Citation Nr: 1805049 Decision Date: 01/25/18 Archive Date: 02/05/18 DOCKET NO. 08-30 018A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for a sleep disability, to include sleep apnea and insomnia, including as secondary to a service-connected disability. 2. Entitlement to service connection for hypertension, to include as due to exposure to herbicides and as secondary to a service-connected disability. 3. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as due to exposure to herbicides and as secondary to a service-connected disability. 4. Entitlement to service connection for a prostate disability, diagnosed as benign prostatic hypertrophy, to include as due to exposure to herbicides. 5. Entitlement service connection for a lung disability, diagnosed as chronic obstructive pulmonary disorder (COPD), to include as due to exposure to herbicides and as secondary to a service-connected disability. 6. Entitlement to an initial disability rating in excess of 10 percent for duodenitis. 7. Entitlement to an initial disability rating in excess of 10 percent for coronary artery disease (CAD). 8. Entitlement to a disability rating in excess of 10 percent for residuals of a shrapnel wound of the left (minor) wrist with retained shrapnel. 9. Entitlement to a disability rating in excess of 20 percent for healed scar of the left (minor) thumb, post shrapnel wound with residual hypoesthesia, distal to thumb from radial nerve damage. 10. Entitlement to an initial disability rating in excess of 70 percent prior to May 20, 2015 for posttraumatic stress disorder (PTSD). 11. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities prior to March 4, 2014. 12. Entitlement to Dependents' Educational Assistance (DEA) under 38 U.S.C. Chapter 35 prior to March 4, 2014. REPRESENTATION Veteran represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD Saira Spicknall, Counsel INTRODUCTION The Veteran served on active duty from August 1966 to July 1969 with service in the Republic of Vietnam from September 1968 to July 1969. His decorations include the Combat Infantryman Badge (CIB) and Purple Heart Medal. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In a January 2008 rating decision, the RO granted service connection for PTSD and assigned an initial 30 percent rating effective August 28, 2007. The Veteran appealed this rating action to the Board. By an August 2008 rating decision, the RO granted an increased initial rating for PTSD, assigning a 50 percent rating, effective August 28, 2007. The Board remanded the claim for an increased initial rating for PTSD in December 2011. In a June 2014 decision, the Board granted a 70 percent rating to the service-connected PTSD, and remanded the issue of entitlement to an initial rating in excess thereof to the RO for additional development. In the June 2014 decision, the Board also found that a TDIU claim had been raised by the record during the pendency of this appeal and that claim was remanded for additional development. See Rice v. Shinseki, 22 Vet. App. 447 (2009). By an August 2014 rating decision, the RO effectuated the Board's decision and awarded an initial 70 percent rating to the service-connected PTSD, effective August 28, 2007. In a July 2015 rating decision, the RO granted an initial 100 percent rating to the service-connected PTSD, effective May 20, 2015 and awarded claims of entitlement to a TDIU and DEA, effective April 24, 2015. The Veteran disagreed with the effective date awarded for the TDIU and DEA issues and perfected an appeal on these claims. This appeal also stems from an April 2014 rating decision issued by the above RO, wherein the RO, in part, granted service connection for CAD and duodenitis and assigned initial 10 percent ratings, effective August 13, 2012 and September 13, 2013, respectively. The RO also denied service connection for hypertension and prostate, gastrointestinal, lung, and sleep disabilities. Finally, the RO reopened a previously denied claim for service connection for bilateral hearing loss and denied the underlying claim on its merits. The Veteran appealed the RO's assignment of initial 10 percent disabling ratings assigned to the service-connected CAD and duodenitis; the effective dates of August 13, 2012 and September 13, 2013 for the awards of service connections for these two disabilities, respectively; and the denial of service connection for hypertension and prostate, gastrointestinal, lung, and sleep disabilities to the Board. The issues of entitlement to increased ratings for the left wrist and left thumb were denied in an August 2014 rating decision and the Veteran filed a notice of disagreement (NOD) with respect to this decision in September 2014. The issues were remanded by the Board in September 2016 for the issuance of a statement of the case (SOC). Thereafter, an SOC was issued in January 2017 and a substantive appeal was received in March 2017. In a September 2016 decision, the Board reopened and remanded the claim for entitlement to service connection for hearing loss. The Board also denied entitlement to an earlier effective date for the grant of service connection for CAD and awarded an earlier effective date for the award of service connection for duodenitis. The remaining issues on appeal were remanded for additional development. During the pendency of this appeal, entitlement to service connection for hearing loss was granted by a April 2017 rating decision, thereby constituting a full grant of the benefits sought on appeal and thus, this issue is no longer in appellate status before the Board. In a March 2017 rating decision, the RO awarded the assignment of an effective date of March 4, 2014 for the issues of TDIU and DEA. The issues of entitlement to service connection for a sleep disability and entitlement to an increased rating for the left wrist are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The probative evidence of record demonstrates that the Veteran's hypertension did not originate in service or for many years thereafter, is not related to any incident during active service, is not caused or aggravated by a service-connected disability and is not related to in-service herbicide agent exposure and cannot be presumptively related to in-service herbicide agent exposure. 2. The probative evidence of record demonstrates that the Veteran's GERD did not originate in service or for many years thereafter, is not related to any incident during active service and is not caused or aggravated by any service-connected disability. 3. The probative evidence of record demonstrates that the Veteran's prostate condition, diagnosed as benign prostate hypertrophy, did not originate in service or for many years thereafter, is not related to any incident during active service, and is not related to in-service herbicide agent exposure and cannot be presumptively related to in-service herbicide agent exposure. 4. The probative evidence of record demonstrates that the Veteran's lung disability, diagnosed as COPD, did not originate in service or for many years thereafter, is not related to any incident during active service and is not caused or aggravated by any service-connected disability. 5. The probative evidence of record indicates the Veteran's duodenitis, at worst, has been productive of mild recurrent symptoms. 6. The probative evidence of record indicates the Veteran's CAD, at worst, has been productive of symptoms requiring continuous medication. 7. The probative evidence of record indicates the Veteran's healed scar of the left (minor) thumb, post shrapnel wound with residual hypoesthesia, distal to thumb from radial nerve damage, at worst, has been productive of moderate incomplete paralysis of the radial nerve. 8. For the period prior to March 6, 2014, the probative evidence of record indicates the Veteran's PTSD has been productive of occupational and social impairment with deficiencies in most areas, including work, judgment, thinking and mood. 9. For the period from March 6, 2014, the probative evidence of record indicates that the Veteran's PTSD has been productive of total occupational and social impairment. 10. For the period prior to March 4, 2014, the probative evidence of record does not demonstrate that the Veteran's service-connected disabilities prevented him from securing and following substantially gainful employment. 11. For the period prior to March 4, 2014, the criteria for basic eligibility for DEA under Title 38, United States Code, Chapter 35, are not met. CONCLUSIONS OF LAW 1. The criteria for the establishment of service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 2. The criteria for the establishment of service connection for GERD are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 3. The criteria for the establishment of service connection for a prostate disability, diagnosed as benign prostatic hypertrophy, are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 4. The criteria for the establishment of service connection for a lung disability, diagnosed as COPD, are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 5. The criteria for an initial disability rating in excess of 10 percent for duodenitis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.114, Diagnostic Code (DC) 7305 (2017). 6. The criteria for an initial disability rating in excess of 10 percent for CAD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.104, DC 7305 (2017). 7. The criteria for a disability rating in excess of 20 percent for healed scar of the left (minor) thumb, post shrapnel wound with residual hypoesthesia, distal to thumb from radial nerve damage have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, DC 8514 (2017). 8. Prior to March 6, 2014, the criteria for an initial disability rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, DC 9411 (2017). 9. From March 6, 2014, the criteria for an initial 100 percent disability rating for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, DC 9411 (2017). 10. For the period prior to March 4, 2014, the criteria for a TDIU have not been met. 38 C.F.R. § 4.16(a) (2017). 11. For the period prior to March 4, 2014, the criteria for the grant of eligibility for DEA benefits under 38 U.S.C.A. Chapter 35, have not been met. 38 U.S.C. §§ 3501, 3510, 5110 (2012); 38 C.F.R. §§ 3.400, 3.807(a), 21.3021 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veteran was provided notice letters pursuant to the Veterans Claims Assistance Act (VCAA) in September 2007, May 2008, October 2008, and February 2014. 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017); see Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). See Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA also has a duty to assist the Veteran in the development of the claims. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. All relevant evidence necessary for an equitable resolution of the issues on appeal has been identified and obtained, to the extent possible. Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claims in this Board decision. There is no indication there exists any additional evidence that has a bearing on this case that has not been obtained and that is obtainable. The Veteran has been accorded ample opportunity to present evidence and argument in support of this appeal. See 38 C.F.R. § 3.103 (2017). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service connected disease or injury; or, for any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progression of the nonservice-connected disease. 38 C.F.R. § 3.310(a)-(b); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). If a Veteran was exposed to an "herbicide agent," such as Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam from January 9, 1962, to May 7, 1975, then, absent affirmative evidence to the contrary, certain diseases will be presumptively service connected even if there is no record of the disease in service. 38 U.S.C. §§ 1110, 1116, 1131; 38 C.F.R. §§ 3.307(a)(6), (d), 3.309(e). Initially the Board observes that, although the Veteran served in the Republic of Vietnam during the Vietnam War era and is presumed to have been exposed to an herbicide agent during that service, hypertension, GERD, benign prostatic hypertrophy and COPD are not included in the list of diseases which are deemed associated with herbicide exposure, under current VA law. 38 U.S.C. § 1116(f); 38 C.F.R. §§ 3.307(a)(6)(iii), 3.309(e). Thus the presumptive regulations for diseases associated with herbicide exposure do not apply in this case. 38 C.F.R. §§ 3.307(a)(6)(iii), 3.309(e). The claim with therefore be analyzed on the basis of direct service connection. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). 1. Hypertension The probative evidence of record demonstrates a current diagnosis of hypertension, however, there is no evidence of this disability during the Veteran's active service, no evidence indicating this disability is related to the Veteran's active service, including exposure to herbicides, and no evidence indicating this disability was caused or aggravated by any service-connected disability. The STRs are wholly absent of any complaints, treatment or findings of high blood pressure or hypertension. The post-service medical evidence, including private and VA medical records, demonstrates that hypertension was initially diagnosed many years after the Veteran's separation from active service. Finally, there is no probative medical evidence indicating the Veteran's hypertension is related to his active service or to a service-connected disability. The Veteran was diagnosed with hypertension in a March 2014 VA examination, at which time the Veteran also reported the date of diagnosis as 1972. In an accompanying April medical opinion, the VA examiner opined that it was less likely than not that hypertension was secondary to service-connected PTSD. In so finding, the examiner explained that the Veteran's blood pressure was less severe than typical for his age, being moderately controlled on only one medication. He cited to medical literature, noting that the prevalence of hypertension was greater than 50 percent in people aged 60 or older. The examiner also noted that, although some statistical studies showed a correlation between PTSD and risk of insomnia, no consistent link had been found. While he also reported that a growing body of literature supports an association between psychological state and physical health, few studies had considered PTSD and hypertension, despite the fact that plausible theories suggested potential mechanistic links between the two conditions. The examiner then noted that behavioral factors may mediate associations between PTSD and hypertension such as elevated alcohol intake, which was common in military populations and amongst people with PTSD and was also a known risk factor for hypertension in males. He then noted that a systematic review investigating PTSD and specific physical diagnoses identified little published material in the field, and reported that there were inconsistent findings for many conditions, including hypertension. In a February 2017 VA examination, the Veteran was diagnosed with hypertension and reported a history of onset in 1975. In a separate February 2017 opinion, the examiner found it was less likely than not that the currently diagnosed hypertension was etiologically related to or had its onset during active military service, to include the Veteran's confirmed exposure to Agent Orange or was manifest to a compensable degree within one year of separation from active duty in July 1969. He also opined that it was less likely than not that the currently diagnosed hypertension was caused or aggravated by the service-connected PTSD or CAD. In so finding, the examiner pointed out the Veteran reported he was found to have "silent" hypertension on routine checkup in 1975. He also noted that hypertension preceded the diagnosis of CAD, which was diagnosed in 2010, and that CAD did not cause hypertension. The examiner then noted that the Veteran had primary hypertension, which tended to develop gradually over many years, and his hypertension was well controlled with a minimal dose of Lisinopril, low salt diet and exercise. While he noted that various conditions and medications could lead to secondary hypertension, the examiner specified the Veteran had primary (essential) hypertension. He also found that PTSD was not listed as a cause of hypertension, explaining that hypertension and PTSD may coexist, but there was no statistically significant cause and effect relationship between the two. The Board has considered the Veteran's claims his hypertension was caused by exposure to herbicides in service or in the alternative, that hypertension was secondary to a service-connected disability, including CAD or PTSD. While a Veteran is competent to report treatment and symptoms of a disorder, he is not competent to diagnose or medically attribute any in-service symptom or incident to a current disorder. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). With respect to these statements regarding the etiology of hypertension as due to herbicide exposure or as due to a service-connected disability, such would constitute medical conclusions, which the Veteran is not competent to make as a lay person and thus these statements are afforded no probative value. See Jandreau, 492 F.3d at 1377 n.4; Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010); Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine, however, as the preponderance of the evidence is against the Veteran's claim for service connection for hypertension that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Therefore, the Veteran's claim for service connection for hypertension is denied. 2. GERD The probative evidence of record demonstrates a current diagnosis of GERD, however, there is no evidence of this disability during the Veteran's active service, no evidence indicating this disability is related to the Veteran's active service, including exposure to herbicides, and no evidence indicating this disability was caused or aggravated by any service-connected disability. The STRs are wholly absent of any complaints, treatment or findings of GERD. The post-service medical evidence, including private and VA medical records, demonstrates that GERD was initially diagnosed many years after the Veteran's separation from active service. Finally, there is no probative medical evidence indicating the Veteran's GERD is related to his active service or to a service-connected disability. In a March 2014 VA examination, the Veteran was diagnosed with GERD, noted to have developed in 2012. In an April 2014 VA medical opinion, the examiner found that it was less likely than not that GERD was secondary to PTSD or to an ulcer diagnosed in 1970. The examiner found that the most likely cause of GERD symptoms was hiatal hernia, noted as a congenital anatomic abnormality. The examiner noted that the Veteran admitted to having two to three alcoholic drinks daily in the PTSD VA examination, which was also a major risk factor for GERD. He explained that the ulcer the Veteran experienced in service and thereafter was in the duodenum, beyond the stomach, while GERD occurred in the esophagus, before the stomach. Upon a review of additional medical literature, the examiner noted that articles on GERD made no reference to PTSD and that articles on PTSD made no reference to GERD. In a February 2017 VA examination the Veteran was diagnosed with GERD, with a reported history of onset in 2012 and the examiner noted date of onset in 2002 after a review of VA treatment records. In a separate February 2017 VA medical opinion, a VA examiner opined that it was less likely than not that the currently diagnosed gastrointestinal disability, notably GERD, was etiologically related to or had its onset during active military service, to include the Veteran's confirmed exposure to Agent Orange, or was manifested to a compensable degree within one year of separation from active duty in July 1969. The examiner then also found it was less likely than not that the currently diagnosed GERD was caused or aggravated (permanently worsened) by either the service-connected PTSD or duodenitis, to include medications prescribed thereof. He explained that exposure to Agent Orange did not cause a gastrointestinal disability, namely GERD. The examiner also noted that the paperless claims processing system, the Veterans Benefits Management System (VBMS), and VA medical records provided no nexus of GERD manifested to a compensable degree within one year of separation from active duty in July 1969. He reported that a comprehensive review of a VA new patient clinic note in January 2002 did not report GERD. The examiner also found that the Veteran's GERD was related to his diet, including spicy food, not to PTSD or duodenitis. He observed the Veteran was on no medication for duodenitis and his GERD symptoms were controlled with diet and exercise. The examiner noted the Veteran was not on any medication for GERD. The Board has considered the Veteran's claims his GERD was caused by exposure to herbicides in service or in the alternative, that GERD was secondary to a service-connected disability, including PTSD or duodenitis. While a Veteran is competent to report treatment and symptoms of a disorder, he is not competent to diagnose or medically attribute any in-service symptom or incident to a current disorder. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). With respect to these statements regarding the etiology of GERD as due to herbicide exposure or as due to a service-connected disability, such would constitute medical conclusions, which the Veteran is not competent to make as a lay person and thus these statements are afforded no probative value. See Jandreau, 492 F.3d at 1377 n.4; Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010); Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine, however, as the preponderance of the evidence is against the Veteran's claim for service connection for GERD that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Therefore, the Veteran's claim for service connection for GERD is denied. 3. Benign Prostatic Hypertrophy The probative evidence of record demonstrates a current diagnosis of benign prostatic hypertrophy, however, there is no evidence of this disability during the Veteran's active service and no evidence indicating this disability is related to the Veteran's active service, including exposure to herbicides. The STRs are wholly absent of any complaints, treatment or findings of exposure to herbicides or benign prostatic hypertrophy. The post-service medical evidence, including private and VA medical records, demonstrates that benign prostatic hypertrophy was initially diagnosed many years after the Veteran's separation from active service. Finally, there is no probative medical evidence indicating the Veteran's benign prostatic hypertrophy is related to his active service. In a February 2017 VA examination, the Veteran was diagnosed with benign prostate hypertrophy, with a noted date of diagnosis of 2002. In a separate February 2017 VA opinion, the examiner opined that it was less likely than not that the currently diagnosed prostate disability, benign prostate hypertrophy, was etiologically related to or had its onset during active military service, to include the Veteran's confirmed exposure to Agent Orange, or was manifested to a compensable degree within one year of separation from active duty in July 1969. The examiner noted that a January 2002 VA outpatient treatment report included a comprehensive new patient clinic note which did not report the claimed prostate condition. He also noted the Veteran was between 20 to 23 years of age during active duty, which was not the age for benign prostate hypertrophy. The examiner explained that exposure to Agent Orange did not cause any prostate disability other than prostate cancer. He then noted VA outpatient treatment notes from April 2002 demonstrated complaints of nocturia three times, some urgency and weak stream and he was given a "Palmetto trial" for benign prostatic hypertrophy, which helped. The examiner also cited to findings in a June 2008 VA cystoscopy report and September 2008 VA uroflow report. The Board has considered the Veteran's claims his prostate condition was caused by exposure to herbicides in service. While a Veteran is competent to report treatment and symptoms of a disorder, he is not competent to diagnose or medically attribute any in-service symptom or incident to a current disorder. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). With respect to these statements regarding the etiology of benign prostatic hypertrophy as due to herbicide exposure, such would constitute medical conclusions, which the Veteran is not competent to make as a lay person and thus these statements are afforded no probative value. See Jandreau, 492 F.3d at 1377 n.4; Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010); Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine, however, as the preponderance of the evidence is against the Veteran's claim for service connection for benign prostatic hypertrophy that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Therefore, the Veteran's claim for service connection for a prostate disability, diagnosed as benign prostatic hypertrophy, is denied. 4. COPD The probative evidence of record demonstrates a current diagnosis of COPD, however, there is no evidence of this disability during the Veteran's active service, no evidence indicating this disability is related to the Veteran's active service, including exposure to herbicides, and no evidence indicating this disability was caused or aggravated by any service-connected disability. The STRs are wholly absent of any complaints, treatment or findings of a respiratory/lung disability. The post-service medical evidence, including private and VA medical records, demonstrates that a respiratory disability, diagnosed as COPD, was initially diagnosed many years after the Veteran's separation from active service. Finally, there is no probative medical evidence indicating the Veteran's COPD is related to his active service or to a service-connected disability. In an April 2014 VA opinion report, the examiner found that it was less likely than not that the Veteran's claimed lung condition was secondary to GERD. He explained that the connection between GERD and lung disease involved reflux severe enough that stomach acid was aspirated into the lungs and the Veteran's EGD report did not show the esophagitis one would expect to find in a patient with GERD that was severe enough to cause lung disease. Citing to a December 2013 VA outpatient treatment report, the examiner noted that the VA pulmonologist at the time stated that COPD was likely caused by the Veteran's smoking. In a February 2017 VA examination, the Veteran was diagnosed with COPD with 2013 noted as the date of diagnosis. At that time, the Veteran reported having no pulmonary complaints prior to December 2012. In a separate February 2017 VA opinion, the examiner found that it was less likely than not that the currently diagnosed lung disability, COPD and left hemidiaphragm paralysis were etiologically related to or had their onset during active military service, to include the Veteran's confirmed exposure to Agent Orange, or were manifested to a compensable degree within one year of separation from active duty in July 1969. The examiner explained that VBMS and VA medical records provided no nexus of a lung disability manifested to a compensable degree within one year of separation from active duty in July 1969. He then noted a January 2002 VA new patient clinic noted did not report the claimed condition. The examiner also explained that Agent Orange did not cause the claimed disability. He then cited to the Veteran's own report that he did not have pulmonary complaints prior to December 2012, he was diagnosed with COPD in 2013 and elevated left hemidiaphragm was detected for the first time in a May 2013 VA CT scan and March 2016 VA chest x-ray. The examiner concluded that the Veteran's breathing problems were well controlled with bronchodilator inhaler, which supported the diagnosis of COPD for his breathing problems. In a March 2017 addendum report, the VA examiner also found that COPD was a group of progressive lung diseases, the single biggest cause of which was cigarette smoking. He noted that about 90 percent of people who had COPD were smokers or former smokers and that, among smokers, 20 to 30 percent developed COPD. The examiner also concluded that duodenitis, or medications used to treat it, does not cause or exacerbate COPD. The Board has considered the Veteran's claims his COPD was caused by exposure to herbicides in service or in the alternative, that COPD was secondary to a service-connected disability, including GERD or duodenitis. While a Veteran is competent to report treatment and symptoms of a disorder, he is not competent to diagnose or medically attribute any in-service symptom or incident to a current disorder. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). With respect to these statements regarding the etiology of COPD as due to herbicide exposure or as due to a service-connected disability, such would constitute medical conclusions, which the Veteran is not competent to make as a lay person and thus these statements are afforded no probative value. See Jandreau, 492 F.3d at 1377 n.4; Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010); Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine, however, as the preponderance of the evidence is against the Veteran's claim for service connection for a lung disability, diagnosed as COPD, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Therefore, the Veteran's claim for service connection for a lung disability, diagnosed as COPD, is denied. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. See 38 C.F.R. § 4.7 (2017). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different "staged" ratings may be warranted for different time periods. Where the question for consideration is the propriety of the initial evaluation assigned after the granting of service connection, separate ratings may also be assigned for separate periods of time based on facts found, i.e. "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). 1. Duodenitis The Veteran's service-connected duodenitis is rated as a digestive disability by analogy under DC 7399-7305 (duodenal ulcer). 38 C.F.R. § 4.114 (2017). In this regard, the primary manifestations of the Veteran's service-connected duodenitis are similar to the symptomatology of a stomach ulcer. Under DC 7305 for a duodenal ulcer, a 10 percent evaluation is warranted for a mild duodenal ulcer with recurring symptoms once or twice yearly. A 20 percent evaluation is warranted for a moderate duodenal ulcer with recurring episodes of severe symptoms two or three times per year averaging ten days in duration; or with continuous moderate manifestations. A 40 percent evaluation is warranted for a moderately severe duodenal ulcer; less than severe but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging ten days or more in duration at least four or more times per year. A maximum 60 percent evaluation is warranted for a severe duodenal ulcer; pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. 38 C.F.R. § 4.114. The probative evidence of record, including the Veteran's lay statements and testimony, private and VA medical records and VA examinations, demonstrates that, throughout the duration of the appeal, the Veteran's duodenitis, at worst, has been productive of mild recurrent symptoms. In an April 2014 VA opinion, the examiner found that it was more likely than not that that the currently diagnosed duodenitis was secondary to ulcer diagnosed in 1970. In an April 2014 addendum to the March 2014 and April 2014 VA examinations, the examiner found that while the ulcer noted in 1970 presumably healed completely without sequel, the current duodenitis was likely a recurrence of the same condition. In a June 2015 VA examination the Veteran's symptoms included recurring episodes of symptoms that were not severe, which occurred four or more times per year and lasted less than one day. Continuous abdominal pain was noted to be only partially relieved by standard ulcer therapy and mild nausea was noted to occur four or more times a year, lasting less than a day. Accordingly the Veteran's duodenitis therefore more nearly approximates the criteria for a 10 percent disability rating throughout the duration of the appeal, under DC 7305. 38 C.F.R. § 4.114. The probative evidence of record does not demonstrate findings of moderate duodenal ulcer with recurring episodes of severe symptoms two or three times per year averaging ten days in duration; or with continuous moderate manifestations so as to warrant a higher disability rating. See id. Accordingly, the Board concludes that the Veteran's duodenitis does not warrant an initial disability rating in excess of 10 percent throughout the duration of the appeal. 38 C.F.R. §§ 3.102, 4.3 (2017). See also 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990); Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 2. CAD The Veteran's CAD is rated under DC 7005, for rating arteriosclerotic heart disease. Under DC 7005, a 10 percent rating is warranted for a workload of greater than 7 METs but not greater than10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication. A 30 percent rating is warranted for coronary artery disease with a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electro-cardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned when there is more than one episode of acute congestive heart failure in the past year, or when a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; where there is left ventricular dysfunction with an ejection fraction of 30 percent to 50 percent. A 100 percent rating is assigned where there is chronic congestive heart failure; or when there is a workload of 3 METs or less which results in dyspnea, fatigue, angina, dizziness, or syncope; or when there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005 (2017). One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, DC 7005, Note (2) (2017). The probative evidence of record, including the Veteran's lay statements and testimony, VA medical records and VA examinations, demonstrates that, throughout the duration of the appeal, the Veteran's CAD, at worst, has been productive of symptoms requiring continuous medication. A March 2014 VA examination reflects the Veteran's heart condition required continuous medication and the examination cited to May 2010 test results which revealed ejection fraction of 60 percent. Although an interview based METs test revealed a METs level of 1 to 3 with activities such as eating, dressing, taking a shower and slow walking for one to two blocks, the examiner attributed the METs level limitations to the Veteran's pulmonary, age and musculoskeletal disabilities and not his heart disability. In a June 2015 VA examination of the heart, continuous medication was noted to have been required to control the Veteran's heart condition. This examination also found no evidence of congestive heart failure, cardiac hypertrophy or cardiac dilation. A coronary artery angiogram from May 2010 was noted to include normal left ventricular function with an ejection fraction of 60 percent. METs testing also revealed no exercise test was performed because it was not indicated for the Veteran's condition and an interview based METs test was performed. The interview-based METs test the examiner reported that the Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. Thus, the Veteran's CAD therefore more nearly approximates the criteria for a 10 percent disability rating throughout the duration of the appeal, under DC 7005. 38 C.F.R. § 4.104. The probative evidence of record does not demonstrate findings of a workload greater than 5 METs or less that was also attributable to the Veteran's heart condition, ejection fraction of 30 to 50 percent or less, or evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram or x-ray so as to warrant a higher disability rating. See id. Accordingly, the Board concludes that the Veteran's CAD does not warrant an initial disability rating in excess of 10 percent throughout the duration of the appeal. 38 C.F.R. §§ 3.102, 4.3 (2017). See also 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990); Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 3. Left Thumb The Veteran's left thumb disability is rated under DC 8514, used for rating the radial nerve. Under this provision, complete paralysis of the radial nerve with drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity warrants a 70 percent rating in the major extremity, and a 60 percent rating in the minor extremity. Incomplete paralysis of the radial nerve of the major extremity is rated as follows: severe (50 percent); moderate (30 percent); and mild (20 percent). Incomplete paralysis of the radial nerve of the minor extremity is rated as follows: severe (40 percent); moderate (20 percent); and mild (20 percent). 38 C.F.R. § 4.124a, DC 8514. The Board observes that, per the VA examinations of record, the Veteran's left thumb is on his minor extremity. The words "mild," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. The probative evidence of record, including the Veteran's lay statements and testimony, VA medical records and VA examinations, demonstrates that, throughout the duration of the appeal, the Veteran's healed scar of the left (minor) thumb, post shrapnel wound with residual hypoesthesia, distal to thumb from radial nerve damage, at worst, has been productive of moderate incomplete paralysis of the radial nerve. An April 2014 VA examination of the peripheral nerves reflects findings of mild constant pain in the left upper extremity, moderate intermittent pain of the left upper extremity, moderate paresthesias and/or dysesthesias of the left upper extremity and moderate numbness of the left upper extremity. The examiner found moderate incomplete paralysis of the left radial nerve. A June 2015 VA examination of the peripheral nerves reflects findings of moderate constant pain in the left upper extremity, severe intermittent pain of the left upper extremity, moderate paresthesias and/or dysesthesias of the left upper extremity and moderate numbness of the left upper extremity. Despite the one finding of severe intermittent pain in the left upper extremity, in considering the remaining symptoms of the Veteran's peripheral nerve condition of the left upper extremity were found to be moderate, the examiner concluded that the Veteran's left radial nerve was overall productive of moderate incomplete paralysis. Thus, the Veteran's left thumb disability therefore more nearly approximates the criteria for a 20 percent disability rating throughout the duration of the appeal, under DC 8514. 38 C.F.R. § 4.124a. The probative evidence of record does not demonstrate findings of severe incomplete paralysis so as to warrant a higher disability rating. See id. As noted above, although the June 2015 VA examination noted a finding of severe intermittent pain in the left upper extremity, the examiner concluded that the Veteran's left radial nerve was overall productive of moderate incomplete paralysis given the moderate findings of constant pain, paresthesias and/or dysesthesias and numbness. Accordingly, the Board concludes that the Veteran's healed scar of the left (minor) thumb, post shrapnel wound with residual hypoesthesia, distal to thumb from radial nerve damage does not warrant a disability rating in excess of 20 percent throughout the duration of the appeal. 38 C.F.R. §§ 3.102, 4.3 (2017). See also 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990); Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 4. PTSD The Veteran's PTSD has been assigned a 70 percent disability rating for the period prior to May 20, 2015 and a 100 percent disability rating thereafter under 38 C.F.R. § 4.130, DC 9411, which is evaluated under the general rating formula for mental disorders. Under this general rating formula, a 70 percent rating is warranted when there is 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 work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to 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, 442 (2002). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266 (1996); Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). See also Diagnostic and Statistical Manual of Mental Disorders, (4th ed. 1994) (DSM-IV). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Accordingly, GAF scores are but one factor to be considered in conjunction with all the other evidence of record. The Board notes that the DSM-IV has been recently updated with a Fifth Edition (DSM-V). Effective August 4, 2014, VA issued an interim rule amending the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to refer to certain mental disorders in accordance with DSM-V. The provisions of the interim final rule only apply, however, to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014. The probative evidence of record, including the Veteran's lay statements and testimony, private and VA medical records and VA examinations, collectively demonstrates that, for the period prior to March 6, 2014, the probative evidence of record indicates the Veteran's PTSD has been productive of occupational and social impairment with deficiencies in most areas, including work, judgment, thinking and mood and for the period from March 6, 2014, the probative evidence of record indicates that the Veteran's PTSD has been productive of total occupational and social impairment. Although the May 2015 VA examination of PTSD indicates symptoms that are productive of 100 percent, it is clear these symptoms had increased since the last VA examination in March 2014 and therefore were present also prior to the May 2015 VA examination. This conclusion is supported by relevant medical and lay evidence dated during this time. Accordingly, the probative lay and medical evidence of record supports the assignment of a disability rating 100 percent for PTSD from the date of the March 2014 VA examination, from March 6, 2014. Although an increased 100 percent rating is warranted for the period from March 6, 2014, the preponderance of the evidence is against a finding of entitlement to an evaluation exceeding 70 percent at any time prior to March 6, 2014. As noted in Mauerhan, the Veteran need not have all or even most of the particular symptoms in order to warrant a 100 percent evaluation, however, his psychiatric symptomatology does not demonstrate total social and occupational impairment. See Mauerhan, 16 Vet. App. 436. Despite some reports and findings of suicidal thoughts and ideation and the Veteran's statement in August 2013 that he was a danger to himself and others, VA outpatient treatment reports and VA examinations throughout the duration of the appeal has not demonstrated the Veteran to be a persistent danger of hurting himself or others. In this regard, an April 2013 VA outpatient treatment report, the Veteran was assessed as having no suicidal ideation or risk at the time and he was already receiving the needed treatment. The Board acknowledges the various statements and PTSD assessments made by private treatment providers during the period of the appeal, which include September 2013, December 2014 and July 2015 reports by private physician F.B. M.D., September 2013 and July 2014 reports by private counselor K.J.T. and an April 2015 report by private counselor G.L.M. Although these reports address the Veteran's PTSD symptoms as chronic and severe, they discuss his impairment as related to his occupational functioning and do not address impairments to his social functioning. As discussed below, prior to March 6, 2014, the Board has awarded the Veteran a TDIU based on his total occupational impairment. VA medical records reflect the Veteran has maintained relationships with his family, namely his spouse, to some degree. Although the September 2013 private psychiatric evaluation with Dr. F.B., M.D. reflects the Veteran was experiencing marital trouble with his spouse of 45 years at the time, they underwent couples counseling and remained together. Considering all the lay and medical evidence of record as it relates to PTSD's impact on the Veteran's social and occupational impairment, the Boards finds that this evidence does not demonstrate total social and occupational impairment prior to March 6, 2014. Therefore, the probative evidence of record does not more nearly approximate the criteria for a 100 percent schedular disability rating at any time prior to March 6, 2014 since the filing of the claim for this disability. 38 C.F.R. §§ 4.3, 4.7. Accordingly, the Board concludes that for the period prior to March 6, 2014 the Veteran's PTSD warrants a disability rating of 70 percent, but no higher, and for the period from March 6, 2014, the Veteran's PTSD warrants a 100 percent disability rating. 38 C.F.R. §§ 3.102, 4.3 (2016). See also 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990); Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Overall, there exists no basis under the schedular criteria for an initial disability rating in excess of 70 percent for this disability at any time prior to March 6, 2014. 38 C.F.R. §§ 4.3, 4.7 (2017). Lay Statements The Board has considered the lay statements of record regarding the severity of the Veteran's duodenitis, CAD, left thumb and PTSD and has relied on these reports in determining appropriate disability rating under the benefit-of-the-doubt doctrine. 38 C.F.R. §§ 4.3, 4.7 (2017). The Veteran is competent to report on factual matters of which he has firsthand knowledge and his statements regarding his symptoms are also credible, and thus, probative. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Baldwin v. West, 13 Vet. App. 1 (1999). Where the Veteran has not discussed particular findings that are necessary for application to the rating criteria, the Board has accorded greater probative weight to objective medical findings of record which specifically address the rating criteria. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Extraschedular Consideration The question of entitlement to referral for consideration of an extraschedular rating is neither an issue argued by the claimant nor reasonably raised by the record through evidence of the collective impact of the claimant's service-connected disabilities. Yancy v. McDonald, 27 Vet. App. 484, 494-95 (2016). TDIU Total disability ratings are authorized for any disability or combination of disabilities provided the schedular rating is less than total, when the disabled person is unable to secure and maintain substantially gainful employment because of the severity of his service-connected disabilities. If there is only one such disability, it must be rated as at least 60 percent disabling. 38 C.F.R. § 4.16(a). If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. Id. In this case, the Veteran meets the preliminary schedular criteria for a TDIU under 38 C.F.R. § 4.16(a) for the period prior to March 6, 2014. Id. The Board observes that the issue of entitlement to a TDIU, on a derivative basis as part of the claim for an initial higher evaluation for PTSD is possibly moot for that time frame from March 4, 2014 as the Veteran is already in receipt of the highest possible rating for PTSD during that period. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) (finding a request for TDIU moot where 100 percent schedular rating was awarded for the same period). However, a grant of a 100 percent disability rating does not always render the issue of TDIU moot. As is potentially relevant here, VA's duty to maximize a claimant's benefits includes consideration of whether his disabilities establish entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). Specifically, SMC may be warranted if the Veteran has a 100 percent disability rating for a single disability, and VA finds that TDIU is warranted based solely on the disabilities other than the disability that is rated at 100 percent. See Bradley, 22 Vet. App. 280 (analyzing 38 U.S.C. § 1114 (s)); see also 75 Fed. Reg. 11,229 -04 (March 10, 2010) (withdrawing VAOPGCPREC 6-1999). In this case, for the period from March 6, 2014, the Board finds that the medical evidence demonstrates that a TDIU would be warranted based solely on the service-connected PTSD disability. Therefore, as the Veteran is already in receipt of a total (100 percent) disability rating for his PTSD from March 6, 2014, the issue of entitlement to a TDIU due to PTSD for that time period is moot. See Herlehy, 15 Vet. App. 33. Accordingly, the Board will address the issue of entitlement to a TDIU for the period prior to March 4, 2014. As entitlement to a TDIU was inferred from the initial rating claim for PTSD on appeal by the Board in a June 2014 decision, which was initially filed as a claim for entitlement to service connection for PTSD in August 2007, the claim for entitlement to TDIU from August 28, 2007 to March 4, 2014 will be addressed below. When viewed as a whole, the evidence does not support a finding that, prior to March 4, 2014, the Veteran was not capable of substantially gainful employment as a result of his service-connected disabilities. The Board observes that private treatment reports, including a September 2013 PTSD evaluation private physician F.B. M.D. and a September 2013 report by private counselor K.J.T., address the Veteran's PTSD symptoms as chronic and severe, and specifically discuss his impairment of occupational functioning and the inability to work due to his PTSD. However, in considering the Veteran's employment information provided in his TDIU applications, VA Forms 21-8940, as well as the reports from his past employers, it is clear the Veteran was continually and gainfully employed in the mortgage lending field prior to March 4, 2014. Accordingly, for the period prior to March 4, 2014 the probative evidence of record demonstrates that the Veteran was neither unemployable nor capable of no more than marginal employment due to his service-connected disabilities. Accordingly, the criteria for a TDIU prior to March 4, 2014, have not been met. DEA/Chapter 35 Benefits In a July 2015 rating decision, the Veteran was granted basic eligibility for DEA benefits effective from April 24, 2015, based upon the grant of TDIU that was effective as of the same date. Thereafter, in a March 2017 rating decision, the RO awarded basic eligibility for DEA benefits back to March 4, 2014, also based upon the award of TDIU back to the same effective date. For the purposes of educational assistance under 38 U.S.C.A. Chapter 35, the child or surviving spouse of a Veteran will have basic eligibility if the following conditions are met: (1) The Veteran was discharged from service under conditions other than dishonorable, or died in service; and (2) the Veteran has a permanent total service-connected disability; or (3) a permanent total service-connected disability was in existence at the date of the Veteran's death; or (4) the Veteran died as a result of a service-connected disability. 38 U.S.C. §§ 3501, 3510; 38 C.F.R. §§ 3.807 (a), 21.3021. Except as provided in subsections (b) and (c), effective dates relating to awards under Chapters 30, 31, 32, and 35 of this title or Chapter 106 shall, to the extent feasible, correspond to effective dates relating to awards of disability compensation. 38 U.S.C. § 5113. In the award of DEA in the March 2017 rating decision, the RO recognized that the Veteran's disability was permanent as of the date of the total rating. In this decision, the Board has also recognized that the Veteran's disability was permanent as of the date of the total rating. Therefore, entitlement to DEA benefits pursuant to Chapter 35 is not warranted prior to March 4, 2014. ORDER Service connection for hypertension is denied. Service connection for GERD is denied. Service connection for a prostate disability, diagnosed as benign prostatic hypertrophy, is denied. Service connection for a lung disability, diagnosed as COPD, is denied. An initial disability rating in excess of 10 percent for duodenitis is denied. An initial disability rating in excess of 10 percent for CAD is denied. A disability rating in excess of 20 percent for healed scar of the left (minor) thumb, post shrapnel wound with residual hypoesthesia, distal to thumb from radial nerve damage is denied. Prior to March 6, 2014, an initial disability rating in excess of 70 percent for PTSD is denied. From March 6, 2014, an initial 100 percent disability rating for PTSD is granted, subject to the law and regulations applicable to the payment of monetary benefits. Prior to March 4, 2014, a TDIU is denied. Prior to March 4, 2014, entitlement to DEA benefits under 38 U.S.C.A. Chapter 35 is denied. REMAND Although VA examinations and opinions were afforded in March 2014, April 2014 and February 2017 for a sleep disability, to include sleep apnea and insomnia, however, the examiners failed to address the specific diagnosis of insomnia, made in the March 2014 VA examination, in their opinions and whether insomnia was incurred or otherwise related to the Veteran's active service or whether insomnia was caused or aggravated by any service-connected disability. Therefore, the claim for entitlement to service connection for a sleep disability must be remanded to afford the Veteran a VA examination and opinion regarding this matter. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Locklear v. Nicholson, 20 Vet. App. 410 (2006); see Waters v. Shinseki, 601 F.3d 1274, 1276 (2010); Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Veteran was afforded VA examinations for his left wrist in March 2014 and June 2015, however, these examinations failed to address all of the following together: pain on active and passive range of motion, pain with weight bearing and non-weight bearing, range of motion of the opposite wrist and functional loss during flare-ups. The United States Court of Appeals for Veterans Claims (Court) has held that "to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of" 38 C.F.R. § 4 .59. See Correia v. McDonald, 28 Vet. App. 158 (2016). The referenced portion of 38 C.F.R. § 4.59 states that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Id.; See also Sharp v. Shulkin, 29 Vet. App. 26, 22 (2017), providing that the examiner should "estimate the functional loss that would occur during flares." In accordance with 38 C.F.R. § 3.326 (a), the Veteran should be afforded a new examination for the left wrist that is in accordance with recent precedent of the Court. As the record reflects the Veteran has received continuing treatment at VA, any outstanding and current ongoing medical records should also be obtained. 38 U.S.C. § 5103A(c) (2012); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file all pertinent VA and private medical records the Veteran adequately identifies, including any outstanding VA medical records. 2. Upon receipt of all additional records, schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed sleep disorder. The Veteran's electronic claims file, to include a copy of this remand, must be made available prior to completion of the evaluation. All clinically-indicated diagnostic testing should be performed. The examiner is asked to review and comment on the diagnosis of insomnia made in the March 2014 VA examination. The examiner is then asked to answer the following: (a). Does the Veteran have a currently diagnosed sleep disability? If not, please address the diagnosis of insomnia made in the March 2014 VA examination. (b). Whether it is at least as likely as not (50 percent or greater probability) that a sleep disability, to include sleep apnea or the insomnia diagnosed in March 2014, was incurred during the Veteran's active service or was otherwise caused by the Veteran's military service. (c). Whether it is at least as likely as not (50 percent or greater probability) that any currently diagnosed sleep disability was caused, OR alternatively, aggravated by any service-connected disability, to include PTSD. It is essential the examiner provide explanatory rationale for opinions on these determinative issues, citing to specific evidence in the file supporting conclusions. 3. Upon receipt of all additional records, schedule the Veteran for a VA examination to determine the severity of the Veteran's service-connected left wrist disability. The claims folder and a copy of this remand are to be made available to and reviewed by the examiner in connection with the examination. The evaluations of the left wrist should consist of all necessary testing including range of motion testing for BOTH WRISTS based on (1) active motion; (2) passive motion; (3) weight-bearing; and (4) non-weight bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why this is so. The examiner is asked to comment on the following: (a). The degree of severity and the functional effects of this disability on his activities of daily living and capacity for work. (b). The extent of any weakened movement, excess fatigability and incoordination. The examiner should assess the additional functional impairment due to weakened movement, excess fatigability, or incoordination in terms of the degree of additional range of motion loss. (c). Whether there would be additional functional impairment on repeated use or during flare-ups. The examiner should assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. If the examination is not conducted during a flare-up, the functional impact of a flare-up should be estimated based on the Veteran's reports. Please explain the reasons for any opinions rendered and include a discussion of the relevant evidence. If no opinion can be provided without resorting to mere speculation, please explain the reasons for such conclusion. 4. Ensure the examiner's opinions are responsive to the determinative issues of etiology of a sleep disorder and the severity of the left wrist at issue in this appeal. If not, return the report(s) for all necessary additional information. 5. Then, readjudicate the claims for service connection for a sleep disability and an increased rating for the left wrist disability in light of this and all other additional evidence. If the issues are denied, send the Veteran and his attorney a supplemental statement of the case (SSOC) and give them time to respond to it before returning the file to the Board for further appellate consideration of these claims. The Veteran 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). (Continued on the next page) 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). S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs