Citation Nr: 18142210 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 15-03 679 DATE: October 15, 2018 ORDER For the entire period on appeal, an initial rating of 70 percent for posttraumatic stress disorder (PTSD) is granted, subject to the laws and regulations governing the payment of monetary benefits. For the entire period on appeal, a total disability rating based on individual unemployability (TDIU) is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to an initial rating in excess of 70 percent for PTSD is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for sleep apnea, including as secondary to service-connected PTSD, is remanded. Entitlement to recognition of D.S. as the helpless child of the Veteran on the basis of permanent incapacity for self-support prior to attaining the age of 18 is remanded. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran’s PTSD symptoms most nearly approximate occupational and social impairment with deficiencies in most areas, such as work, school, family, relations, judgment, thinking, or mood. 2. For the entire period on appeal, the Veteran’s service-connected disabilities rendered him unable to obtain and maintain substantially gainful employment consistent with his educational and occupational background. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 70 percent for PTSD are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2017). 2. For the entire period on appeal, the criteria to establish a TDIU are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.1, 4.3, 4.16, 4.25 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from March 1966 to January 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from multiple rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In a June 2011 rating decision, the RO denied entitlement to service connection for sleep apnea and erectile dysfunction. In a December 2011 rating decision, the RO, in pertinent part, awarded service connection for PTSD and assigned a 30 percent initial rating, effective February 9, 2009. In an April 2014 rating decision, the RO denied entitlement to a TDIU and recognition of D. as the helpless child of the Veteran on the basis of permanent incapacity for self-support prior to attaining the age of 18. In a December 2014 rating decision, the RO increased the rating for PTSD from 30 percent to 50 percent, effective November 18, 2013. Because less than the maximum available benefit for a schedular rating was awarded and to the extent that the increase was not awarded for the entirety of the claims period, the claim remains before the Board. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35 (1993). In a February 2015 rating decision, the RO denied entitlement to service connection for residuals of traumatic brain injury (TBI). The Veteran filed a notice of disagreement and VA issued a statement of the case in August 2018. As no substantive appeal has been received as of the date of this decision, it is not in appellate status. The Board does not have jurisdiction over this issue and will not address it herein. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Rating Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1 (2017); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. It is the Board’s responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran is competent to testify on factual matters of which he or she has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). The Veteran is competent to provide evidence of observable symptoms, including pain. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). See also Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, the current diagnosis, and the demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the Veteran. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). In doing so, equal weight is not accorded to each piece of evidence in the record as every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert, 1 Vet. App. at 53; see also 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. Entitlement to an initial rating in excess of 30 percent for PTSD prior to November 18, 2013, and in excess of 50 percent thereafter. The Veteran is currently in receipt of a 30 percent rating for PTSD prior to November 18, 2013, and a 50 percent rating thereafter, under 38 C.F.R. § 4.130, DC 9411 (2017). He contends that a higher rating is warranted throughout the initial rating period on appeal. All psychiatric disabilities are evaluated under a general rating formula for mental disorders. 38 C.F.R. § 4.130. Under such formula, a 30 percent rating is warranted for occupational and social impairment with 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 de-pressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. A 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, 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 an 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); and inability to establish and maintain effective relationships. A total schedular rating of 100 percent is warranted when the disorder results in 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 mental and personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. In applying the above criteria, the Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102 (2017); Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so). Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term “psychosis” to remove outdated references to the DSM-IV and replace them with references to the updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction on or after August 4, 2014. Id. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014. See 80 Fed. Reg. 53, 14308 (March 19, 2015). Here, the RO certified the Veteran’s appeal to the Board after August 4, 2014; therefore, the PTSD claim is governed by DSM 5 and the Global Assessment of Functioning (GAF) scores are not relevant for consideration. See Golden v. Shulkin, 29 Vet. App. 221, 225-26 (2018). When evaluating mental health disorders, the factors listed in the Rating Schedule are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; the analysis should not be limited solely to whether a veteran exhibited the symptoms listed in the Rating Schedule. Rather, the determination should be based on all of a veteran’s symptoms affecting his level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The lists of symptoms under the Rating Schedule are meant to be examples of symptoms that would warrant the disability evaluation, but are not meant to be exhaustive. Id. After a review of the evidence, both lay and medical, the Board finds that the Veteran’s PTSD symptoms have most nearly approximated occupational and social impairment with deficiencies in most areas for the entire period on appeal. The evidence reflect that the Veteran has a history of suicidal ideations. See March 1982, March 1983, and April 1983 private treatment records and September 2009 and September 2010 VA treatment records. In addition, the evidence reflects that the Veteran PTSD manifested in impaired impulse control with unprovoked irritability and periods of violence. A January 1982 treatment record indicated that the Veteran had a short temper and had problems at work because he did not get along with authority figures. A March 1982 treatment record indicated that the Veteran had recently lost his temper, hit his wife with an open hand, and hit the wall hard enough to create a hole. A March 1983 treatment record indicated that the Veteran put his fist through his windshield. A March 2009 VA treatment record indicted that the Veteran felt angry and irritable. He reported that he sometimes had to go in a different room at his house to watch television and cool off because his wife had aggravated him in some way. A November 2009 VA treatment record indicated the Veteran experienced intense anger, leading to him punching holes in house walls and being verbally loud at times. A September 2010 VA treatment record indicated that the Veteran had a history of irritability and felt like he had a very short fuse. A December 2012 treatment record indicated that the Veteran would lose his temper suddenly and with minimal provocation, leading to his striking his wife or breaking objects. The evidence also reflects that the Veteran’s PTSD has resulted in symptoms of depressed mood, suspiciousness, chronic sleep impairment, anxiety, memory loss, disturbances of motivation and mood, impaired memory, impaired judgment, poor concentration, speech intermittently illogical, obscure, and irrelevant, obsessional rituals, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. See July 2011 and November 2013 VA examination reports, and March 1982, December 1982, March 2009, September 2010, and July 2011 VA treatment records. For these reasons, the Board finds that the Veteran’s PTSD symptoms more nearly approximated occupational and social impairment with deficiencies in most areas throughout the rating period on appeal. For these reasons, the Board finds that the Veteran’s PTSD symptoms more nearly approximate the criteria under DC 9411 for a rating of 70 percent for the entire initial rating period on appeal. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 4.3, 4.7, 4.130. The issue of entitlement to an initial rating in excess of 70 percent for PTSD is addressed in the remand section, below. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Entitlement to a TDIU. It is the established policy of VA that all veterans who are unable to secure and maintain substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. §§ 3.340(a)(1), 4.15. Controlling laws provide that a TDIU may be assigned when a veteran has one service-connected disability rated at 60 percent or more, or two or more service-connected disabilities where at least one disability is rated at 40 percent or more and the combined rating is at least 70 percent. 38 C.F.R. § 4.16(a). The record must also show that the service-connected disabilities alone result in such impairment of mind or body that the average person would be precluded from securing or maintaining a substantially gainful occupation. Id. The Veteran in this case met the schedular percentage requirements for a TDIU, as of February 2, 2009, as he was in receipt of service connection for PTSD, rated 70 percent disabling from February 2, 2009; tinea versicolor of the namuum and pedis with onychomycosis, rated 30 percent disabling from February 9, 1976; benign growths of the skin, rated 30 percent disabling from July 2, 1974 to May 31, 1984, and 10 percent disabling thereafter; and bilateral hearing loss, rated 10 percent disabling from September 29, 2009. The remaining question is whether these service-connected disabilities preclude the Veteran from securing and following a substantially gainful occupation. See 38 C.F.R. § 4.16(a). The fact that a veteran is unemployed or has difficulty finding employment does not alone warrant assignment of a TDIU, as a high rating itself establishes that his disability makes it difficult for him to obtain and maintain employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Rather, the evidence must show that she is incapable “of performing the physical and mental acts required” to be employed. Id. at 363. Thus, the central question is whether a veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability, and not whether a veteran could find employment. Id. Consideration may be given to a veteran’s education, training, and special work experience, but not to her age or to impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2017). In Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013), the Federal Circuit held that, when a veteran is claiming TDIU based upon the combined effects of multiple service-connected disabilities, VA’s duty to assist “does not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities.” See also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011) (VA is not required to obtain an industrial survey from a vocational expert before making a TDIU determination but may choose to do so in an appropriate case). Although VA must give full consideration, per 38 C.F.R. § 4.15, to “the effect of combinations of disability,” VA regulations place responsibility for the ultimate TDIU determination on VA adjudicators, not a medical examiner’s opinion. Geib, 733 F.3d at 1354; see also 38 C.F.R. § 4.16(a). The ultimate issue of whether TDIU should be awarded is not a medical issue, but rather is a determination for the VA adjudicator. See Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator), rev’d on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). There is no regulatory definition of “substantially gainful employment.” 38 C.F.R. § 4.16(a) provides guidance in that it states: “Marginal employment shall not be considered gainful employment.” It also says definitively that marginal employment exists when a veteran’s earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. 38 C.F.R. § 4.16(a). The Veteran’s DD-214 indicates that he served on active duty for almost two years. His military occupational specialty was communications technician. In October 2012, the Veteran submitted VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. He stated that he last worked full-time in 1997 and became too disabled to work in 1997. He stated that his PTSD prevented him from securing or following any substantially gainful employment. In addition, the Veteran indicated that he had worked full-time from 2000 to 2006 in sales marketing. The Veteran had completed four years of college. He majored in journalism and worked in that field for approximately 30 years. He had training in journalism, news, and marketing. The Veteran stated that he was unable to maintain substantially gainful employment because he is reclusive, confrontational, untrusting, and had been terminated from every prior job. In an attached statement, the Veteran stated that he worked in the field of broadcast journalism for nearly three decades. He used VA vocational rehabilitation benefits to enter and graduate from Columbia Broadcasting school, as well as to attend about seven colleges and universities while working. He had been fired from every job he had as a broadcast journalist. He had physical and verbal confrontations with fellow broadcast employees and especially with supervisors to whom he reported. He stated that he “received virtually every local, regional and national news award available,” including many prestigious awards. The Veteran gave up trying to work in broadcasting or anywhere else in 1999. Thereafter, he did some independent writing assignments from time-to-time. The Veteran contends that his sporadic work history and reputation as a confrontational employee made it impossible for him to obtain and maintain substantially gainful employment. He is currently supplementing his income by advertising on Craigslist as a “professional writer,” but indicated that inquiries were very few and far between. After a review of all the evidence of record, lay and medical, the Board finds that the Veteran has been unable to secure or maintain substantially gainful employment due to his service-connected PTSD for the entire period on appeal. A March 1982 treatment record indicated that the Veteran had a short temper, did not get along with authority, and was having problems at work. A March 2009 VA treatment record indicated that the Veteran reported having chronic difficulties keeping work, despite winning numerous awards. He had chronic confrontations at work sites and would be unable to keep his job. The July 2011 VA examiner opined that the Veteran’s PTSD symptoms, including poor concentration, speech intermittently illogical, obscure, and irrelevant, and weak interpersonal skills, would result in marked difficulty sustaining employment. The VA examiner specifically noted that the Veteran had been terminated from jobs on at least 12 occasions and had not sustained gainful employment since 1999 for fear of additional terminations. In addition, the Veteran reported during the July 2011 VA examination that he was convicted of destruction of property (a felony) in 1970 when, after becoming increasingly frustrated that his employer was not paying him in what he perceived to be a timely fashion, he returned to the facility after hours, “got drunk and just trashed the place.” In addition, a July 2011 VA treatment record indicated that the Veteran reported memory loss for immediate and recent information, including fairly simple tasks such as recalling his own address and the date. The Veteran has also submitted numerous statements from former co-workers. In April 1983, the Veteran’s co-worker, C.B., stated that the Veteran had recently been demoted. C.B. described an incident he witnessed in which the Veteran, without provocation, launched into a verbal attack on another employee that continued for five minutes. C.B. stated that the Veteran appeared to be enraged and out of control. The Veteran appeared to be close to hitting the employee several times. When C.B. tried to intervene, the Veteran turned on him and “continued to act like a mad man.” The Veteran stormed out of the office while screaming obscenities. As a result of this incident, the Veteran was demoted and C.B. indicated that he understood the Veteran would have been terminated had it not been for the medical problems the Veteran experienced between the time of the incident and the time the action was made in the case some two weeks later. C.B. stated that the Veteran seemed to have alienated himself from everyone at work, despite their concern for him. For these reasons, the functional impact of his service-connected PTSD has rendered him unable to obtain and maintain substantially gainful employment for the entire period on appeal. Indeed, given the significant impact of his service-connected PTSD on the Veteran’s ability to function in a work setting and interact with co-workers and authority figures, the weight of the evidence supports a finding that his service-connected PTSD precluded him from obtaining and maintaining substantially gainful employment for the entire period on appeal. The Board found the July 2011 VA examiner’s opinion, as well as the Veteran’s numerous terminations and demotions due to his PTSD symptoms, to be highly probative evidence that the Veteran’s PTSD symptoms rendered him unable to maintain substantially gainful employment, despite his education and many awards. Therefore, as the competent and credible evidence is in favor of a finding of unemployability due to the service-connected PTSD, entitlement to a TDIU is warranted for the entire period on appeal. REASONS FOR REMAND 1. Entitlement to an initial rating in excess of 70 percent for PTSD is remanded. The record reflects that pertinent VA-generated evidence has been added to the claims file since the claim was last adjudicated in the December 2014 statement of the case (SOC). In this regard, VA treatment records were added to the record in February 2015, after the December 2014 SOC, and a supplemental statement of the case (SSOC) was not issued with consideration of this new evidence. As there is no indication that the Veteran has specifically waived initial AOJ adjudication of the new evidence, a remand is also required for the AOJ to consider it in a SSOC. 2. Entitlement to service connection for erectile dysfunction is remanded. Once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was afforded a VA examination in November 2013. Therefore, the VA examiner concluded that it is less likely than not that the Veteran’s erectile dysfunction is secondary to PTSD. The VA examiner explained that there are no available medical records indicating that erectile dysfunction is secondary to PTSD. The examiner noted that pathophysiologically, many factors both physical and psychological, can affect erectile function. This opinion is inadequate because the VA examiner did not provide a sufficient explanation as to why, of the many factors affecting erectile function, the Veteran’s PTSD is not the cause of his erectile dysfunction. In addition, the VA examiner did not address whether the medications the Veteran was prescribed for treatment of PTSD caused his current erectile dysfunction, despite the Veteran’s submission in July 2011 of an article regarding sexual dysfunction in male PTSD patients. Finally, the VA examiner did not address the significance of the Veteran’s documented treatments for penile conditions during service, including urinary inflammation, and bacterial urethritis. For these reasons, remand is necessary to obtain an adequate opinion as to the etiology of the Veteran’s current erectile dysfunction. 3. Entitlement to service connection for obstructive sleep apnea is remanded. The Veteran was afforded a VA examination in November 2013 and the examiner opined that the Veteran’s obstructive sleep apnea is less likely than not related to the service-connected PTSD. However, the examination is inadequate as the examiner did not provide an opinion as to whether the Veteran’s sleep apnea has been aggravated by his service-connected PTSD. In addition, the VA examiner did not discuss the relevance, if any, of the articles the Veteran submitted in July 2011 regarding a link between PTSD and sleep apnea. For these reasons, remand is necessary to obtain an adequate medical opinion that addresses the etiology of the Veteran’s diagnosed sleep apnea. 4. Entitlement to recognition of D.S. as the helpless child of the Veteran on the basis of permanent incapacity for self-support prior to attaining the age of 18 is remanded. A February 2011 treatment record indicated that D.S. had applied for disability. As such records may be pertinent to the present claim, D.S.’s complete Social Security Administration (SSA) records, if available, should be obtained and associated with the claims file. See Murincsak v. Derwinski, 2 Vet. App. 363, 370-72 (1992); Collier v. Derwinski, 1 Vet. App. 413, 417 (1991); see also Quartuccio v. Principi, 16 Vet. App. 183, 187-88 (2002) (stating that “the possibility that the SSA records could contain relevant evidence... cannot be foreclosed absent a review of those records.”). The matter is REMANDED for the following action: 1. Obtain and associate with the claims folder the Veteran’s updated VA treatment records. 2. Obtain from SSA, any and all records pertaining to a claim for disability benefits for the Veteran’s daughter, D.S. The requested records should include copies of all medical records considered in deciding any SSA disability claim. If the records are not available, that should be documented in the record. 3. Obtain an addendum medical opinion from the VA examiner who conducted the November 2013 VA examination, or a suitable substitute, as to the etiology of the Veteran’s sleep apnea. The claims file must be made available to and reviewed by the examiner. *The need for another examination is left to the discretion of the examiner. After review of the claims file, the examiner is asked to: Provide an opinion as to whether it is at least as likely as not that the Veteran’s sleep apnea was caused or AGGRAVATED by the Veteran’s service-connected disabilities, to include PTSD. In doing so, the examiner is asked to consider all evidence of record, to include the articles submitted by the Veteran in July 2011 regarding a connection between PTSD and sleep apnea. A complete rationale for all opinions expressed must be provided. 4. Obtain an addendum medical opinion from the VA examiner who conducted the November 2013 VA examination, or a suitable substitute, as to the etiology of the Veteran’s erectile dysfunction. The claims file must be made available to and reviewed by the examiner. *The need for another examination is left to the discretion of the examiner. After review of the claims file, the examiner is asked to provide the following opinions: (a) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s current erectile dysfunction is related to the penile conditions he was diagnosed with and treated for during service? (b) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s erectile dysfunction was AGGRAVATED by his service-connected PTSD, to include any medications prescribed for the treatment of PTSD? In making these opinions, the examiner’s attention is called to the following evidence: **A September 1956 service treatment record (STR) indicating that the Veteran experienced burning when he urinates, but did not have a urethral discharge. An impression of urinary inflammation was noted. **An April 1967 STR indicating that the Veteran complained of penile discharge for three days. **A May 1967 STR indicating the Veteran complained of burning urination for one week and had venereal warts. **A June 1967 STR indicating the Veteran still had a burning sensation with urination. **A September 1967 STR indicating the Veteran complained of warts on his groin area. He said they were getting bigger and spreading. He also experienced burning while urinating. Venereal warts were present on the shaft and base of the penis. **An October 1967 STR indicated the Veteran complained of a burning sensation when urinating and a physical urethral drip for one week. Bacterial urethritis was noted. **The articles submitted by the Veteran in July 2011 regarding a link between PTSD treatment and erectile dysfunction. A complete rationale for all opinions expressed must be provided. 5. Then, readjudicate the remanded issues on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Thomas, Associate Counsel