Citation Nr: 1803218 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 14-00 866 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for sleep apnea. 2. Entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD), to include a generalized anxiety disorder. 3. Entitlement to a compensable rating for pulmonary tuberculosis, inactive. 4. Entitlement to an initial rating in excess of 30 percent for PTSD. 5. Entitlement to a rating in excess of 10 percent for hemorrhoids. 6. Entitlement to a rating in excess of 10 percent for hiatal hernia/gastroesophageal reflux disease (GERD) and peptic ulcer. 7. Entitlement to an initial compensable rating for hypertension. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. Cannon, Associate Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The Veteran served on active duty in the United States Air Force from August 1961 to September 1983, including service in the Republic of Vietnam. He was awarded the Distinguished Flying Cross and was honorably discharged. This matter comes before the Board of Veterans' Appeals (Board) from September 2010, November 2011, and April 2012 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. A hearing was not requested. The Board has re-characterized the Veteran's claim of entitlement to service connection for a generalized anxiety disorder to a claim of entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD), to include a generalized anxiety disorder, since PTSD is already a service-connected psychiatric disorder. The issues of entitlement to service connection for sleep apnea, service connection for an acquired psychiatric disorder other than PTSD, to include a generalized anxiety disorder, and a compensable rating for pulmonary tuberculosis, inactive, are addressed in the REMAND portion of the decision below and are REMANDED to the RO. In April 2010, the Veteran filed claims of entitlement to service connection for tinea cruris and entitlement to an increased rating for hearing loss. In a September 2010 rating decision, the RO denied these claims. The Veteran timely filed a notice of disagreement regarding these claims and a statement of the case was issued in February 2014. These claims have not been the subject of a VA Form 9. They were also not listed in the August 2016 VA Form 8 or addressed in the December 2017 brief submitted by the Veteran's counsel. Therefore, the Board finds that it does not have jurisdiction over these claims. FINDINGS OF FACT 1. Prior to July 30, 2014, the Veteran's service-connected PTSD was characterized by occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships, but not by occupational and social impairment with deficiencies in most areas or total social and occupational impairment. 2. From July 30, 2014, the Veteran's PTSD is characterized by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but not by occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total social and occupational impairment. 3. From April 26, 2010, the Veteran's hemorrhoids are characterized as large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences, but are not characterized by persistent bleeding with secondary anemia, or with fissures. 4. From April 26, 2010, the Veteran's hiatal hernia/gastroesophageal reflux disease (GERD) and peptic ulcer is characterized by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, but not by symptoms that are productive of considerable impairment of health. 5. The Veteran's hypertension is characterized by continuous use of medication, but not by a history of diastolic pressure predominantly 100 or more. CONCLUSIONS OF LAW 1. Prior to July 30, 2014, the criteria for a disability rating of 50 percent, but no greater, for PTSD have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.130, Diagnostic Code 9411 (2017). 2. From July 30, 2014, the criteria for a disability rating in excess of 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.130, Diagnostic Code 9411 (2017). 3. From April 26, 2010, the criteria for a disability rating in excess of 10 percent for hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.114, Diagnostic Code 7336 (2017). 4. From April 26, 2010, the criteria for a disability rating in excess of 10 percent for hiatal hernia/gastroesophageal reflux disease (GERD) and peptic ulcer have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.114, Diagnostic Code 7346 (2017). 5. The criteria for an initial compensable rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.104, Diagnostic Code 7101 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R. Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to 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 facts found, a practice known as "staged ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Posttraumatic Stress Disorder In November 2011, the RO granted the Veteran service connection for posttraumatic stress disorder (PTSD) at an initial rating of 30 percent under Diagnostic Code 9411 from August 18, 2011. The Veteran is appealing that decision. Because the claim is an initial claim, the Board will consider evidence of symptomatology from August 18, 2011, the date that the claim was filed. 38 C.F.R. § 3.400(o). PTSD is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. A 10 percent rating is appropriate when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. Id. A 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of the inability to be able to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: a depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is appropriate when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: Flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is provided for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: Suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is provided 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 of the veteran 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 symptoms associated with the rating criteria are not intended to constitute exhaustive lists, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). A Veteran may only qualify for a disability rating under 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration that result in the levels of occupational and social impairment provided. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). To adequately evaluate and assign the appropriate disability rating to the Veteran's service-connected psychiatric disability, the Board must analyze the evidence as a whole, including the Veteran's GAF scores and the enumerated factors listed in 38 C.F.R. § 4.130. Mauerhan, 16 Vet. App. at 436. As this claim was certified to the Board after August 4, 2014, DSM V is applicable to the claim. The Veteran is service-connected for PTSD, diabetes, tinnitus, hemorrhoids, hiatal hernia, inactive tuberculosis, bilateral hearing loss, and hypertension, but not for other mental disorders. The Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so. Mittleider v. West, 11 Vet. App. 181 (1998). Prior to July 30, 2014, the Veteran's symptomatology is consistent with a 50 percent rating based on occupational and social impairment with reduced reliability and productivity due primarily to disturbances of mood and difficulty in establishing and maintaining effective work and social relationships. This is based primarily on the consistent report of symptoms regarding outbursts of anger and nervousness. See November 2011 lay statement from wife; October 2011 VA examination; August 2011 lay statement. There is some indication that the Veteran's symptoms were improving in late 2011 and early 2012. See December 2011 VA medical record (reporting only "some depression and irritability"); January 2012 VA medical note (reporting "minimal depressive [symptoms]," but still feeling depressed more than half the days of the week). Also, during the October 2011 VA examination, the Veteran states that his mental problems do not interfere with his work as a pastor. Nevertheless, the weight of this evidence as a whole supports a finding of disturbances of mood. Evidence regarding difficulty in establishing and maintaining effective work and social relationships is at least in equipoise during this period. Weighing against such a finding is the fact that the Veteran has been working full time as a probation officer, while also working as a pastor. See December 2011 VA medical note. Also weighing against such a finding is the Veteran's recorded sadness over the death of the loss of a member of his congregation who "had been a good friend to him over the past several years." See January 2012 VA medical record. Evidence of such relationships weighs against a finding of difficulty in establishing and maintaining effective work and social relationships. There is also evidence a difficulty in establishing and maintaining effective work and social relationships. In an August 2011 statement, the Veteran describes himself as a loner who withdraws from crowds. A November 2011 VA medical record describes the Veteran as being withdrawn at holidays due to difficulty dealing with people and family members. Some of the Veteran's relationships, including that with is wife, are strained because of his outbursts of anger. See November 2011 lay statement from wife; September 2011 VA medical record. As the evidence is at least in equipoise, the Veteran is entitled to favorable finding regarding difficulty in establishing and maintaining effective work and social relationships. The evidence weighs against the existence of impaired judgment and abstract thinking. In VA medical notes dated December 2011 and September 2011, the Veteran articulates clearly his fears regarding the side-effects of his current medications. An October 2011 VA examination indicates that the Veteran is competent to be able to handle his finances. In a November 2011 VA medical record, the Veteran discusses that he likes his job as a probation officer, "but has difficulty hearing about some of the things people have had to endure." Consistent with this, in a January 2012 VA medical record, the Veteran indicates that retirement could be "a good thing because [he] cares too much at times." In summary, the Veteran's strong capacity for empathy and critical thinking that is captured in these records weighs against a finding of impaired judgment and abstract thinking. At the same time, however, the evidence supports the existence of disturbances of mood and difficulty in establishing and maintaining effective work and social relationships. As the weight of the total evidence prior to July 30, 2014, supports a rating of 50 percent, the Veteran is entitled to prevail on his claim for a disability rating of 50 percent for PTSD prior to July 30, 2014. The evidence does not support a rating of 70 percent. Although the Veteran indicates sometimes feeling as though he would be better off dead, he regularly denies suicidal ideation. See, e.g., September 2011 VA medical record. The Veteran is able to articulate concerns regarding the side-effects of current medications, and at no point do his medical providers indicate speech that is illogical, obscure, or irrelevant. There are also no indications of bad hygiene. The fact that the Veteran can work 40 hours a week as a probation officer and also serve as a pastor weighs against a finding of inability to establish and maintain effective relationships. The strongest evidence in favor of a 70 percent rating is that the Veteran's angry outbursts constitute impaired impulse control. But as the weight of the evidence is against a finding of occupational and social impairment with deficiencies in most areas, the Veteran is not entitled to a rating of 70 percent. For similar reasons, the Veteran is not entitled to a rating of 100 percent. The fact that the Veteran can work 40 hours a week as a probation officer and also serve as a pastor weighs strongly against a finding of total occupational and social impairment. His lay statements and the reports from his doctors weigh strongly against a finding of gross impairment in thought processes or communication. There is no evidence of delusions, hallucinations, grossly inappropriate behavior, persistent danger to hurting himself or others, intermittent inability to perform activities of daily living, or disorientation as to time or place. Clearly, the evidence does not support a 100 percent rating. As already noted, with regards to disturbances of motivation and mood there was an indication that the Veteran's symptoms were improving in late 2011 and early 2012. See December 2011 VA medical record (reporting only "some depression and irritability"); January 2012 VA medical note (reporting "minimal depressive [symptoms]," but still feeling depressed more than half the days of the week). This improvement is manifest by July 30, 2014. From this date, the Veteran's symptomatology is consistent with the 30 percent rating that he is currently assigned, as shown more fully below. From July 30, 2014, the weight of the evidence does not reveal disturbances of motivation and mood. A VA medical record of that date reads: "Psychological: not depressed." Consistent with this, a September 2015 VA medical record contains a negative screen for depression and states that the Veteran does not experience "[l]ittle interest or pleasure in doing things" or "[f]eeling down, depressed, or hopeless." A March 2016 VA psychological examination indicates that the Veteran has had no panic attacks and that he "sometimes feels depressed but nothing continuous." Several records suggest that the Veteran's depression is primarily the result of retirement. See May 2016 VA medical record (Veteran "states he feels 'really good about myself' but feeling more down since retirement."); April 2016 VA medical record. Also, the May 2016 VA medical record indicates that "anxiety symptoms made it somewhat difficult to do his work, take care of things at home, or get along with others." Importantly, though, these records do not indicate outbursts of anger. Given the relative infrequency of depression and the fact that the depression he feels appears to be related to retirement, not PTSD, the weight of the evidence from July 30, 2014, does not demonstrate disturbances of motivation and mood so as to support a rating of 50 percent. Rather, such symptoms are more consistent with a finding of intermittent periods of inability to perform occupational tasks due to depressed mood and anxiety so as to support the Veteran's current rating of 30 percent for this time period. The weight of the evidence also does not demonstrate impaired judgment and abstract thinking so as to support a rating of 50 percent. According to a March 2016 VA psychology examination, the Veteran is competent to manage his own funds and is deemed to be of at least average intelligence "based on general fund of knowledge, vocabulary, and complexity of concepts." In a VA medical record dated May 11, 2016, he speaks actively with a doctor about herbal supplements as an alternative to his current regimen of pills. In a VA medical record dated May 16, 2016, the Veteran states that as he transitions to retirement, "he is already starting to create a structure and routine for himself," which includes exercising and helping take care of his mother-in-law, who has dementia. The lucidity displayed in the records weighs against a finding of impaired judgment and abstract thinking. The evidence also does not reveal difficulty in establishing and maintaining effective work and social relationships. A May 2016 VA medical record indicates that the Veteran has "[c]ontact with friends or relatives . . . [s]everal times a week" and that "[f]riends and relatives make him feel love and cared for . . . [a] great deal." The Veteran also indicates that his marriage is strong and that "he has received great satisfaction from serving others and from his ministry." The March 2016 VA psychology examination notes that "[f]amily relations are good" and that Veteran lives with his mother-in-law who has dementia and plans to help his wife take care of her when he retires. The strongest evidence in support of relational difficulties comes from the March 2016 VA psychology examination, which indicates that the Veteran is suspicious, has "no friends other than acquaintances at church," and "prefers to stay at home and be with family." However, the evidence as a whole establishes the existence of positive relationships with individuals in the Veteran's family and church, including a mother-in-law with dementia, despite apparent suspiciousness of individuals outside of his family and church circles. Taken together, the weight of this evidence does not reflect difficulty in establishing and maintaining effective work and social relationships. The weight of the evidence is also against a rating of 50 percent from July 30, 2014. As already noted, the evidence of record does not reflect impaired judgment or abstract thinking, disturbances of motivation and mood, or difficulty in establishing and maintaining effective work and social relationships. Additionally, the March 2016 VA psychology examination contains a specific finding of "[o]ccupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication." The evidence also does not support a rating of 70 percent from July 30, 2014. From this date, the Veteran has denied suicidal ideation and displayed no apparent instances of bad hygiene. The fact that he can actively speak with his doctor about the benefits of alternative medicines weighs against a finding of speech that is intermittently illogical, obscure, or irrelevant. The March 2016 VA examination indicates that the Veteran has been working as eight years as a probation officer, that family relations are good, and that he plans on helping his wife take care of his elderly mother-in-law with dementia after retirement. For similar reasons, the evidence also does not support a rating of 100 percent from July 30, 2014. Weighing against a finding of total occupational and social impairment is the fact that the Veteran can manage his own funds and intend to take care of his mother-in-law. The Veteran's lucidity during medical visits weighs against a finding of gross impairment in thought process or communication. There is no evidence of delusions, hallucinations, grossly inappropriate behavior, persistent danger to hurting himself or others, intermittent inability to perform activities of daily living, or disorientation as to time or place. The evidence does not support a 100 percent rating. The evidence does not support additional staged ratings for any time period on appeal and for no period would the Veteran be entitled to a higher rating under a different Diagnostic Code. II. Hiatal Hernia/Gastroesophageal Reflux Disease and Peptic Ulcer The Veteran is service-connected for hiatal hernia/gastroesophageal reflux disease (GERD) and peptic ulcer from October 1, 1983. On April 26, 2010, the Veteran filed a claim for an increased rating. In September 2010, granted the Veteran an increased rating of 10 percent under Diagnostic Code 7346 from April 26, 2010. The Veteran has appealed that decision. Because the claim is a non-initial claim, the Board will consider evidence of symptomatology from one year prior to when the claim was filed. 38 C.F.R. § 3.400(o). See A.B. v. Brown, 6 Vet. App. 35 (1993) (holding that a claim remains in controversy where less than the maximum available benefit is awarded unless the Veteran expresses an intent to limit the appeal to a specific disability rating). If an increase in severity of disease is ascertainable prior to a year before the filing date, the effective date shall be the date that the increase in severity is discernible. See Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010). Diagnostic Code 7346 provides ratings for hiatal hernia. 38 C.F.R. § 4.114. A 60 percent rating is appropriate for hiatal hernia with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Id. A 30 percent rating is appropriate for hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Id. A 10 percent rating is appropriate for hiatal hernia with two or more of the symptoms for the 30 percent rating of less severity. Id. Ratings under Diagnostic Codes 7301 to 7329, 7331, 7342, and 7345 to 7348 will not be combined with each other. 38 C.F.R. § 4.114. A single rating will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. Id. The evidence does not support symptoms productive of considerable impairment of health so as to support a rating in excess of 10 percent. An August 2010 VA examination reveals dysphagia and regurgitation, but no pyrosis or arm pain. A November 2010 lay statement indicates arm pain, regurgitation, and heartburn. A November 2010 private medical opinion notes chest pain and reflux. A March 2014 VA Form 9 describes arm pain, regurgitation, burning chest pain with indigestion attacks, having to "sleep with [his] back elevated all the time," and the use of medicines. But since these symptoms appear to be somewhat fluctuating and the Veteran can still sleep with slight adjustments, these symptoms do not appear to be productive of considerable impairment of health. Consistent with this, the March 2016 VA hernia examination indicates that the Veteran's disorder does not impact his ability to work, despite symptoms such as pyrosis, reflux, regurgitation, and taking Nexium daily. Taken together, the evidence as a whole supports a finding of two or more symptoms such as recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, which is consistent with the current rating of 10 percent. The evidence does not support considerable impairment of health so as to support a rating of 30 percent. There is also no evidence of material weight loss and hematemesis or melena with moderate anemia so as to support a rating of 60 percent. The evidence does not support additional staged ratings for any time period on appeal, and for no period would the Veteran be entitled to a higher rating under a different Diagnostic Code. III. Hemorrhoids The Veteran is service-connected for hemorrhoids from October 1, 1983. On April 26, 2010, he filed a claim for an increased rating. In a September 2010 decision, the RO denied the Veteran's claim. The Veteran is appealing that decision. In a January 2014 decision, the RO granted the Veteran an increased rating of 10 percent under Diagnostic Code 7336 from April 26, 2010. Because the claim is a non-initial claim, the Board will consider evidence of symptomatology from one year prior to April 26, 2010, the date that the claim was filed. 38 C.F.R. § 3.400(o). See Brown, 6 Vet. App. at 35. If an increase in severity of disease is ascertainable prior to a year before the filing date, the effective date shall be the date that the increase in severity is discernible. See Gaston, 605 F.3d at 984. Under Diagnostic Code 7336, a 0 percent rating is appropriate for mild or moderate internal or external hemorrhoids. 38 C.F.R. § 4.114. A 10 percent rating is appropriate for large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences. Id. A 20 percent rating is appropriate for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. Id. The evidence does not support a rating of 20 percent because there is no evidence of persistent bleeding with secondary anemia or with fissures. An August 2010 VA examination notes that there is no evidence of bleeding, but that there are irreducible hemorrhoids that are constantly present and moderate in size. A November 2010 lay statement indicates that there is consistent bleeding, but does not indicate anemia or fissures. Consistent with this, a March 2014 VA Form 9 indicates bleeding and recurrent inflammation, but not anemia or fissures. A March 2016 VA hemorrhoids examination states that the Veteran has "occasional bright red blood tinged toilet water when passing hard bowel movement and characterizes his overall symptoms as "mild or moderate." Unfortunately, like the rest of the evidence, there is no indication of anemia or fissures so as to support a rating in excess of 20 percent. In reaching this conclusion, the Board has considered the Veteran's lay statements, including his statements that he continuously uses over-the-counter medications. The Veteran is competent to report these symptoms because they are within the knowledge and personal observations of lay witnesses. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Unfortunately, such testimony by itself is insufficient to support a rating in excess of 10 percent under the mechanical application of Diagnostic Code 7336. IV. Hypertension In a September 2010 decision, the RO granted service connection for hypertension at an initial non-compensable rating under Diagnostic Code 7101 from April 26, 2010, the date that the claim was filed. The Veteran is appealing that decision. Because the claim is an initial claim, the Board will consider evidence of symptomatology from the date that the claim was filed. 38 C.F.R. § 3.400(o). Diagnostic Code 7101 provides ratings for hypertensive vascular disease (hypertension and isolated systolic hypertension). 38 C.F.R. § 4.104. A rating of 10 percent is appropriate for hypertensive vascular disease with diastolic pressure predominantly 100 or more, systolic pressure predominantly 160 or more, or minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. Id. A rating of 20 percent is appropriate for hypertensive vascular disease with diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more. Id. A rating of 40 percent is appropriate for hypertensive vascular disease with diastolic pressure predominantly 120 or more. Id. A rating of 60 percent is appropriate for hypertensive vascular disease with diastolic pressure predominantly 130 or more. Id. Note (1) to Diagnostic Code 7101 provides that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90 mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. Note (2) provides that hypertension that is due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, is to be rated as part of the condition causing it rather than by a separate rating. Note (3) to Diagnostic code 7101 provides that hypertension is to be rated separately from hypertensive heart disease and other types of heart disorders. Id. In every case where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. While the evidence supports continuous use of medication, it does not support a diastolic blood pressure reading of 100 or more from April 26, 2010, so as to support a compensable rating under Diagnostic Code 7101. For the year 2010, medical records contain blood pressure readings of 130/80 and 120/80, as measured in the months of May and November, respectively. Additionally, an August 2010 VA examination reports three blood pressure readings of 140/81. For the year 2011, medical records contain blood pressure readings of 128/82, 130/78, 140/79, 140/82, 150/98, and 154/91, as measured in the months of March, May, June (1 of 2), June (2 of 2), November (1 of 2) and November (2 of 2), respectively. For the year 2014, medical records contain blood pressure readings of 129/76, 125/67, 130/80, and 130/80, as measured in the months of March, July, September (1 of 2), and September (2 of 2), respectively. For the year 2015, medical records contain blood pressure readings of 130/79 and 137/77, as measured in the months of March and September, respectively. A March 2016 VA hypertension examination contains an average blood pressure reading of 131/73. From April 26, 2010, VA examinations contain two average blood pressure readings and medical records contain 14 individual blood pressure readings. None of the blood pressure readings contain a single diastolic pressure in excess of 100 or a systolic pressure in excess of 160 so as to support a compensable rating under Diagnostic Code 7101. There is evidence that the Veteran has been using medication continuously during this time period. See March 2016 VA hypertension examination; August 2010 VA examination. Unfortunately, the use of medication alone is insufficient to support a compensable rating under the mechanical application of Diagnostic Code 7101. In reaching this conclusion, the Board has considered the Veteran's lay statements, including his March 2014 VA Form 9 statement that he had to go to the emergency room because of his blood pressure. The Veteran is competent to report that he went to the emergency room because this is within the knowledge and personal observations of lay witnesses. See Barr, 21 Vet. App. at 307. Consistent with this, a January 2010 private medical record indicates that the Veteran was admitted to the emergency room for high blood pressure, and contains a blood pressure reading of 195/102. Also, in a November 2010 statement, the Veteran states that his blood pressure consistently exceeds the 140/80 measurements reported at the August 2010 VA examination. Unfortunately, the weight of the medical evidence as a whole is against a finding of diastolic blood pressure readings that are predominantly in excess of 100. Because the Veteran's statements about trends in his blood pressure readings are not supported by contemporaneous medical findings, the blood pressure readings in the Veteran's medical records are more credible than his lay statements regarding his blood pressure values. And the greater weight of the medical evidence is against a compensable rating under Diagnostic Code 7101. Also, the January 2010 blood pressure reading is outside of the time period that can be used to rate the Veteran's initial claim. Even if the Board were to consider this blood pressure reading, a single diastolic blood pressure reading of 195/102 over the course of seven years does not constitute a trend so as to support a finding of diastolic blood pressure predominantly 100 or more or systolic pressure predominantly 160 or more. Taken together, the weight of the evidence is against a grant of a compensable rating under Diagnostic Code 7101. ORDER Prior to July 30, 2014, entitlement to an initial rating of 50 percent, but no greater, for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. From July 30, 2014, entitlement to a rating in excess of 30 percent for PTSD is denied. Entitlement to a rating in excess of 10 percent for hemorrhoids is denied. Entitlement to a rating in excess of 10 percent for hiatal hernia/gastroesophageal reflux disease (GERD) and peptic ulcer is denied. Entitlement to an initial compensable rating for hypertension is denied. REMAND For the Veteran's remaining claims, a remand is required to obtain an addendum medical opinion and VA examinations. I. Sleep Apnea For the claim of entitlement to service connection for sleep apnea, a remand is required to obtain an addendum medical opinion that addresses service connection on a direct basis and on a secondary basis. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr, 21 Vet. App. at 312. "A medical opinion is adequate when it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Id. at 311 (internal citations and quotations omitted). The opinion must also consider all raised theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). For secondary service connection claims, the opinion must discuss whether a service-connected condition caused or aggravated the veteran's condition. Allen v. Brown, 7 Vet. App. 439, 449-50 (1995). It is important that a medical examiner provide this information, because "[w]ithout a medical opinion that clearly addresses the relevant facts and medical science, the Board is left to rely on its own lay opinion, which it is forbidden from doing." Stefl, 21 Vet. App. at 124 (citing Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991)). The December 2011 private medical opinion is inadequate. This opinion states: "[I]t is my belief that there is a 50% probability that [the Veteran] suffered from sleep apnea during his time in the [United States Air Force]. Certainly his sleep disruption could have been caused by being in combat and it continuing [sic] to his diagnosis of Post Traumatic Stress Disorder [PTSD], also caused by combat." There are two problems with this medical opinion. With regard to direct service connection, it only opines that the Veteran had the disorder in service without any stated rationale other than it "could" have resulted from combat. With regard to secondary service connection, the examiner states that sleep apnea "could" be related to PTSD. The United States Court of Appeals for Veterans Claims has specifically held that "using the term 'could,' without supporting data . . . is too speculative." Bloom v. West, 12 Vet. App. 185, 187 (Vet. App. 1999) (holding that). For these reasons, the December 2011 private medical opinion is inadequate. However, the March 2016 VA medical opinion is also inadequate. That opinion states that it is less likely than not that the Veteran's sleep apnea was aggravated by service-connected PTSD, but does not address direct service connection.. An addendum opinion is therefore required that addresses service connection on a direct and secondary basis. II. Acquired Psychiatric Disorder A remand is also required regarding the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder other than PTSD, to include a generalized anxiety disorder. In a June 2016 supplemental statement of the case, the RO states that the Veteran's claim of entitlement to service connection for a generalized anxiety disorder is denied. The rationale is that a March 2016 VA examination does not provide a current diagnosis of an anxiety disorder. However, the March 2016 VA examination is a PTSD-specific examination, not a general psychological examination, and the Board finds that it would not be appropriate to rely on a PTSD-specific examination as the sole basis for denying a claim of entitlement to service connection for an acquired psychiatric disorder other than PTSD. A medical examination or medical opinion is necessary in a claim for service connection when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). See also 38 U.S.C. § 5103A(d)(2) (2012); 38 C.F.R. § 3.159(c)(4)(i) (2017). These four requirements are satisfied for the Veteran's claim. Regarding the first element, the Veteran has consistently testified that he experiences anxiety. Regarding the second element, the Veteran has consistently testified that his psychiatric symptoms are the result of participating in over 100 combat missions in Vietnam. Regarding the third and fourth elements, there is an indication that his current anxiety could be the result of his in-service combat missions, but there is insufficient evidence of record by which the Board can reach this decision. As all four McLendon elements are satisfied, a VA examination is required. III. Pulmonary Tuberculosis, Inactive A new VA examination is required for the Veteran's pulmonary tuberculosis, inactive. The Veteran is service-connected for this disorder at an initial non-compensable rating under Diagnostic Code 6731. These rating criteria are based on pulmonary function testing and other symptoms as listed under the General Rating Formula for Interstitial Lung Disease, the General Rating Formula for Restrictive Lung Disease, and Diagnostic Code 6600. 38 C.F.R. § 4.97, Diagnostic Code 6731. These include measurements of Forced Vital Capacity (FVC), Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)), maximum exercise capacity, Forced Expiratory Volume in one second (FEV-1), Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC), and maximum oxygen consumption. The Veteran's most recent pulmonary function testing measurements are for FVC and FEV-1, as reported in an August 2010 VA examination. As these values are over seven years old, new measurements are required. See 38 C.F.R. § 3.327(a) ("Generally, reexaminations will be required if it is likely that . . . there been a material change in a disability . . . ."). A VA tuberculosis examination was conducted in March 2016, but no pulmonary function measurements were taken, and no explanation was provided as to why. As there are no current findings related to pulmonary function disorder, a new examination is required. VA treatment records to May 17, 2016, have been associated with the claims file. Therefore, the RO should obtain all relevant VA treatment records dated from May 18, 2016, to the present before the remaining issues are decided on the merits. Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Associate with the claims folder all records of the Veteran's VA treatment from May 18, 2016, to the present. If no records are available, the claims folder must indicate this fact. Any additional records identified by the Veteran during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the Veteran, and associated with the claims file. 2. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide the following opinions: a. Whether the Veteran has any current or previously-diagnosed sleep apnea; b. Whether it is at least as likely as not (a 50 percent or better probability) that any current or previously-diagnosed sleep apnea was incurred by the Veteran's service; and c. Whether the Veteran has any current or previously-diagnosed sleep apnea that (i) is proximately due to the Veteran's service-connected PTSD or (ii) was aggravated by the Veteran's service-connected PTSD. In rendering these opinions, the examiner should consider the Veteran's April 2012 lay statement and the articles submitted by the Veteran in January 2012, February 2012, and April 2012. For purposes of rendering this opinion, the examiner is to assume that the Veteran's reports of in-service sleeping difficulties are credible. The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. Whether or not to schedule the Veteran for an additional examination is left to the discretion of the examiner selected to write the addendum opinion. 3. After obtaining any additional records to the extent possible, provide an examination and obtain a medical opinion regarding the nature and etiology of any current or previously-diagnosed acquired psychiatric disorder other than PTSD, to include a generalized anxiety disorder. The examiner should review the entire claims file, conduct all necessary tests and studies, and provide the requested opinions: a. Whether the Veteran has any current or previously-diagnosed acquired psychiatric disorder other than PTSD, to include a generalized anxiety disorder; and b. Whether it is at least as likely as not (a 50 percent or better probability) that any current or previously-diagnosed acquired psychiatric disorder other than PTSD, to include a generalized anxiety disorder, was incurred in the Veteran's service, including but not limited to participating in combat missions. In rendering these opinions, the examiner should address the Veteran's March 2014 VA Form 9, in which he states that frequently panics when driving and cannot go to movies or be in crowds because of anxiety. The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. 4. After obtaining any additional records to the extent possible, provide an examination and obtain a medical opinion regarding the nature and severity of the Veteran's service-connected pulmonary tuberculosis, inactive. The claims folder should be made available to the examiner for review prior to the examination and the examiner should acknowledge such review in the examination report. Pulmonary function testing measurements should be taken as appropriate. 5. After the requested development has been completed, together with any additional development as may become necessary, readjudicate the Veteran's claims. If the benefit sought on appeal remains denied, issue to the Veteran and the Veteran's representative a supplemental statement of the case and give an opportunity to respond thereto. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ Michael J. Skaltsounis Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs