSIONS OF LAW 1. The assignment of an initial staged rating of 60 percent for prostate cancer was incorrect, and a 100 percent disability rating from March 1, 2013 to November 3, 2014 is warranted. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.115a, 4.115b, Diagnostic Code 7528 (2017). 2. The reduction of the rating for status post robotic prostatectomy due to prostate cancer from 60 percent to 40 percent, effective July 1, 2015, was improper, and restoration of the 60 percent disability rating is warranted. 38 U.S.C. §§ 1155, 5107, 5112 (2012); 38 C.F.R. §§ 3.105, 4.1, 4.115a, 4.115b, Diagnostic Code 7528 (2017). 3. The criteria for a disability rating in excess of 60 percent from November 3, 2014 for status post robotic prostatectomy due to prostate cancer have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.115a, 4.115b, Diagnostic Code 7528 (2017). 4. Resolving reasonable doubt in favor of the Veteran, the criteria for an initial 70 percent disability rating, but no higher, prior to February 14, 2017 for PTSD have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.130 (2017). 5. The criteria for SMC at the housebound rate have been met from March 1, 2013 to November 3, 2014. 38 U.S.C. §§ 1114(s), 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.350(i) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Neither the Veteran nor his representative 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 duty to assist argument). Rating Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Prostate Cancer Propriety of Initial Staged Rating A September 2013 rating decision granted service connection for prostate cancer with a 100 percent rating effective March 1, 2013, and assigned a 60 percent rating from November 1, 2013. The Veteran contends the 100 percent disability rating should have continued until a VA examination was performed. See May 2015 videoconference hearing testimony. The Veteran's prostate cancer is rated under Diagnostic Code 7528, which provides a 100 percent disability rating for malignant neoplasms of the genitourinary system. Diagnostic Code 7528 provides that, following the cessation of surgical, x-ray, antineoplastic chemotherapy, or other therapeutic procedure, the 100 percent rating shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e). If there has been no local reoccurrence or metastasis, the residuals are to be rated as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115b, Diagnostic Code 7528. At the time of the September 2013 rating decision, the AOJ found that based upon an April 2013 Emory Healthcare operative report and the Veteran's VA treatment records, the Veteran did not receive any treatment for his prostate cancer following the April 2013 prostatectomy. He was therefore assigned a 100 percent rating for six months following the April 2013 surgery, and a 60 percent disability rating effective November 1, 2013. With specific regard to Diagnostic Code 7528, VA has no discretion to reduce or otherwise change a 100 percent disability rating during the six-month period following treatment for malignant neoplasms, and until a medical examination report supports such a change. Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010) (also referred to as "Tatum I"). It is the information in a medical opinion, and not the date the medical opinion was provided that is relevant when assigning an effective date. Id. The phrase "the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure," in Diagnostic Code 7528 refers to the cessation of treatment for the applicable malignant neoplasm of the genitourinary system. Thus, the 100 percent rating will end as of the date the veteran received final treatment for cancer, the cessation of treatment for the cancer itself, as opposed to treatment for residuals secondary to the cancer or further treatment required as a result of the treatment for the disease. Tatum v. Shinseki, 26 Vet. App. 443, 447-48 (2014) (also referred to as "Tatum II"). Here, the Veteran was not provided with the required VA examination at the end of the six-month period following cessation of medical treatment as required by Diagnostic Code 7528. Notably, the AOJ was able to determine the date of cessation of the Veteran's treatment for his malignant prostate cancer, which determined the minimum six-month period during which the 100 percent disability rating must continue, based on the Veteran's medical records. However, given that the AOJ failed to provide the Veteran with a mandatory examination following the six-month period, the AOJ could not practically determine that assignment of a rating was warranted, or rather, whether the Veteran experienced a local reoccurrence or metastasis, which would warrant a continued 100-percent disability rating. 38 C.F.R. § 4.115b, Diagnostic Code 7528. Accordingly, the Board concludes that the assignment of a staged rating of 60 percent for residuals of prostate cancer was incorrect without the mandatory examination. Therefore, the Veteran's initial rating should be reinstated to 100 percent as of November 1, 2013. Next, although an examination was not immediately provided after the six-month period, the Veteran was provided a VA examination in November 2014, which reflects that his prostate cancer was in remission and that he had not received any cancer treatment following the April 2013 prostatectomy. Given that it can be discerned from this examination report that the Veteran had no local reoccurrence or metastasis of his prostate cancer, the Board finds that adjustment of the initial rating is appropriate as of the date of the examination, November 3, 2014. This finding is in compliance with the Note to Diagnostic Code 7528 that if the examination finds no local recurrence or metastasis, then any cancer residuals are evaluated based on voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115b, Diagnostic Code 7528; see generally Tatum II, 26 Vet.App. at 447-48 (explaining the mechanics of 38 C.F.R. §§ 4.115a and 4.115b). Accordingly, the Board finds an initial 100 percent disability rating for the Veteran's prostate cancer was warranted from March 1, 2013 to November 3, 2014. Prostate Cancer Residuals: Legal Criteria As noted above, under Diagnostic Code 7528 residuals of malignant neoplasms of the genitourinary system are to be rated as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115b. Voiding dysfunction may be rated based on urine leakage, frequency, or obstructed voiding. In pertinent part, for evaluations based on urine leakage, due to continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence, a 60 percent rating is warranted for voiding dysfunction requiring the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. A 40 percent rating is warranted for voiding dysfunction requiring the wearing of absorbent materials which must be changed two to four times per day. 38 C.F.R. § 4.115a. For evaluations based on urinary frequency, in pertinent part, a 40 percent rating is warranted for daytime voiding interval less than one hour, or; awakening to void five or more times per night. 38 C.F.R. § 4.115a. A 30 percent disability rating is the maximum schedular rating for evaluations based on obstructed voiding. 38 C.F.R. § 4.115a. Renal dysfunction requiring regular dialysis or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80 mg%; or, creatinine more than 8 mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular, warrants the assignment of a 100 percent rating. Renal dysfunction with persistent edema and albuminuria with BUN 40 to 80 mg%; or, creatinine 4 to 8 mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion warrants an 80 percent rating. Renal dysfunction with constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101 warrants a 60 percent disability rating. 38 C.F.R. § 4.115a. Prostate Cancer Residuals: Rating Reduction The law provides that where a rating reduction was made without observance of law, although a remand for compliance with that law would normally be an adequate remedy, in a rating reduction case the erroneous reduction must be vacated and the prior rating restored. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). A veteran's disability rating shall not be reduced unless an improvement in the disability is shown to have occurred. 38 U.S.C. § 1155. When a veteran's disability rating is reduced by a RO without following the applicable regulations, the reduction is void ab initio. See Greyzck v. West, 12 Vet. App. 288, 292 (1999). Prior to reducing a veteran's disability rating, VA is required to comply with several general VA regulations applicable to all rating-reduction cases, regardless of the rating level or the length of time that the rating has been in effect. See 38 C.F.R. §§ 4.1, 4.2, 4.10. These provisions impose a clear requirement that VA rating reductions be based upon review of the entire history of the veteran's disability. Schafrath, 1 Vet. App. at 594. Such review requires VA to ascertain, based upon review of the entire recorded history of the condition, whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. Thus, in any rating-reduction case, not only must it be determined that an improvement in a disability has actually occurred but also that that improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. See Faust v. West, 13 Vet. App. 342, 350 (2000). In certain rating reduction cases, VA benefits recipients are to be afforded greater protections, set forth in 38 C.F.R. § 3.344. The provisions of 38 C.F.R. § 3.344(c), however, specify that the provisions of 38 C.F.R. § 3.344(a) and (b) are only applicable for ratings which have continued for long periods at the same level (five years or more). They do not apply to disabilities which have not become stabilized and are likely to improve. Further, under the provisions of 38 C.F.R. § 3.105, when a reduction in the evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The veteran must be notified at his latest address of record of the contemplated action and furnished detailed reasons therefore. Additionally, a veteran must be given notice that he has (1) 60 days to present additional evidence to show that compensation payments should be continued at the present level, and (2) 30 days to request a predetermination hearing. 38 C.F.R. § 3.105(e), (i). Here, in the September 2013 rating decision the RO assigned a 60 percent evaluation from November 1, 2013. In a December 2014 proposed rating decision, the Veteran was informed of a proposed reduction of the disability rating for the residuals of prostate cancer from 60 percent to 40 percent. He was notified of the material facts and reasons for the proposed reduction, and the December 2014 letter accompanying the rating decision notified the Veteran he was afforded 60 days to respond, and he had 30 days to request a predetermination hearing. No response to the December 2014 letter and proposed rating decision was received by VA within 60 days. Accordingly, the Board finds the notification requirements of 38 C.F.R. § 3.105 were met. In a March 2015 rating decision, the AOJ reduced the Veteran's rating for residuals of prostate cancer to 40 percent disabling, effective July 1, 2015. Accordingly, the greater protections set forth in 38 C.F.R. § 3.344 do not apply in this case because the 60 percent disability rating for residuals of prostate cancer was not in effect for five or more years at the time of the reduction effective July 2015. Therefore, the issue before the Board is whether the Veteran's residuals of prostate cancer improved as of the March 2015 rating decision. The Board must focus on the evidence available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of evaluating whether the condition had demonstrated actual improvement. Cf. Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-82 (1992). In addition, it must be determined that an improvement in a disability had actually occurred; and that such improvement actually reflected an improvement in the Veteran's ability to function under the ordinary conditions of life and work. See 38 C.F.R. §§ 4.1, 4.2, 4.13; see also Brown v. Brown, 5 Vet. App. 413, 420-22 (1993). The Board must consider the entire medical history and apply the preponderance of the evidence standard in its determination. Schafrath, supra; Brown, supra. After reviewing the evidence of record, the Board finds that there is competent and credible evidence that the Veteran's residuals of prostate cancer had not improved at the time of the March 2015 rating decision. The Board is mindful that, in reducing the disability rating from 60 percent to 40 percent, the AOJ considered the results of the Veteran's November 2014 VA examination, which tended to show that the Veteran's residuals of prostate cancer did not meet the criteria for a 60 percent disability rating. Crucially, however, the AOJ failed to make a specific determination that there was an actual improvement in the Veteran's ability to function under the ordinary conditions of work and life. After considering the Veteran's entire medical history, a preponderance of the evidence does not show a material improvement in the service-connected residuals of prostate cancer. In April 2013, the Veteran underwent a prostatectomy to treat his malignant prostate cancer. An August 2013 VA oncology resident follow-up note indicated the Veteran had difficulty with urinary incontinence since the surgery, and needed to change incontinence briefs five times per day. An October 2013 VA radiation oncology note indicated the Veteran was still having urinary incontinence, using three-to-four pads per day. In May 2014, the Veteran reporting to his treating VA mental health provider that he continued to leak urine at times. During a May 2014 VA radiation oncology visit, the physician noted the Veteran was still having urinary incontinence, using three-to-four pads per day. A July 2014 Prostate Cancer Disability Benefits Questionnaire completed by the Veteran's VA primary care physician indicated the Veteran had a voiding dysfunction which caused urinary leakage and required absorbent material to be changed two-to-four times per day. In July 2014, the Veteran reported to his treating VA mental health provider that he continued to struggle with urinary incontinence, reporting he had to go to the bathroom several times in a day, and struggled with the odor of urine because of wearing diapers. The Veteran reported his urinary problems had not been getting any better in the almost two years since his surgery [sic]. During the November 2014 VA prostate cancer examination, the Veteran reported his condition had gotten worse and he urinated a lot. The VA examiner reported the Veteran had a voiding dysfunction which required the use of an appliance, which the examiner stated was pads. The VA examiner stated the voiding dysfunction caused urine leakage requiring absorbent materials to be changed two-to-four times per day. During an April 2015 VA urology consultation, the Veteran reported continued urinary incontinence since his radical prostatectomy. During the May 2015 videoconference hearing before the Board, the Veteran testified that he continued to use both absorbent pads and absorbent underwear, and that from the time he got up in the morning until the time he went to bed at night he changed those absorbent materials at least seven times. The Veteran testified this had been the same since his 2013 surgery. In September 2015, the Veteran continued to report to his treating VA mental health providers that he was experiencing urinary incontinence. A March 2016 VA radiation oncology note indicated the Veteran complained at that time of urinary incontinence, and the provider stated the Veteran's urinary incontinence was stable at seven-to-eight pads per day. In January 2017, the Veteran was afforded a new VA examination, and at that time the VA examiner reported the Veteran did not have any voiding dysfunction. However, a January 2017 VA infectious disease note stated the Veteran had chronic incontinence after his prostate surgery which was unchanged. Further, the Veteran's VA treatment records indicate the Veteran continues to request renewals of his absorbent briefs. See, e.g., July 2017 VA TAP progress note; May 2017 VA primary care telephone encounter note. Accordingly, when considering the November 2014 VA examination findings in conjunction with the VA treatment records, as well as the Veteran's competent statements regarding his urinary incontinence, the Veteran's overall disability picture remained essentially unchanged. Although the evidence of record includes varied reports of whether the Veteran had to change his absorbent materials up to or more than four times per day, the totality of the medical evidence of record indicates the Veteran continued to experience urinary incontinence essentially unchanged since his 2013 surgery, and treating medical professionals have not indicated that the variation in reports has reflected an actual improvement in the Veteran's urinary incontinence. Although the January 2017 VA examiner indicated improvement and that the Veteran no longer experienced urinary incontinence, the Board finds this opinion is outweighed by the Veteran's VA treatment records, in which the Veteran's treating providers indicated continued urinary incontinence and the requirement of absorbent briefs. Further, the Veteran has provided competent testimony that since his 2013 surgery, in a "day" that consists of the time he gets up to the time he goes to bed he has to change his absorbent materials at least seven times per day, and a March 2016 VA oncology provider has indicated the Veteran's urinary incontinence was stable at requiring seven-to-eight pads per day. As VA has failed to meet its burden to demonstrate actual improvement of the Veteran's residuals of prostate cancer resulting in an improvement in his ability to function under the ordinary conditions of life and work, the restoration of a 60 percent disability rating effective July 1, 2015 is warranted. Prostate Cancer Residuals: Increased Rating However, the Board finds the criteria for a disability rating in excess of 60 percent from November 3, 2014 for residuals of prostate cancer have not been met. The evidence of record indicates that the Veteran's prostate cancer has been in sustained remission since the April 2013 prostatectomy. There is no evidence in the Veteran's treatment records of any increase in the Veteran's PSA levels, or any mention of a recurrence of the Veteran's prostate cancer. See, e.g., July 2017 VA palliative care progress note; May 2016 VA radiation oncology note. Further, the evidence of record indicates therapeutic procedures for the Veteran's prostate cancer ended with the April 2013 prostatectomy. An August 2013 VA oncology resident follow-up note indicated that the pathology report from the April 2013 prostatectomy was significant for a focally positive apical margin, and recommended adjuvant radiation therapy. However, an August 2013 addendum to that note indicated that after discussing the findings with the urologist, the resident was going to check the Veteran's PSA levels because an apical margin could be an artifact of the Veteran's robotic prostatectomy. A subsequent addendum in August 2013 indicated that because the Veteran's PSA level was less than 0.01, the VA providers recommended no further treatment at that time, but continued surveillance. Accordingly, the Board finds the evidence of record indicates treatment for the Veteran's prostate cancer ended with the April 2013 prostatectomy. Therefore, because there has been no recurrence of the prostate cancer, or treatment for the prostate cancer, since November 3, 2014, a disability rating in excess of 60 percent is not warranted under Diagnostic Code 7528. 38 U.S.C.A. §38 C.F.R. § 4.115b; see also Tatum II, 26 Vet. App. at 447-48. For residuals of prostate cancer rated as voiding dysfunction, 60 percent is the maximum schedular rating. 38 C.F.R. § 4.115a. Finally, the Board finds a disability rating in excess of 60 percent for prostate cancer residuals rated as renal dysfunction is not warranted, as the medical evidence of record indicates the Veteran's renal dysfunction is not a residual of his prostate cancer. The Veteran's VA treatment records indicate that in 2015 he had blood in his urine. See, e.g., February 2015 VA physician letter. However, an April 2015 CT scan did not show any problem with the Veteran's kidneys. See April 2015 VA test results notification. In December 2015, the Veteran's treating VA physician indicated a small amount of protein in the Veteran's urine was likely the result of an effect of the Veteran's diabetes mellitus on his kidneys. See December 2015 VA test results notification. Beginning in 2016, chronic kidney disease was diagnosed. See, e.g., February 2017 VA primary care note; November 2016 addendum to VA hematology/oncology note. However, in April 2017 a VA nephrologist opined the Veteran's chronic kidney disease was likely secondary to cisplatin, a medication used to treat his lung cancer. See April 2017 VA nephrology consultation; see also May 2016 addendum to May 2016 VA hematology/oncology consultation (recommending cisplatin-based adjuvant chemotherapy for the Veteran's lung cancer). Accordingly, because the medical evidence of record does not indicate the Veteran's chronic kidney disease is a residual of his prostate cancer, a disability rating in excess of 60 percent for renal dysfunction residuals is not warranted. 38 C.F.R. § 4.115a, 4.115b, Diagnostic Code 7528. Conclusion As shown above, and as required by Schafrath, 1 Vet. App. at 594, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran. In this case, the Board finds an initial disability rating of 100 percent until November 3, 2014 is warranted for the Veteran's prostate cancer. The Board finds the restoration of a 60 percent disability rating effective July 1, 2015 for the residuals of the Veteran's prostate cancer is also warranted. However, the Board finds no provision upon which to assign the Veteran a disability rating in excess of 60 percent from November 3, 2014 for the residuals of his prostate cancer. PTSD Legal Criteria When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustments during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on the social and occupational impairment, rather than solely on the examiner's assessment of the level of disability at the moment of examination. The rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. PTSD (Diagnostic Code 9411) is rated under the schedule of ratings for mental disorders, 38 C.F.R. § 4.130. In relevant part, the rating criteria are as follows: 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 complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. A 70 percent rating 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 that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is 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. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Although the Veteran's symptomatology is the primary consideration, the Veteran's level of impairment must be in "most areas" applicable to the relevant percentage rating criteria. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). In evaluating psychiatric disorders, VA has adopted and employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM). See 38 C.F.R. § 4.130. As such, the diagnosis of a mental disorder should conform to the DSM. See 38 C.F.R. § 4.125(a). Effective August 4, 2014, VA amended the portion of its Rating Schedule dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the Fourth Edition of the DSM (DSM-IV) and replace them with references to the recently updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094 (August 4, 2014). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board on or before August 4, 2014, even if such claims are subsequently remanded to the AOJ. See 80 Fed. Reg. 53, 14308 (March 19, 2015). Because the RO certified the Veteran's appeal to the Board in April 2014, this claim is governed by the DSM-IV. Under the DSM-IV, diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). According to the DSM-IV, in relevant part, a GAF score between 41 and 50 is indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score between 51 and 60 is indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). Analysis As discussed in the Introduction of this decision, the time period in issue is prior to February 14, 2017. The Board initially notes that, in addition to PTSD, diagnoses of other nonservice-connected mental disorders are of record. The Board is precluded from differentiating between symptomatology attributed to a service-connected disability and a nonservice-connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Notably, in this case, the medical evidence of record is unclear in distinguishing between symptoms caused by the Veteran's nonservice-connected mental disorders and those caused by his service-connected PTSD. Resolving all reasonable doubt in the Veteran's favor, for the purposes of this decision, the Board will consider all of the Veteran's mental health symptoms to be related to his service-connected PTSD in the adjudication of this claim. Following careful review of all the evidence of record, to include the Veteran's VA treatment records, his VA examination reports, Social Security Administration (SSA) records, and the competent and credible lay statements of record, the Board finds that there is an approximate balance of positive and negative evidence as to whether the Veteran's psychiatric symptoms prior to February 14, 2017 more nearly approximated occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, as contemplated by a 70 percent disability rating. However, the Board finds that total occupational and social impairment, as contemplated by a 100 percent disability rating, was not shown. See 38 C.F.R. §§ 4.7, 4.130. First, the evidence of record indicates the Veteran retired prior to the appeal period. However, the Board finds the totality of the evidence of record is in equipoise as to whether the Veteran's PTSD was manifested by symptoms prior to February 14, 2017 which more nearly approximated total occupational impairment. Accordingly, the Board will afford the Veteran the benefit of reasonable doubt, and finds these symptoms resulted in what more nearly approximated total occupational impairment. The medical evidence of record indicates the Veteran's PTSD manifested in symptoms such as anger, irritability, forgetfulness, impaired concentration, and social anxiety. The Veteran reported he previously worked as a bus mechanic, but took an early retirement from that job due to his irritability and anger, and a bad relationship with his supervisor. The Veteran reported that he realized as he was driving to work he was contemplating physical aggression when imagining confrontations, and that he wanted to fight the supervisor. The Veteran clarified, however, that no physical confrontation ever occurred, and that he did not experience homicidal intent at that time, or since that time. See February 2011 VA mental health TRP intake note; see also December 2013 VA mental health note (angry at the mechanic job, but did not have to deal with a lot of people there). The Veteran also testified that he stopped working in 2009 in part due to altercations with co-workers, but for the most part he had been kept in jobs where he could keep to himself. See May 2015 videoconference hearing testimony; August 2012 DRO hearing testimony. Further, the evidence of record throughout the appeal period repeatedly noted the Veteran's reports that he preferred to stay home and avoid people because he experienced anxiety and/or panic attacks in crowds because of concerns over his safety, and he was concerned about angry outbursts and/or irritability when interacting with people. See, e.g., September 2015 VA mental health note; May 2015 videoconference hearing testimony; April 2015 VA mental health note; August 2012 VA Form 21-8940; March 2012 VA examination report; October 2011 VA mental health TRP individual psychotherapy note; July 2011 VA mental health psychiatry general note; May 2011 SSA disability decision; March 2011 VA mental health psychiatry general progress note; February 2011 VA mental health TRP intake note. The Veteran reported volunteering up to a few days a week at a local public transit station directing other veterans to a free shuttle to the local VA medical center, but reported he was better able to interact with other veterans than the general public. See, e.g., September 2011 VA mental health VASH general note; July 2011 VA mental health psychiatry general progress note; May 2011 VA mental health psychiatry general progress note; September 2010 VA mental health VASH general notes. The evidence of record also indicates the Veteran's PTSD was manifested by impaired concentration and forgetfulness which would affect his ability to function at times. See, e.g., May 2015 videoconference hearing testimony; August 2012 DRO hearing testimony; February 2011 VA psychiatry general progress note; February 2011 VA mental health TRP intake note. Although the evidence of record indicates that following prolonged exposure therapy in 2011 and 2012 the Veteran experienced a period during which his anxiety and panic attacks lessened, and he was more willing and able to go out and remain in public places, the totality of the evidence of record indicates this period of remission was temporary. The Veteran reported an increase in his anger and irritability once he was out and about more, and the Veteran's anxiety and social withdrawal regarding leaving home increased again following various medical issues. See December 2015 VA mental health note; June 2015 VA mental health note; May 2015 videoconference hearing testimony; July 2014 VA mental health note; July 2013 VA mental health psychiatric assessment note; October 2012 VA mental health psychotherapy note; August 2012 VA mental health psychotherapy note; June 2012 VA mental health psychotherapy note; April 2012 VA mental health supportive psychotherapy note; February 2012 VA mental health psychiatry general progress note; October 2011 VA mental health TRP individual psychotherapy note. Accordingly, the Board finds the Veteran's PTSD symptoms including anxiety, panic attacks, social withdrawal, irritability, anger, impaired concentration, and forgetfulness impaired the Veteran's ability go into public due to concerns for his own safety or his anger and/or irritability toward others, and impaired his ability to establish and maintain effective relationships with non-veterans and to adapt to stressful circumstances including a work-like setting. The Board affords the Veteran the benefit of reasonable doubt, and finds his PTSD manifested in what more nearly approximated total occupational impairment prior to February 14, 2017. However, the Board finds the totality of the evidence of record does not indicate the Veteran's PTSD manifested in total social impairment prior to February 14, 2017. As discussed, the evidence of record indicates the Veteran's PTSD symptoms impaired his ability to go out into public. The evidence of record also indicates the Veteran's PTSD impacted his ability to maintain romantic relationships. See, e.g., May 2015 videoconference hearing testimony; December 2013 VA mental health note; December 2012 VA examination report; August 2012 VA mental health psychotherapy note; February 2011 VA psychiatry note. However, the Veteran's VA treatment records indicate the Veteran maintained a close relationship with his nephew throughout the appeal period, in that his nephew would visit and check on him often, and drive him to his medical appointments. See May 2015 videoconference hearing testimony; May 2014 VA mental health note; February 2014 VA mental health note; August 2013 VA mental health note; January 2013 VA mental health psychotherapy note; February 2011 VA mental health TRP intake note. The Veteran talked with his grandson regularly, would take him out and about on weekends as the Veteran was feeling up to do so, and the Veteran was even granted custody of the grandson for a period of time. See, e.g., March 2016 VA mental health note; December 2015 VA mental health note; September 2015 VA mental health note; December 2013 VA mental health note; May 2012 VA mental health TRP individual psychotherapy note; March 2012 VA mental health TRP note; February 2012 VA mental health psychiatry note; February 2011 VA mental health TRP intake note. Following the release of the Veteran's son from prison, he also lived with the Veteran for a period of time, and then continued to live close to the Veteran, and the Veteran reported a close relationship with him as well. See, e.g., March 2016 VA mental health notes; December 2015 VA mental health note; July 2014 VA mental health note; February 2011 VA mental health TRP intake note. The Veteran also reported occasionally seeing other family members. See October 2014 VA mental health note; June 2012 VA mental health psychotherapy note; July 2011 VA mental health psychiatry note. Further, the Veteran reported maintaining a close friend from his last job, continued to volunteer working with other veterans at the local transit station, and he reported he worked with kids in his neighborhood teaching them how to repair their bicycles, and that the other veterans including from his PTSD support group continued to check on him and act as a great support system throughout his medical issues. See, e.g., December 2016 VA palliative care consultation; June 2015 VA mental health note; April 2015 VA mental health note; May 2014 VA mental health note; December 2013 VA mental health note; February 2013 VA mental health note; January 2013 VA mental health initial evaluation note; February 2012 VA mental health psychiatry note; August 2011 VA mental health note; February 2011 VA psychiatry note; February 2011 VA mental health TRP intake note. Accordingly, the Board finds that while the Veteran's PTSD may have manifested in symptoms including social anxiety, withdrawal, and isolation, the preponderance of the competent and credible evidence of record is against finding total social impairment prior to February 14, 2017. Further, the Board acknowledges that throughout the period on appeal the licensed clinical social worker who conducted the Veteran's VA PTSD group therapy sessions assigned the Veteran a GAF score of 50, which suggests serious impairment in social and/or occupational functioning. However, the Board notes the Veteran's VA treating psychiatrists and psychologists have assigned various GAF scores throughout the appeal period, ranging from 52 to 60. See, e.g., August 2013 VA mental health note (60); February 2013 VA mental health note (55); January 2013 VA mental health initial evaluation note (55); November 2012 VA psychotherapy note (55); October 2012 VA psychotherapy note (60); August 2012 VA psychotherapy note (60); April 2012 VA psychotherapy note (58); February 2012 VA psychiatry note (58); October 2011 VA psychiatry note (60); July 2011 VA psychiatry note (57); May 2011 VA psychiatry note (57); April 2011 VA psychiatry note (54); March 2011 VA mental health note (52); February 2011 VA psychiatry note (52). These scores would indicate moderate difficulty in social and/or occupational functioning. The Board affords the GAF scores assigned by the Veteran's treating VA psychiatrists and psychologists more weight of probative value than those assigned during his PTSD group sessions. The GAF scores included in the notes regarding the Veteran's PTSD group therapy sessions do not include an explanation as to the continued assignment of a score of 50, despite contemporaneous treatment records regarding slight fluctuations in the Veteran's symptoms and functioning. However, the treatment notes completed by the treating psychiatrists and psychologists indicate these scores were assigned based upon the treating practitioner's interview and thorough assessment of the Veteran's functioning at that time. Accordingly, the Board finds the Veteran's GAF scores during the appeal period indicate moderate difficulty in occupational and social functioning, and do not support an initial disability rating in excess of 70 percent. Finally, although the Veteran may meet some of the criteria for a 100 percent rating, see Mauerhan, 16 Vet. App. at 442, the Board finds the Veteran's PTSD symptoms, including their frequency, severity, and duration, more closely approximated those enumerated in the schedule of ratings for mental disorders for a 70 percent disability rating, not a 100 percent disability rating. See 38 C.F.R. § 4.130. The evidence of record indicates that in January 2010, the Veteran was admitted to a private hospital due to severe anxiety, depression, and suicidal ideation. See February 2010 Anchor Hospital discharge summary. Following the Veteran's diagnosis of prostate cancer, VA treatment records indicated the Veteran was at moderate risk for suicide. See January 2013 VA mental health initial evaluation note. However, throughout the appeal period the Veteran has repeatedly denied any suicidal intent or plan, and stated he has not experienced suicidal ideation since January 2010. See, e.g., March 2016 VA mental health note; September 2015 VA suicide risk assessment; June 2015 VA mental health note; October 2014 VA mental health note; July 2014 VA mental health note; February 2013 VA psychiatry note; March 2011 VA mental health note; February 2011 VA mental health TRP intake note. Further, as discussed above, the Veteran reported he previously found himself contemplating physical aggression when imagining confrontations with a former supervisor, but the Veteran confirmed that no physical altercation ever occurred. The Veteran has reported his PTSD manifested in anger and irritability during the appeal period, and he would experience increases in these symptoms while out in public, to include the possibility of verbally snapping at someone. See, e.g., June 2015 VA mental health note; April 2012 VA psychotherapy note (professional baseball game with son); March 2011 VA mental health note (someone saying something provoking to Veteran). During a July 2011 VA psychiatry visit the Veteran stated he could not go out around people or crowds because he was afraid he was going to get hurt or killed, or that he was going to hurt someone else and go to jail. The Veteran gave an example of a confrontation on public transit where someone bumped into him, that individual continued to antagonize the Veteran, and the police were ultimately called. The Veteran stated he would rather stay home and avoid such confrontations. The Veteran also testified before the Board in May 2015 that his sister is afraid of him because he is not the same person he once was. However, the Board finds the evidence of record does not indicate the Veteran's PTSD symptoms have resulted in any physical altercations, homicidal ideation, or threats by the Veteran toward another individual. See, e.g., January 2013 VA psychotherapy note (Veteran very angry at QTC examiner and wanted to hurt him, but held himself back and will talk to the patient advocate); April 2012 VA psychotherapy note (doing a good job of walking away rather than getting in trouble); April 2011 VA psychiatry note (disagreement with store clerk handled well based on what Veteran learned in anger management); February 2011 VA mental health TRP intake note. Accordingly, the Board finds the Veteran's reports of suicidal ideation prior to the appeal period, and anger and/or irritability toward others including verbally snapping at individuals, are not of the frequency, severity, and duration of a persistent danger of hurting himself or others as enumerated in the schedule of ratings for mental disorders under a 100 percent disability rating. Therefore, the Board has considered the Veteran's claim, and the lay and medical evidence of record, and concludes that based upon the totality of the evidence of record, the Veteran's level of social and occupational impairment due to the symptoms of his service-connected PTSD warrants an initial rating of 70 percent, but no higher, prior to February 14, 2007. The Board finds total occupational and social impairment was not shown, and the evidence of record more closely approximates the criteria for a 70 percent rating. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Accordingly, entitlement to an initial disability rating of 70 percent, but no higher, prior to February 14, 2017 for PTSD is granted. SMC at the Housebound Rate The Board must consider entitlement to SMC if raised by the rating issue on appeal. Akles v. Derwinski, 1 Vet. App. 118 (1991). SMC at the (s) rate is payable if 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). For the purpose of meeting the first criterion (a single service-connected disability rated at 100 percent), ratings of 100 percent may be based on any of the following grants of a total rating: on a schedular basis; on an extraschedular basis; on the basis of a TDIU if granted for a single disability; or, on the basis of a temporary total rating. In the September 2013 rating decision, SMC at the statutory housebound (s) rate was granted from March 1, 2013 to November 1, 2013. As discussed above, the Board has awarded entitlement to a 100 percent disability rating on a schedular basis for prostate cancer up to November 3, 2014. As such, the first element of entitlement to SMC at the (s) rate is shown up to November 3, 2014. Prior to November 3, 2014, service connection had also been established for the following disabilities: status post surgery for ganglion, left wrist with scar, rated as 10 percent disabling; tinnitus, rated as 10 percent disabling; bilateral hearing loss, rated as 10 percent disabling; and per this decision, PTSD rated as 70 percent disabling. When combined under 38 C.F.R. § 4.25, these additional service-connected disabilities had a combined evaluation of 60 percent or more. Accordingly, the second element of entitlement to SMC at the (s) rate is shown. Accordingly, as both elements have been shown, the Board finds entitlement to SMC at the statutory housebound (s) rate is granted from March 1, 2013 to November 3, 2014. ORDER An initial 100 percent disability rating from March 1, 2013 to November 3, 2014 for service-connected status post robotic prostatectomy due to prostate cancer is granted. A 60 percent disability rating for service-connected status post robotic prostatectomy due to prostate cancer with residual urinary incontinence and frequency is restored, effective July 1, 2015. A disability rating in excess of 60 percent from November 3, 2014 for service-connected status post robotic prostatectomy due to prostate cancer with residual urinary incontinence and frequency is denied. Entitlement to an initial disability rating of 70 percent, but no higher, prior to February 14, 2017 for PTSD is granted. Entitlement to SMC at the (s) rate is granted from March 1, 2013 to November 3, 2014. REMAND In the July 2015 remand, the Board instructed the AOJ to afford the Veteran a VA examination regarding his sleep apnea, and asked the VA examiner to address the Veteran's contentions that his in-service sinus problems were early signs and symptoms of his current sleep apnea. Following a January 2017 examination, the VA examiner opined the Veteran's sleep apnea is not directly related to his active duty service, stating there is no correlation between sinusitis, hay fever, or any sinus disease and sleep apnea, as sleep apnea can only be diagnosed by sleep study. However, the VA examiner stated later in his opinion that sleep apnea tends to be multifactorial in nature, including sinus conditions and upper respiratory conditions. Further, the VA examiner did not address the April 2015 opinion from Dr. S.P. as requested by the Board. Accordingly, the Board finds the January 2017 VA examiner's opinion did not adequately respond to the Board's directives regarding the theory of direct service connection, and an addendum opinion is necessary. Further, the January 2017 VA examiner opined the Veteran's current sleep apnea was not caused or aggravated by his service-connected PTSD. However, the VA examiner indicated one of the factors which may lead to sleep apnea is drug abuse and lifestyle. The Veteran's VA treatment records indicate a long history of alcohol and marijuana use and/or abuse beginning after the Veteran's return from Vietnam, and indicate this use/abuse was related to the Veteran's service-connected PTSD. See, e.g., December 2013 VA mental health note (Veteran states marijuana use relaxes him); February 2010 Grady Health System psychiatry consultation (self-medicates PTSD symptoms with alcohol); January 2010 VA mental health initial evaluation note (stared drinking heavily in Vietnam); October 2009 VA mental health initial evaluation note (prior to 1992 Veteran was a heavy, daily drinker). On remand, the AOJ should obtain an addendum opinion from the January 2017 VA examiner to address any relationship between the Veteran's alcohol and drug use/abuse related to his service-connected PTSD and his current sleep apnea. Accordingly, the case is REMANDED for the following action: 1. Obtain an addendum opinion from the January 2017 VA sleep apnea examiner. If the examiner is no longer available, obtain an opinion from another appropriate examiner to determine the nature and etiology of the Veteran's sleep apnea. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The addendum opinion must include a notation that this record review took place. After the record review, the VA examiner is asked to respond to the following inquiries: a) Is it at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran's current sleep apnea was either incurred in, or is otherwise related to, the Veteran's active duty service? The examiner should specifically address the Veteran's contention that his in-service sinus problems were early signs and symptoms of his current sleep apnea, and address the statement in the January 2017 VA examination opinion that sinus conditions and upper respiratory conditions may be factors in the development of sleep apnea. The examiner should also specifically address the April 2015 opinion from Dr. S.P., the Veteran's treating VA primary care physician. b) Is it at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran's sleep apnea was caused by the Veteran's service-connected PTSD? The examiner should specifically address the Veteran's heavy alcohol and marijuana use and/or abuse following his return from Vietnam until at least 1992 to self-treat his PTSD symptoms, as well as his continued use over the years, as discussed in the Veteran's treatment records. c) Is it at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran's current sleep apnea is aggravated by the Veteran's service-connected PTSD? Aggravation indicates a worsening of the underlying condition as compared to an increase in symptoms. If aggravation is found, the examiner should attempt to identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred. The examiner should specifically address the Veteran's use and/or abuse of alcohol and marijuana to self-treat his PTSD symptoms. The complete rationale for all opinions should be set forth. 2. After the above development has been completed, adjudicate the claim. If the benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case, and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter 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 (West 2014). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs