Citation Nr: 1806284 Decision Date: 01/31/18 Archive Date: 02/07/18 DOCKET NO. 11-25 864 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to Agent Orange exposure and service-connected diabetes mellitus. 2. Entitlement to a rating in excess of 10 percent for residuals of a torn ligament, left knee, and for a rating in excess of 10 percent for instability (left knee disability). 3. Entitlement to an initial rating in excess of 10 percent for tinea versicolor prior to April 23, 2008, and in excess of 30 percent thereafter. 4. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to October 27, 2015, and in excess of 50 percent thereafter. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). ATTORNEY FOR THE BOARD P. Daugherty, Associate Counsel INTRODUCTION The Veteran served in the United States Navy with active duty from September 1968 to September 1970, to include service in the Republic of Vietnam. The Veteran received the Vietnam Service Medal with two Bronze Stars, among other awards and distinctions. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2007, March 2010, and September 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. This claim was previously before the Board in October 2014, at which time it was remanded for further development, to include affording the Veteran with new VA examinations. As substantial compliance with the Board's October 2014 remand directives has been completed, the claim has now returned to the Board for further appellate action. See Stegall v. West, 11 Vet. App. 268 (1998). The issues of entitlement to service connection for hypertension, entitlement to an increased rating for left knee disabilities, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to April 23, 2008, the Veteran's tinea versicolor was manifested by hypopigmented lesions to the chest and back that covered approximately 8 percent of the entire body or exposed areas affected, and the skin disorder does not require the use of systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more. 2. Beginning April 23, 2008, the Veteran's tinea versicolor has been manifested by hypopigmented lesions to the chest and back that cover approximately 20 to 40 percent of the Veteran's total body or exposed body areas but no more, and the skin disorder does not require the use of systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more. 3. Prior to October 27, 2015, the Veteran's PTSD was manifested by symptoms such as depressed mood, anxiety, chronic sleep impairment, hypervigilance, and mild memory loss, which resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although general functioning satisfactorily). 4. Beginning October 27, 2015, the Veteran's PTSD has been manifested by symptoms such as depressed mood, suspiciousness, panic attacks that occur weekly or less often, difficulty understanding complex commands, impaired abstract thinking, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control, resulting in occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for tinea versicolor prior to April 23, 2008, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Codes 7800-7806 (2017). 2. The criteria for a rating in excess of 30 percent for tinea versicolor beginning April 23, 2008, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Codes 7800-7806 (2017). 3. The criteria for an initial rating in excess of 30 percent for PTSD prior to October 27, 2015, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2017). 4. The criteria for a rating in excess of 50 percent for PTSD beginning October 27, 2015, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Under the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to provide notification to the Veteran with respect to establishing entitlement to benefits, and a duty to assist with development of evidence under 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012) ; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Under 38 U.S.C. § 5102 VA first has a duty to provide an appropriate claim form, instructions for completing it, and notice of information necessary to complete the claim if it is incomplete. Second, under 38 U.S.C. § 5103(a), VA has a duty to notify the claimant of the information and evidence needed to substantiate and complete a claim, i.e., existence of a current disability, the degree of disability, and the effective date of any disability benefits. The appellant must also be notified of what specific evidence he is to provide and what evidence VA will attempt to obtain. Third, VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. This includes obtaining all relevant evidence adequately identified in the record and, in some cases, affording VA examinations. 38 U.S.C. § 5103A. In Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006), the United States Court of Appeals for Veterans Claims (Court) observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. 38 U.S.C. § 5103(a). Here, letters sent to the Veteran in May 2006, October 2006, December 2009, January 2010, March 2010 and November 2012, plus additional development letters, satisfied the VCAA notice requirement for his increased rating claims because they provided the Veteran with notice that fulfills the provisions of 38 U.S.C. § 5103(a) including notice of the laws and regulations governing disability ratings and effective dates as required by the Court in Dingess. While the Veteran may not have been provided with adequate notice before all the claims were adjudicated, the Board finds that providing him with adequate notice in the above letters followed by a readjudication of the claims in the June 2017 supplemental statement of the case "cures" any timing problem associated with inadequate notice or the lack of notice prior to the initial adjudication. Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (Mayfield III), citing Mayfield II, 444 F.3d at 1333-34. Furthermore, the Veteran has had the opportunity to allege that notice in this case was less than adequate and he has not done so. See Goodwin v. Peake, 22 Vet. App. 128 (2008). VA also has a duty to assist the Veteran in the development of his claims. This duty includes assisting the Veteran in the procurement of pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all relevant facts have been properly developed and that all evidence necessary for equitable resolution of the claims has been obtained. The Veteran's service treatment records and post-service VA treatment records have been obtained and associated with the claims file and he has not indicated that there are any additional records that VA should seek to obtain on his behalf. The Veteran was most recently provided medical examinations in connection with these issues in February 2016 and October 2017. A review of the examination reports shows that they contain sufficient clinical findings and discussion of the history and features of the disabilities to constitute an adequate medical examination. Barr v. Nicholson, 21 Vet. App. 303 (2007). As the Veteran has not identified any additional evidence pertinent to his claims, and as there are no additional records to obtain, the Board concludes that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103 (a), or 38 C.F.R. § 3.159, and that the Veteran will not be prejudiced by the Board's adjudication of his claim. II. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. See 38 U.S.C.. § 1155; 38 C.F.R. Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Rating Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. See 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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, 4.3. Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board observes that the words "slight," "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." 38 C.F.R. § 4.6 (2016). It should also be noted that use of descriptive terminology such as "mild" by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 U.S.C.A. § 7104 (a) (West 2014); 38 C.F.R. §§ 4.2, 4.6. Once the evidence has been assembled, it is the Board's responsibility to evaluate the evidence. 38 U.S.C.A. § 7104 (a) (West 2014). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.. § 5107 (West 2014); 38 C.F.R. § 3.102 (2016); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). a. Tinea Versicolor The Veteran is service-connected for tinea versicolor which is rated under 38 C.F.R. § 4.118, Diagnostic Code 7806 for dermatitis or eczema. Under this code, a 10 percent rating is warranted if at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six week during the past 12-month period. A 30 percent rating requires that 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas be affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A maximum rating of 60 percent is warranted when the skin disability covers an area of more than 40 percent of the entire body or when more than 40 percent of exposed areas is affected, or; when constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. 38 C.F.R. § 4.1118, Diagnostic Code 7806. Additionally, eczema can be alternatively rated as disfigurement of the head, face or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801-7805). 38 C.F.R. § 4.118, Diagnostic Code 7806. At the outset, the Board notes that effective October 23, 2008, VA amended criteria for rating the skin so that it more clearly reflects VA's policies concerning the evaluation of scars. Specifically, these amendments concern 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 and apply to all applications for benefits received by VA on or after October 23, 2008. See, Notice, 73 Fed. Reg. 54, 708 (September 23, 2008). A Veteran previously evaluated under the previous criteria may request review under the revised criteria. Id. In the instant case, the Board notes that none of the evidence of record indicates that the Veteran's skin disability affects his head, face or neck. As such, consideration of the rating criteria based on disfigurement of the head, face or neck (Diagnostic Code 7800) under the old or new criteria is not warranted. Additionally, none of the medical evidence indicates that the Veteran's has scars from his skin disability, such that consideration of diagnostic codes for scars (Diagnostic Codes 7801-7805) under the old or new criteria is also not warranted. As such, the Veteran's skin disability is appropriate considered under the criteria of Diagnostic Code 7806 for dermatitis or eczema, which has remained unchanged. In a rating disability under this criteria, VA is required to address the frequency, duration, and outbreaks of skin disease exacerbation and to consider the skin disorder at those times when it was most disability during the relevant period. i. Prior to April 23, 2008 The Veteran was first afforded with a VA examination in connection with his tinea versicolor in September 2006, which confirmed the tinea versicolor diagnosis. During this examination, the examiner noted that condition covered approximately 8 percent of the Veteran's entire body and none of it was in the exposed area. The Veteran's tinea versicolor was treated with a topical medication only. See, September 2006 VA examination. As this medical opinion was furnished following a review of the Veteran's claims file and an in-person examination and there is no conflicting medical evidence of record, the Board has assigned this opinion with high probative value. As outlined above, in order to be entitled to an initial rating in excess of 10 percent, a 30 percent rating requires that 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas be affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12-month period and a maximum rating of 60 percent is warranted when the skin disability covers an area of more than 40 percent of the entire body or when more than 40 percent of exposed areas is affected, or; when constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. As the Veteran's skin disability did not cover more than 20 percent of the entire body, nor did it require any kind of systemic therapy such as corticosteroids or other immunosuppressive drugs at all, the Board finds that the Veteran's disability picture is more closely approximates the criteria for the assigned 10 percent rating prior to April 23, 2008. Accordingly, the Board finds that preponderance of the evidence is against a rating in excess of 10 percent prior to April 23, 2008, for tinea versicolor. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. ii. Beginning April 23, 2008 The Veteran submitted private treatment records dated April 23, 2008, which indicated that his tinea versicolor disability had worsened, specifically noting that "there is significant epidermal hyperplasia with papillomatosis and compact orthohyperkeratosis." See, April 2008 private treatment record. Following the receipt of this private treatment record, the Veteran was subsequently afforded a new VA examination in January 2010. During the Veteran's January 2010 VA examination, it was noted that the Veteran's condition had spread to his back, chest, arms, neck, back of the knees and hands, but not his head. The examiner noted that the skin lesion coverage relative to the whole body is 20% and the skin lesion coverage of the exposed area is 15%. There was no indication of any kind of systemic therapy such as corticosteroids or other immunosuppressive drugs at all. See, January 2010 VA examination. Following the January 2010 VA examination, the Veteran stated in his September 2011 VA Substantive Appeal that his tinea versicolor had continued to worsen. Accordingly, in October 2014, the Board remanded this issue to afford the Veteran with an examination in order to determine the current severity of his tinea versicolor disability. The Veteran's most recent VA examination for his tinea versicolor took place in October 2017. During this examination, the VA examiner reported that the Veteran's tinea versicolor covered approximately 20 to 40% of the Veteran's total body area, none of which was an exposed area. The skin disability was noted to be present on the chest and back. The Veteran's treatment included a topical medication, but did not include constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. See, October 2017 VA examination. As this medical opinion was furnished following a review of the Veteran's claims file and an in-person examination and there is no conflicting medical evidence of record, the Board has assigned this opinion with high probative value. As stated above, in order to be entitled to the maximum 60 percent rating for tinea versicolor, the skin disability must cover an area of more than 40 percent of the entire body or when more than 40 percent of exposed areas is affected, or; when constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. The Board notes that, beginning April 23, 2008, there is no medical evidence of record to support a rating in excess of 30 percent because the Veteran's skin disability does not cover more than 40 percent of the Veteran's body, nor does the treatment require constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. Accordingly, the Board finds that preponderance of the evidence is against a rating in excess of 30 percent beginning April 23, 2008, for tinea versicolor. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. b. PTSD The Veteran is service-connected for PTSD which is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under 38 C.F.R. § 4.130, Diagnostic Code 9411, a 30 percent rating is warranted for when there is occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted 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; the Veteran's difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability evaluation 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 work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation 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 of the Veteran to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. The use of such terminology permits consideration of items listed and other symptoms and contemplates the effect of those symptoms on the Veteran's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board acknowledges that 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." Id., at 442. In adjudicating a claim for a higher rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id., at 443. A Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, represents the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. GAF scores included in the record are a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). In this regard, the Board acknowledges that effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV, AMERICAN PSYCHIATRIC ASSOCIATION: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th Edition (1994). The amendments replace those references with references to the recently updated DSM-5, and examinations conducted pursuant to the DSM-5 do not include GAF scores. As the Veteran's increased ratings claims were in the process of adjudication prior to and during the adoption of the DSM-V, both the DMS-IV and DSM-V criteria will be utilized in the analysis set forth below. i. Prior to October 27, 2015 The Veteran was first afforded a VA examination in connection with his PTSD claim in February 2010. During this examination, the Veteran's psychiatric disability was confirmed as PTSD. The Veteran reported symptoms such as chronic sleep impairment, depressed mood, difficulty getting along with others, poor concentration, hypervigilance, and social withdrawal. While the Veteran indicated that he self isolates, he also stated that he has a good relationship with his family and with his supervisor and coworkers. Additionally, the VA examiner noted that the Veteran's hygiene was appropriate, his affect and mood was normal, his speech and communication were within normal limits, no hallucinations were present, and there were no homicidal or suicidal ideations. The VA examiner opined that the Veteran's GAF score was 60, indicating moderate symptoms. Overall, the examiner concluded that the Veteran's PTSD symptoms resulted in "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, though generally the person is functioning satisfactorily with routine self-behavior, self-care and normal conversation." See, February 2010 VA examination. As this medical opinion was furnished following a review of the Veteran's claims file and an in-person examination and there is no conflicting medical evidence of record, the Board has assigned this opinion with high probative value. As stated above, in order to be entitled to a rating of 50 percent, there must be occupational and social impairment with reduced reliability and productivity. In order to be granted a higher disability evaluation of 70 percent, occupational and social impairment with deficiencies in most areas must be shown. A 100 percent rating is warranted when there is total occupational and social impairment. The Board finds that the Veteran's 30 percent rating most appropriately approximates the Veteran's disability picture prior to October 27, 2015. Specifically, the Veteran's reported symptomatology during the February 2010 VA examination closely aligns with the criteria for a 30 percent rating, such as symptoms of depressed mood, anxiety, chronic sleep impairment, and mild memory loss resulting in occupational and social impairment with occasional decrease in work efficiency. The Veteran does not endorse the symptoms that are required to warrant a higher rating such as panic attacks more than once a week, difficulty understanding complex commands, suicidal ideations, obsessional rituals, impaired impulse control, or gross impairment in thought processes or communication, persistent delusions or hallucinations, or grossly inappropriate behavior. Additionally, while the Veteran does take medication for his PTSD, there is no evidence of record indicating any additional treatment for the Veteran's symptoms. Accordingly, the Board finds that the Veteran's overall disability picture for his PTSD prior to October 27, 2015, was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of the inability to perform occupational tasks, which is consistent with a 30 percent rating. Therefore, the Board finds that preponderance of the evidence is against a rating in excess of 30 percent prior to October 27, 2015. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.130, Diagnostic Code 9434 ii. Beginning October 27, 2015 The Veteran's next VA examination took place in October 2015. During this examination, the Veteran reported symptoms such as markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, irritable behavior, hypervigilance, problems with concentration, and chronic sleep impairment. Overall, the VA examiner opined that the Veteran's overall disability picture was manifested by occupational and social impairment due to mild or transient symptoms which decrease work effiency and ability to perform occupational tasks only during periods of significant stress. Additionally, the VA examiner noted that the Veteran was "clean and neat in appearance, pleasant and cooperative." The Veteran was also noted be alert, oriented, displaying appropriate affect, and did not pose any threat of danger or injury to self or others. See, October 2015 VA examination. The Veteran's most recent VA examination was in February 2016. During this examination, the Veteran endorsed similar symptoms as he did in October 2015, including depressed mood, anxiety, chronic sleep impairment, and mild memory loss, plus some additional symptoms such as panic attacks that occur weekly or less often, difficulty in understanding complex commands, and impaired abstract thinking and impulse control. Overall, the February 2016 VA examiner opined that the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity. As previously outlined, in order to be granted a higher disability evaluation of 70 percent, occupational and social impairment with deficiencies in most areas must be shown. A 100 percent rating is warranted when there is total occupational and social impairment. The Board finds that the Veteran is not entitled to a rating in excess of 50 percent because he does not endorse the symptoms that are required for a 70 or 100 percent rating, such as occupational and social impairment with deficiencies in most areas or total occupational and social impairment. Specifically, the Board notes that the Veteran's reported symptoms in his October 2015 and February 2016 VA examinations, such as weekly panic attacks, disturbances of motivation and mood, anxiety, chronic sleep impairment, impaired judgment, impaired abstract thinking and difficulty in establishing and maintaining effective work and social relationships more closely approximate the criteria for his current rating of 50 percent disability beginning October 27, 2015. The Board also notes that the conclusions in the October 2015 and February 2016 VA examinations were rendered following a review of the Veteran's claims file, an in-person examination, and are not contradicted by other conflicting medical evidence of record. Therefore, the Board has assigned those opinions with high probative value. Overall, the Board finds that the preponderance of the evidence of record is against a rating in excess of 50 percent beginning October 27, 2015. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.130, Diagnostic Code 9434 ORDER Entitlement to an initial rating in excess of 10 percent prior to April 23, 2008, for tinea versicolor is denied. Entitlement to a rating in excess of 30 percent beginning April 23, 2008, for tinea versicolor is denied. Entitlement to an initial rating in excess of 30 percent prior to October 27, 2015 for PTSD is denied. Entitlement to a rating in excess of 50 percent beginning October 27, 2015, for PTSD is denied. REMAND While the Board sincerely regrets further delay, additional development is required before the Veteran's remaining claims may be adjudicated on the merits. a. Hypertension The Veteran has asserted that he believes that his hypertension may be secondary to his exposure to Agent Orange during his service in the Republic of Vietnam. With respect to whether or not the Veteran's hypertension is secondary to his Agent Orange exposure, the Board notes that hypertension is not listed as a disease associated with herbicide exposure under 38 C.F.R. § 3.309(e)(2017), the National Academy of Sciences Institute of Medicine (NAS) has concluded that there is "limited or suggestive evidence of an association" between herbicide exposure and hypertension. See, 77 Fed. Reg. 47924, 47926-927 (Aug. 10, 2012). Alternatively, the Board notes that the Veteran was service connected for Diabetes Mellitus in December 2015. To support his claim for service connection for Diabetes Mellitus, the Veteran submitted a private medical Disability Benefits Questionnaire (DBQ) dated September 2014. On this DBQ, the Veteran's private physician indicated that the Veteran's current hypertension is at least as likely as not related to the Veteran's diabetes mellitus, but no supporting opinion was provided. See, September 2014 private DBQ. In this regard, the Board notes that it has an obligation to consider all reasonably raised theories of entitlement to service connection, even if not specifically raised by the claimant. Douglas v. Derwinski, 2 Vet. App. 435 (1992). In the context of a service connection claim, theories of entitlement such as direct service connection, secondary service connection and presumptive service connection are deemed as part of the appeal regardless of when the issue has been raised in the record. Accordingly, the Board finds that the issue of entitlement to service connection for hypertension to include as secondary to service connection diabetes mellitus has been raised and must be considered. To date, the Veteran has not been afforded a VA examination for his claim for entitlement to service connection for hypertension. Given that the Veteran has a current disability and that the evidence of record does not contain sufficient competent medical evidence to decide the Veteran's service-connection claim to include as secondary to Agent Orange exposure and as secondary to diabetes mellitus, a VA medical examination is necessary to determine the nature and etiology of his hypertension. 38 C.F.R. § 3.159(c)(4)(2017); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). b. Left Knee Disability The Veteran asserts that he is entitled to a rating in excess of 10 percent for residuals of a torn ligament, left knee, and for a rating in excess of 10 percent for instability. The Board notes that while the Veteran's claim was pending, a precentral decision was issued that requires the Veteran's claim to be remanded. The United States Court of Appeals for Veterans Claims (Court) recent holding in Sharp v. Shulkin, 29 Vet. App. 26 (2017) also requires that the claim be remanded. In Sharp, the Court noted that for a joint examination to be adequate, the examiner "must express an opinion on whether pain could significantly limit" a veteran's functional ability, and that determination "should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. " Furthermore, the Court stated that the examiner must "obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment [resulting from flare-ups] from the veterans themselves." Sharp, 29 Vet. App. at 34. The examiner must also "offer flare opinions based on estimates derived from information procured from relevant sources, including the lay statements of veterans," and the examiner's determination "should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id. at 10. The Veteran's last VA examination for his left knee in October 2015 does not provide an opinion regarding flare-ups, and instead merely states that the examiner is "unable to say without mere speculation" as to whether or not pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups. Accordingly, a remand is warranted for an addendum opinion regarding the Veteran's reported flare-ups. c. TDIU The Board notes that the Veteran's claim for a TDIU is inextricably intertwined with his increased rating claim which remain appeal, as the Veteran has specifically stated that it is his left knee that makes him unable to work. Accordingly, the Board will therefore defer any action with respect to this claim until the completion of the development noted above. Accordingly, the case is REMANDED for the following action: 1. Obtain any outstanding VA and private treatment records and associate them with the Veteran's claims file. 2. Once any outstanding records have been received, schedule the Veteran for VA examination in connection with his claim for service connection for hypertension with the appropriate medical personnel. With respect to the Veteran's claim for entitlement to an increased rating for his left knee disability, return the Veteran's claims file to the October 2015 VA examiner for an addendum opinion. If that examiner is not available, an addendum opinion should be obtained from the appropriate medical personnel. The Veteran's claims file, to include a copy of this remand, should be provided to the examiner. Following a complete review of the record, the examiner who is examining the Veteran for hypertension is asked to provide the following opinions: a. Whether the Veteran's hypertension is due to his military service, to include herbicide exposure. This opinion should include consideration of the Veteran's presumed exposure to certain herbicide agents, such as Agent Orange, as the NAS has concluded that there is "limited or suggestive evidence of an association" between herbicide exposure and hypertension. b. Whether the Veteran's hypertension is caused or aggravated by his service-connected diabetes mellitus. This opinion should include consideration of the September 2014 private DBQ in which the Veteran's private physician indicates that it is at least as likely as not that the Veteran's service-connected diabetes mellitus caused his hypertension. For the Veteran's increased rating for his left knee disability, the October 2015 VA examiner is asked to provide an addendum opinion addressing the following: a. Whether there would be additional functional impairment on repeated use or during flare-ups. The examiner should further assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. The examiner should consider all procurable and assembled data by obtaining all tests and records that might reasonably illuminate the medical analysis. This includes the Veteran's statements regarding the extent of functional loss during any flare-ups. b. A functional assessment of the impact of the Veteran's service-connected disabilities on his ability to secure or follow a substantially gainful employment consistent with his education and occupational experience, and without consideration of his age or any nonservice-connected disabilities. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicated this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 3. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issue on appeal. If any benefits sought on appeal remain denied, in whole or in part, the Veteran should be provided with a Supplemental Statement of the Case, afforded a reasonable opportunity to respond, and the case should then be returned to the Board for further appellate review, if otherwise in order. 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.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Michael J. Skaltsounis Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs