Citation Nr: 18142220 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 15-13 473 DATE: October 15, 2018 ORDER The application to reopen the claim of entitlement to service connection for spondylolisthesis of L-5 sacrum (claimed as a back condition) is granted. The application to reopen the claim of entitlement to service connection for a stomach condition is denied. Entitlement to service connection for a left knee disability (claimed as left knee condition) is denied. Entitlement to service connection for a right knee disability (claimed as right knee condition), to include arthritis, is denied. Entitlement to service connection for residuals of a traumatic brain injury (TBI) is denied. Entitlement to a compensable rating for bilateral hearing loss is denied. Entitlement to a compensable rating for hemorrhoids prior to July 7, 2017, and an increased rating in excess of 10 percent thereafter is denied. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with depression and anxiety is denied. REMANDED Entitlement to service connection for diabetes mellitus, type II associated with PTSD with depression and anxiety, is remanded. Entitlement to service connection for spondylolisthesis of L-5 sacrum is remanded. Entitlement to service connection for drug and alcohol abuse associated with PTSD with depression and anxiety, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. In September 2002, the Board of Veterans’ Appeals (Board) denied the claim of entitlement to service connection for spondylolisthesis of L-5 sacrum, claimed as a back condition. The Veteran did not appeal this decision to the United States Court of Appeals for Veterans Claims (Court) and it became final. 2. The additional evidence received since the September 2002 Board decision relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for spondylolisthesis of L-5 sacrum. 3. In January 2002, the Regional Office (RO) denied the claim of entitlement to service connection for a stomach condition. The Veteran did not appeal this decision and it became final. 4. The additional evidence received since the January 2002 rating decision does not relate to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a stomach condition. 5. The Veteran’s left knee disability, to include arthritis, did not manifest to a compensable degree within the applicable presumptive period and is not otherwise etiologically related to an in-service injury, event, or disease. 6. The Veteran’s right knee disability, to include arthritis, did not manifest to a compensable degree within the applicable presumptive period and is not otherwise etiologically related to an in-service injury, event, or disease. 7. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of residuals of a TBI. 8. During the period on appeal, the Veteran’s hearing loss has been manifested by a Level I hearing loss in both his right and left ears. 9. Prior to July 7, 2017, the Veteran’s hemorrhoids manifested as mild or moderate. 10. Since July 7, 2017, the Veteran’s hemorrhoids has not been manifested as internal or external hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. 11. Throughout the period on appeal, the Veteran’s PTSD has manifested by symptoms which most closely approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as depressed mood, chronic sleep impairment, suspiciousness and mild memory loss. CONCLUSIONS OF LAW 1. The September 2002 Board of Veterans Appeals decision which denied the Veteran’s claim of entitlement to service connection for spondylolisthesis of L-5 sacrum is final. 38 U.S.C. § 7104 (2012); 38 C.F.R. §20.1100 (2017). 2. The criteria for reopening a claim of entitlement to service connection for spondylolisthesis of L-5 have been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The January 2002 rating decision which denied the Veteran’s claim of entitlement to service connection for a stomach disability is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2017). 4. The criteria for reopening a claim of entitlement to service connection for a stomach disability have not been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 5. The criteria for service connection for a left knee disability are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 6. The criteria for service connection for a right knee disability, to include arthritis, are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 7. The criteria for service connection for residuals of a TBI have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. § 3.303. 8. The criteria for a compensable rating for bilateral hearing loss have not been met at any time. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100 (2017). 9. The criteria for a compensable rating for hemorrhoids prior to July 7, 2017, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.97, Diagnostic Code 7336 (2017). 10. Since July 7, 2017, the criteria for a rating in excess of 10 percent for hemorrhoids have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.97, Diagnostic Code 7336 (2017). 11. The criteria for an initial rating in excess of 30 percent for PTSD with depression and anxiety have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1964 to June 1964 and from February 1968 to October 1969. This matter was previously before the Board in April 2017, at which time it was remanded for further development. New and Material Generally, if a claim of entitlement to service connection has been previously denied and that decision has become final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108. New evidence is defined as existing evidence not previously submitted to agency decisionmakers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative, nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In Shade v. Shinseki, 24 Vet. App. 110, 118 (2010), the Court stated that when determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Thus, pursuant to Shade, evidence is new if it has not been previously submitted to agency decision makers and is material if, when considered with the evidence of record, it would at least trigger VA’s duty to assist. Id. VA must review all the evidence submitted since the last final rating decision to determine whether the claim may be reopened. See Hickson v. West, 12 Vet. App. 247, 251 (1999). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). 1. New and material evidence that is sufficient to reopen the Veteran’s claim for service connection for spondylolisthesis L-5 sacrum has been submitted. The Veteran’s claim of entitlement to service connection for spondylolisthesis L-5 sacrum was denied in a September 2002 Board of Veteran’s Appeals decision. The Veteran did not appeal this decision to the Court, nor was any relevant evidence received within one year of the decision; therefore, the decision is final. See 38 U.S.C. § 7104 (2012); 38 C.F.R. § 20.1100 (2017). Service connection for spondylolisthesis L-5 sacrum was denied because there was no evidence establishing that the Veteran’s back disability was related to his time in service. The evidence considered at the time of the September 2002 Board decision included service treatment records (STRs), a private medical opinion, private medical records and VA treatment records. Upon review of the record, the Board finds that new and material evidence has been received to reopen the claim of entitlement to service connection for spondylolisthesis L-5 sacrum. The evidence added to the record since the September 2002 Board decision includes a VA opinion, VA medical records, lay statements, VA examinations, and private medical records. This evidence is “new,” in that it was not previously submitted to agency decision makers, and it is material because it relates to the basis of denial of the original claim. More specifically, the lay statements submitted on behalf of the Veteran raise a reasonable possibility of substantiating the claim. Accordingly, the claim for service connection for spondylolisthesis L-5 sacrum is reopened. See Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). The appeal is granted to that extent only. 2. New and material evidence that is sufficient to reopen the Veteran’s claim for service connection for a stomach condition has not been submitted. The Veteran’s claim of entitlement to service connection for a stomach condition was denied in a January 2002 rating decision which became final. After careful review of the evidence of record, the Board finds that new and material evidence has not been received. Evidence added to the record since the January 2002 rating decision includes private and VA medical treatment records. The recently received medical treatment records do not reflect treatment for the Veteran’s claimed stomach condition. While this medical evidence is “new” as it was not previously submitted to agency decisionmakers, it is not material because it does not relate to an unestablished fact necessary to substantiate the claim. Here, the recently received medical treatment records do not reflect a diagnosis of a stomach disability that is related to the Veteran’s time in service. As the new evidence submitted is not material, the claim for service connection for a stomach condition is not reopened, and the current appeal on this issue is denied on that basis. See 38 U.S.C. § 5108. Although the threshold to reopen is low, such threshold is not met in this case. See Shade, 24 Vet. App. at 118. The benefit-of-the-doubt doctrine is therefore not for application. Annoni v. Brown, 5 Vet. App. 463, 467 (1993) (the benefit-of-the-doubt doctrine is not applicable to applications to reopen unless the threshold burden of submitting new and material evidence has been met). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be “competent”. However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination “medical in nature” and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year (three years for active tuberculous disease and Hansen’s disease; seven years for multiple sclerosis) from the date of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term “chronic disease” refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. 3. Entitlement to service connection for a left knee condition is denied. The Veteran is seeking service connection for a left knee condition. The Veteran’s service treatment records are negative for symptoms involving his left knee as well as for a left knee injury. VA treatment records show that a September 2010 MRI of the left knee revealed a small degenerative tear at the posterior medical meniscus. The Veteran was treated for complaints of left knee pain from September 2010 through September 2011. In January 2014, the Veteran was seen for complaints of bilateral knee pain. The Veteran underwent a VA knee examination in September 2015. The examiner noted the Veteran’s left knee arthritis, diagnosed in November 2013. The Veteran reported that he may have hurt his left knee in an incident in service in which he was climbing up and down a ladder. The Veteran reported that he did not experience left knee pain until about one year prior. He stated that he had an MRI of his left knee but had not received any treatment for the left knee. He did not report experiencing any significant pain on the left knee. The examiner determined that it was less likely than not that the Veteran’s left knee disability was caused by his job duties performed as a heavy equipment operator in service. The examiner noted that there is no record of a left knee injury or treatment for left knee symptoms until September 2010. At that time, the Veteran reported he had been in a motor vehicle accident one year prior to that date and had not experienced any left knee problems prior to the accident. In sum, the September 2015 VA examiner opined that the Veteran’s claimed left knee disability is not at least as likely as not related to an in-service injury, event, or disease, including as due to his work heavy equipment operator in service. The rationale was there is no evidence in the Veteran’s available treatment records of a left knee injury in service. The examiner noted that the Veteran did not seek treatment for left knee symptoms until 2010, at which time he stated he had not experienced any knee problems prior to a motor vehicle accident which occurred one year prior. The Board finds that the examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the Veteran is competent to report having experienced symptoms of left knee pain, he not competent to provide a diagnosis of an orthopedic knee disability which requires specialized training and testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The continuity of the left knee disability is not established. The medical evidence of record shows that the Veteran first sought treatment for complaints of left knee pain in 2010, some 41 years after his discharge from service. The Veteran submitted an application for compensation for a back disability in 1999, but did not claim any problems with his knees at that time. In May 2003, he submitted a claim for an increased rating for bilateral hearing loss. Again, he did not submit a claim pertaining to his left knee. The Veteran submitted his initial claim for compensation for his left knee in April 2015. The Veteran did not inform the examiner who conducted the September 2015 examination that he had injured his knee in an automobile accident in or about 2009. After a thorough review of the Veteran’s medical records and performing a physical examination of the Veteran, the examiner determined that it was less likely than not that the Veteran’s left knee disability was due to his in-service duties as a heavy equipment operator. Therefore, the Board places reduced probative value on the Veteran’s assertions that his left knee disability is related to his time in service. Moreover, the Veteran’s STRs and post-service medical records show that his left knee disability, diagnosed as osteoarthritis at the September 2015 VA examination, which is a “chronic disease” for disability compensation purposes, did not manifest during service or within one year following his discharge from service. 38 C.F.R. § 3.309(a). The first indication of left knee symptoms was in 2010, which is 41 years after the Veteran’s discharge from service. Thus, service connection is not available under the “chronic disease” provisions. 38 C.F.R. § 3.309. The Board concludes that, while the Veteran has current diagnosis of a left knee disability, the preponderance of the evidence weighs against finding that the Veteran’s diagnosed left knee disability began during service or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. §§ 3.303(a), (d), 3.307, 3.309. Accordingly, service connection for a left knee disability is not warranted. In reaching this conclusion, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran’s claim for service connection for a left knee disability the doctrine is not applicable. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). 4. Entitlement to service connection for a right knee condition to include arthritis The Veteran is seeking service connection for a right knee condition, to include arthritis. The Veteran’s STRs are negative for symptoms involving his right knee as well as for a right knee injury. VA treatment records show that in October 2010 the Veteran sought treatment for complaints of right-sided medial knee pain. He again reported that he had a car accident approximately one year prior and had been having problems with his knees ever since. The clinician noted that an MRI of the Veteran’s right knee “showed good joint space both medial and lateral compartment on the right, as well as good patellofemoral compartment. MRI does show a lateral meniscus tear.” Veteran continued to seek treatment for right knee pain through January 2014. The Veteran underwent a VA knee examination in September 2015. The examiner noted the Veteran’s right knee arthritis, diagnosed in October 2010. The Veteran reported that he was a heavy equipment operator with a lot of climbing up and down a ladder “when in 1968 was changing a scraper when he felt something tear in his right knee with pain that has been going on since.” He stated that he did not have his knee evaluated at that time. He reported that his right knee pain got worse in 2009 and he received three injections of Synvisc without improvement. He reported that his right knee was sensitive in the joint and all over the surface. The examiner determined that it was less likely than not that the Veteran’s right knee degenerative joint disease was incurred in service or was caused by the job duties the Veteran performed as a heavy equipment operator. The examiner noted that there is no record of an injury to either knee during service and no evaluation or treatment on record until September 2010. In October 2010, the Veteran complained of right knee pain which he reported started after a motor vehicle accident one year prior. The examiner noted that the medical records indicate the Veteran reported having a motor vehicle accident one year earlier, and had problems with both knees since the accident. The examiner noted that mild degenerative changes were observed on the right knee in the October 2010 MRI and moderate arthritis of the right knee was noted on a November 2013 MRI. The examiner further opined that if the “right knee condition with arthritis was caused by repetitive use of his knees (going up and down ladders) in late 1960 on would expect symmetrical involvement of both knees and that there would be more than mild degenerative change in the left knee after 55 years.” In sum, the September 2015 VA examiner opined that the Veteran’s claimed right knee disability, to include arthritis, is not at least as likely as not related to an in-service injury, event, or disease, including as due to his work heavy equipment operator in service. The rationale was there is no evidence in the Veteran’s available treatment records of a right knee injury in service, and no record of treatment for right knee pain until 2010, some 41 years subsequent to the Veteran’s separation from service. In 2010, the Veteran stated he had not experienced any knee problems prior to a motor vehicle accident which occurred one year earlier. The Board finds that the examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the Veteran is competent to report having experienced symptoms of right knee arthritis, he is not competent to provide a diagnosis of an orthopedic knee disability which requires specialized training and testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The continuity of the right knee disability is not established. The medical evidence of record shows that the Veteran first sought treatment for complaints of left knee pain in 2010, some 41 years after his discharge from service. The Veteran submitted an application for compensation for a back disability in 1999, but did not claim any problems with his knees at that time. In May 2003, he submitted a claim for an increased rating for bilateral hearing loss. Again, he did not submit a claim pertaining to his right knee. The Veteran submitted his initial claim for compensation for his right knee in April 2015. The Veteran did not inform the examiner who conducted the September 2015 examination that he had injured his knee in an automobile accident in or about 2009. After a thorough review of the Veteran’s medical records and performing a physical examination of the Veteran, the examiner determined that it was less likely than not that the Veteran’s right knee disability was due to his in-service duties as a heavy equipment operator. Therefore, the Board places reduced probative value on the Veteran’s assertions that his right knee disability is related to his time in service. Moreover, the Veteran’s STRs and post-service medical records show that his right knee disability, diagnosed as osteoarthritis at the September 2015 VA examination, which is a “chronic disease” for disability compensation purposes, did not manifest during service or within one year following his discharge from service. 38 C.F.R. § 3.309(a). The first indication of right knee symptoms was in 2010, which is 41 years after the Veteran’s discharge from service. Thus, service connection is not available under the “chronic disease” provisions. 38 C.F.R. § 3.309. The Board concludes that, while the Veteran has current diagnosis of a right knee disability, the preponderance of the evidence weighs against finding that the Veteran’s diagnosed right knee disability began during service or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. §§ 3.303(a), (d), 3.307, 3.309. Accordingly, service connection for a right knee disability is not warranted. In reaching this conclusion, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran’s claim for service connection for a right knee disability the doctrine is not applicable. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). 5. Entitlement to service connection for a TBI is denied. The Veteran is asserts he was exposed to an explosion that “threw him back” at Fort Carson, CO in 1969 and that he was involved in the riots in Chicago in March 1968. The Veteran’s STRs reflect no treatment for complaints of a head injury in 1968 or 1969. The STRs reveal that, in May 1964, he sought treatment for a lump on his head; however, the clinician was unable to feel any lump. The Veteran reported no trauma at that time. The Veteran’s post-service medical records are negative for treatment for residuals of a TBI or for symptoms reflecting residuals of a TBI. The Veteran underwent a VA residuals of TBI examination in July 2015. The examiner noted that the Veteran had never had a TBI or any residuals of a TBI. The examiner noted that the Veteran’s STRs from 1960’s mention lumps on the head which were never found; and opined that the reported lumps on the Veteran’s head would not be consistent with any true TBI. The examiner noted that the Veteran did not have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI. The examiner noted that neuropsychological testing was performed and there were no significant diagnostic test findings or results. The examiner stated that the results of the Veteran’s testing were not consistent with residual effects from a neuropsychological standpoint of a TBI. The Veteran also underwent a VA PTSD examination in June 2015, which included a notation from the VA examining psychiatrist indicating the Veteran did not have a diagnosed TBI, and that no TBI had been established previously. The Board concludes that the Veteran does not have a current diagnosis of residuals of a TBI and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The July 2015 VA examiner evaluated the Veteran and determined that he did not experience any subjective symptoms of a TBI and he did not have a diagnosis of a TBI. Further, VA treatment records do not contain a diagnosis of a TBI. While the Veteran believes he has a current diagnosis of residuals of a TBI, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education, knowledge of the interaction between multiple organ systems in the body, and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Therefore, the Board finds that the evidence weighs against a finding of a current disability. There is no current diagnosis on record related to a TBI. Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As such, the Board finds that the evidence weighs against a finding of a current disability and service connection for residuals of a TBI must therefore be denied. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are interpreting reports of examination in light of the whole recorded history; reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where an increase in the level of a service connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1999). In Fenderson v. West, 12 Vet. App. 119 (1999), however, it was held that the rule does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as “staged” ratings. Fenderson, 12 Vet. App. at 126. The Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). That is to say, the Board must consider whether there have been times when her service-connected disability has been more severe than at others, and rate it accordingly. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. 6. Entitlement to a compensable rating for bilateral hearing loss Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled speech discrimination test (Maryland CNC) together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). To evaluate the degree of disability from service-connected defective hearing, the rating schedule establishes 11 auditory hearing acuity levels designated from Level I, for essentially normal hearing acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII, Diagnostic Code 6100 (2016). Disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The Board briefly notes that, although 38 C.F.R. § 4.86 provides an alternative method of evaluation for exceptional patterns of hearing impairment, the evidence in this case does not establish the requisite criteria. Thus, use of Table VIA in determining the Roman numeral designations for the Veteran’s bilateral hearing loss is not appropriate, and only Table VI will be used. See 38 C.F.R. §§ 4.85, 4.86. After review of the evidence of record, the Board finds that a compensable rating is not warranted for the Veteran’s service-connected bilateral hearing loss at any time during the period under review. The Veteran underwent a VA audio evaluation in October 2011. The October 2011 VA examiner noted that the Veteran did not respond to any pure tone stimuli presented via air conduction or bone conduction at the limits of the audiometer, even after re-instruction three times. Nor did the Veteran respond to bone-conducted pure tones that were presented at vibrotactile levels. The examiner noted that the Veteran responded appropriately to questions without visual cues at 65 dB HL and to another individual asking multiple questions at a normal conversational level with no visual cues. The examiner noted that DPOAE testing indicated the presence of DPOAEs for 750 Hz, 1000 Hz, 1500 Hz, and 2000 Hz and the absence of DPOAEs for 3000 Hz, 4000 Hz, 6000 Hz, and 8000 Hz for each ear. The examiner noted that these results are consistent with a high-frequency hearing loss with normal or near-normal hearing for 750-2000 Hz. Additionally, the examiner noted that both ipsilateral and contralateral acoustic reflexes were present bilaterally, also indicating that the veteran has hearing that should be measurable for 500, 1000, 2000 and 4000 Hz. In March 2014, the Veteran was afforded a second VA audio evaluation. The examiner determined that the results of this examination were invalid as the veteran inconsistently responded to tonal and speech stimuli. The examiner noted that the Veteran’s speech reception thresholds, acoustic reflex thresholds and pure tone thresholds had poor “intratest reliability.” The Veteran was re-instructed several times; however, consistency in his responses did not improve. The examiner noted that the Veteran responded appropriately to questions without visual cues at 50 dB HL. Word recognition testing was briefly attempted and presented at 70 dB HL. The examiner noted that the Veteran performed better than one would expect based on his pure tone audiogram. The Veteran was afforded a third VA audio examination in June 2015 which did not document a compensable hearing loss. The audiogram showed pure tone thresholds, in decibels, as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 30 35 55 65 46 LEFT 30 40 60 65 49 Speech audiometry revealed speech recognition ability of 94 percent in the right ear and of 94 in the left ear. Applying these results to Table VI in 38 C.F.R. § 4.85, hearing loss in the right ear is assigned a numeric designation of Level I, and hearing loss in the left ear is also assigned a Level I. Where hearing loss is at Level I both ears, a noncompensable rating is assigned under Table VII. 38 C.F.R. § 4.85. The Veteran has not submitted any additional evidence that shows his hearing loss warrants a higher disability evaluation. The Board has considered the Veteran’s complaints regarding the impact of hearing loss on his daily life, but as noted above, the assignment of disability ratings for hearing impairment is primarily derived from a mechanical formula based on levels of puretone threshold average and speech discrimination. Lendenmann, 3 Vet. App. 345. The functional effects of hearing loss on his daily life activities and occupational functioning were discussed by the Veteran at his VA examination. See 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007). The Veteran is noted to have reported difficulty hearing conversation; however, this is reflective of the types of functional difficulty that would be expected to be caused by his recorded levels of hearing loss. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (Manifestations such as difficulty hearing speech are the types of difficulties contemplated by the schedular criteria for hearing loss.). Accordingly, the examination of record is sufficiently in compliance with the provisions of VA regulations, and it is afforded great probative value in determining the Veteran’s level of hearing impairment. The most probative medical evidence as to the nature of the Veteran’s hearing loss are the audiometric findings, and those discussed above reveal that the Veteran’s hearing loss does not warrant a compensable rating. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; the preponderance of the evidence is against the Veteran’s claim, and the doctrine is not applicable. 38 U.S.C. § 5107(b). 7. Entitlement to an initial compensable rating for hemorrhoids prior to July 7, 2017, and an increased rating in excess of 10 percent thereafter. Service connection for hemorrhoids was established effective October 25, 2013, and a noncompensable evaluation was assigned, pursuant to the rating criteria for Diagnostic Code 7336. In its April 2017 remand, the Board noted that the Veteran’s attorney argued that a March 2014 VA examination was inadequate for evaluation purposes and did not fully reflect the Veteran’s symptoms. The issue was remanded for a new VA examination. Based on the findings of the new examination, a 10 percent disability evaluation was assigned effective July 7, 2017; the date of the examination. The Veteran’s hemorrhoids are rated under DC 7336, which assigns a noncompensable rating for mild or moderate hemorrhoids, external or internal. A 10 percent rating is assigned for internal or external hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A rating of 20 percent, the highest rating, is assigned for internal or external hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. The Veteran underwent a VA rectum and anus examination in March 2014. The Veteran reported that he had received treatment for his hemorrhoids including a hemorrhoidectomy when he was in his mid-forties. He stated that things were good for a few years, but the hemorrhoids returned. He reported that he generally self-treated with over-the-counter Tucks, Preparation H and a stool softener. The examiner noted that the Veteran had mild or moderate internal or external hemorrhoids; described as small or moderate external hemorrhoids. The examiner noted that the Veteran’s medical records revealed no mention of hemorrhoids other than his in-service complaints. The Veteran’s outpatient treatment records include a notation in a November 2014 treatment note that the Veteran has chronic constipation and hemorrhoids. The Veteran underwent a VA examination in July 2017. The examiner noted the Veteran was diagnosed hemorrhoids in 1968. The Veteran reported that he experienced intermittent bleeding, pain and itching. The examiner noted mild or moderate hemorrhoids, and large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. The examiner documented that physical examination revealed two small internal hemorrhoids, non-thrombosed. The examiner noted that the Veteran self-treats with preparation H and witch hazel. Based on the findings of this examination, the Veteran’s disability rating was increased to 10 percent, effective July 7, 2017. The medical evidence outlined above shows that prior to July 7, 2017, the Veteran’s hemorrhoids are best characterized as mild or moderate. VA treatment records do not reflect the Veteran sought treatment for hemorrhoids at any time. Due to the lack of a manifestation of any of the symptoms outlined in the rating criteria, the Board finds that the initial noncompensable evaluation effective up to July 7, 2017 for the Veteran’s service-connected hemorrhoids is appropriate. The July 7, 2017 examination reflects the Veteran’s hemorrhoids were characterized by the examiner as mild or moderate, and as large, thrombotic, irreducible, with excess redundant tissue, evidencing frequent recurrences. The Board deems the findings of the July 7, 2017 examination sufficient to warrant a disability rating of 10 percent, but no higher for service-connected hemorrhoids. For the Veteran to qualify for the next higher rating of 20 percent, there must be external or internal hemorrhoids with persistent bleeding and secondary anemia or fissures. As reported by the examiner and Veteran, his hemorrhoids are active and he self-treats for symptoms; however, review of the medical evidence does not establish that the Veteran has persistent bleeding with secondary anemia or fissures. The Veteran’s symptoms do not rise to the level of those contemplated by the criteria for a 20 percent disability evaluation. The Board deems the findings of the July 7, 2017 VA examination sufficient to warrant a disability rating of 10 percent, but no higher, for service-connected hemorrhoids. Therefore, the Board finds that the criteria to establish entitlement to an initial compensable evaluation for hemorrhoids prior to July 7, 2017 and to an evaluation in excess of 10 percent thereafter have not been met. 8. Entitlement to an increased rating in excess of 30 percent for PTSD with depression and anxiety The Veteran contends he is entitled to an initial disability rating in excess of 30 percent for his service-connected PTSD, with depression and anxiety. The Veteran’s service-connected PTSD is currently assigned an initial disability evaluation of 30 percent under 38 C.F.R. § 4.130, Diagnostic Code 9411. When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant’s capacity for adjustment during periods of remission. VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). Under 38 C.F.R. § 4.130, psychiatric impairment is rated under the General Rating Formula for Mental Disorders (“General Rating Formula”). As relevant here, a 30 percent rating is warranted where there is 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: 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 where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted where 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. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is the Veteran’s symptoms, but it must also make findings as to how those symptoms impact the Veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 426, 442 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the General Rating Formula are also associated with objectively observable symptomatology, and the plain language of the regulation makes it clear that a Veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency and duration. Vazquez-Claudio, 713 F.3d at 118. Service connection for PTSD was established effective June 7, 2013 and assigned a 30 percent evaluation pursuant to the rating criteria for Diagnostic Code 9411. Having carefully considered all the evidence of record, the board finds that based on the overall disability, an initial rating in excess of 30 percent is not warranted. VA treatment records indicate the Veteran sought treatment at the mental health clinic in June 2010. The Veteran was enrolled in a PTSD treatment program in November 2011 and participated in group therapy. The Veteran underwent a VA initial PTSD examination in March 2014. The examiner summarized the Veteran’s level of occupational social impairment as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation. The Veteran reported that he was raised by his parents and has four sisters. He stated that he had been married twice and had two grown children and two grandchildren. After service, the Veteran had many jobs, mostly in labor type work including hauling mail, working a Walmart and as an electrician. The Veteran reported that he has been treated at VA and was on medication. He reported that his alcohol dependence was in remission. The examiner noted that the Veteran exhibited a depressed mood, anxiety and chronic sleep impairment. The examiner documented that the Veteran’s hygiene was fair and he made good eye contact. He denied auditory hallucinations and his speech was clear. The Veteran’s mood was noted to be neutral and affect was restricted. He was fully oriented and insight and judgment were noted to be fair. VA treatment records for the period from April 2014 to December 2014 show the Veteran continued to participate in group counseling. In June 2015, the Veteran underwent a VA review PTSD examination. The examiner summarized the Veteran’s level of occupational social impairment as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation. The Veteran reported experiencing no change in his social, marital or family history since his last examination in March 2014. He continued to be treated at VA and was on medication. He reported that his alcohol dependence was in remission. The examiner noted that the Veteran exhibited a depressed mood, anxiety and chronic sleep impairment. The examiner documented that the Veteran’s hygiene was fair and he made good eye contact. He denied auditory hallucinations and his speech was clear. The Veteran’s mood was noted to be neutral and affect was restricted. He was fully oriented and insight and judgment were noted to be fair. The Veteran was able to recall three items immediately, but only one item five minutes later. The Veteran was not able to perform serial 7 subtractions but was able to spell “world” forward and backwards. VA treatment notes show the Veteran was seen in the mental health clinic in September 2015 for a follow-up. He reported doing fairly well, except for having more anxiety and more symptoms of PTSD. The Veteran’s grooming and hygiene were “ok,” his eye contact was good and his attitude was cooperative. The Veteran’s mood was dysphoric and anxious and his affect was appropriate. His speech was relevant and spontaneous and his thought processes were logical and goal-directed. The Veteran did not exhibit any psychotic symptoms or any evidence of homicidal thoughts. The Veteran continued to attend group therapy. In December 2015 he was seen in the outpatient clinic. He reported doing “so-so.” The clinician noted that the Veteran denied any suicidal and homicidal ideation and his mood was dysphoric and anxious. His thought contend was relevant and his thought processes were logical and goal-directed. VA treatment records from January 2016 through May 2016 indicated the Veteran continued to attend group therapy and receive treatment for PTSD. In July 2017, the Veteran underwent a VA contract PTSD examination.. The contract examiner summarized the Veteran’s occupational and social impairment occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation. The contract examiner noted that the Veteran experienced symptoms of hyperarousal, avoidance, re-experiencing symptoms, suspiciousness, and chronic sleep impairment. The Veteran reported that he was currently living alone as he and his wife had separated about three or four months earlier. He denied any psychological hospitalizations, suicide attempts or individual therapy since his last VA examination. He denied any current thoughts of harming or killing himself or others. The Veteran reported that his medications seem to be working and have helped with his mood. The Veteran reported suspiciousness, chronic sleep impairment, and mild memory loss. The contract examiner noted that the Veteran arrived early for his appointment. He was dressed neatly. His speech was logical and goal-oriented. He was cooperative. The Veteran was oriented to person, place, situation and time. His concentration and attention were good, as were his judgment and insight. He described his mood as “rocky; sometimes I have a good mood.” His affect was slightly depressed, but he was able to brighten during the interview. The Veteran reported that he did not like being around people and was concerned for his safety. He reported he has some difficulty concentrating. The contract examiner determined that the Veteran’s PTSD symptoms were mild and that he has had minimal contact with mental health treatment staff since his last evaluation. The contract examiner noted that the Veteran has a mild neurocognitive disorder which appear to have started in 2014 and noted that there is no objective medical evidence that links this with his service-connected PTSD. Based on the evidence outlined above, the Board finds that the Veteran’s symptomatology most closely approximates the criteria for the currently assigned 30 percent disability rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. In accordance with Mauerhan and Vazquez-Claudio, the Board recognizes that the Veteran’s PTSD produces a range of symptoms, to include depression, sleep impairment, mild memory loss and suspiciousness. The Veteran’s treatment records generated during the appeal period document that the PTSD symptoms have remained unchanged and reflective of the 30 percent disability rating previously assigned. However, there is no evidence associated with the file that indicates the Veteran’s symptoms rise to the level of occupational and social impairment with reduced reliability and productivity. The record is devoid of evidence documenting that the Veteran’s PTSD is productive of symptomology the equivalent of flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships to warrant a 50 percent rating. The Board has considered the applicability of the benefit of the doubt doctrine in reaching this conclusion. However, the Board finds that the preponderance of the evidence is against a rating higher than the 30 percent rating previously assigned herein at any time during the appeal period. See 38 U.S.C. § 5107 (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). REASONS FOR REMAND 1. Entitlement to service connection for diabetes mellitus, type II secondary to PTSD with depression and anxiety is remanded. In April 2017, this issue was remanded by the Board to obtain an addendum medical opinion fully addressing the Veteran’s theory of secondary service connection for diabetes mellitus. As directed by the Board, the AOJ requested a medical opinion as to whether it was at least as likely as not that the Veteran’s claimed diabetes mellitus, type II was proximately due to or the result of his service-connected PTSD with depression and anxiety; or, if not, whether it was at least as likely as not that his diabetes mellitus, type II was aggravated beyond its normal progression by his service-connected PTSD. The examiner was also asked to address the theory that the Veteran’s PTSD caused him to overeat and not exercise, which led to weight gain, which led to him developing diabetes mellitus, type II. The examiner was asked to consider a medical treatise supporting this theory that was submitted by the Veteran’s representative. In the July 2017 medical opinion provided by a VA contract examiner, the contract examiner stated that there was no medical relationship between diabetes and PTSD in any literature to validate the Veteran’s claim. The contract examiner stated that medical literature does suggest most post service veterans gain weight increasing BMI which predisposes to diabetes. It was her medical opinion that the Veteran’s lifestyle choices caused his diabetes and not PTSD. The contract examiner further stated that it was her medical opinion that the Veteran was undergoing treatment for PTSD and was “well controlled with medication which in turn allows this veteran to make the lifestyle choices to exercised and eat healthy. The veteran’s PTSD occurred directly after deployment, if the theory that was presented was correct, the veteran would have developed diabetes directly after deployment as well not several years later.” The Board finds that this medical opinion is inadequate for adjudication purposes as it did not respond to the questions posed by the AOJ; nor did it address the medical treatise submitted in support of the Veteran’s claim. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). On remand, an addendum opinion should be obtained which specifically address the nature and etiology of the Veteran’s diabetes mellitus, type II and addresses the medical treatise submitted by the Veteran in support of his claim. 2. Entitlement to service connection for spondylolisthesis L-5 sacrum is remanded. In July 2015, a VA opinion was obtained regarding the etiology of the Veteran’s lumbar spine degenerative joint disease. The examiner was asked to provide an opinion as to whether it was at least as likely as not that the Veteran’s lumbar spine disability was incurred in or caused by wear and tear on his back due to his duties as a heavy equipment operator in service. The examiner determined that it was less likely than not that this disability was incurred in service or caused by the Veteran’s duties as a heavy equipment operator. The examiner considered the medical article submitted by the Veteran regarding “whole body vibration,” and determined that vibration injuries are more commonly associated with neuropathies and less commonly with degenerative disc disease. The examiner further stated that the Veteran’s STRs and separation examination were silent for any back complaints or conditions. The Board finds that this opinion is inadequate for adjudication purposes as it did not address the lay statements submitted by the Veteran and his family members regarding the back pain he has experienced since his discharge from service. On remand an addendum opinion should be obtained regarding the nature and etiology of the Veteran’s back disability that considers the lay statements submitted by the Veteran and his family members regarding the back symptoms he has experienced since service. 3. Entitlement to service connection for drug and alcohol abuse secondary to PTSD with anxiety and depression is remanded. In April 2017, this issue was remanded by the Board to obtain an addendum medical opinion fully addressing the Veteran’s theory of secondary service connection for drug and alcohol abuse. The Board directed the AOJ to instruct the VA examiner to review the Veteran’s claims file and to provide opinions addressing the following: whether the Veteran had a drug/alcohol addiction abuse problem during the pendency of this appeal, and if not how long has problem been in remission; whether it is at least as likely as not that any drug/alcohol addiction or abuse was either proximately due to PTSD; or, whether any nonservice-connected drug/alcohol abuse or addiction was aggravated by PTSD. The addendum opinion was also directed to address the Veteran’s theory of using drugs and alcohol to self-medicate and cope with his PTSD symptoms, which led to addiction/abuse; as well as the Veteran’s theory that his drug and alcohol abuse was caused or aggravated by his pain of the knees and back. In the July 2017 opinion provided by a VA contract examiner, the contract examiner stated that “the Veteran reported he was drinking heavily in 1964 which is prior to his traumatic events, his PTSD symptoms, and his knee and back pain. Thus, his alcohol use problems clearly and unmistakably existed prior to these issues.” The contract examiner determined that the Veteran had not had an abuse problem during the pendency of the appeal and that his alcohol use disorder had been in remission since 2001. The Board finds that this opinion is inadequate for adjudication purposes as it did provide thorough analyses for its determinations. The Board notes that the Veteran was actually in service from February 1964 to June 1964; which was not discussed by the examiner in stating that the Veteran reported drinking heavily in 1964. Nor does it appear that a thorough review of the Veteran’s file was conducted; as treatment notes from the Veteran’s VA substance abuse treatment program indicate he had a relapse in 2012 which is not addressed. Moreover, this opinion does not adequately address the Veteran’s contentions that he used alcohol and drugs to self-medicate and cope with his PTSD symptoms; nor did it address the possibility of the Veteran’s use of alcohol and drugs to cope with his knee and back pain. On remand, an addendum opinion should be obtained which thoroughly addresses the nature and etiology of the Veteran’s drug and alcohol abuse/addiction. 9. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities is remanded. Finally, because a decision on the remanded issues of a back disability, diabetes mellitus, and drug and alcohol abuse secondary to PTSD could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. A remand of the claim for entitlement to a TDIU is required. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). The matter is REMANDED for the following action: 1. Obtain all outstanding, pertinent VA treatment records and associate them with the electronic file. If any identified records are not obtainable (or none exist), the Veteran and his representative should be notified and the record clearly documented. 2. Provide the Veteran an opportunity to submit any outstanding private treatment records relating to his service-connected disabilities. Provide the Veteran with the appropriate authorization for release form(s). For any outstanding private treatment records identified and authorized by the Veteran, make at least two (2) attempts to obtain such records. All attempts made must be documented in the electronic file, to include the unavailability of any identified records. For any identified records that are not obtained, notify the Veteran of such and provide him with an opportunity to submit those records. 3. Return the file to the VA examiner who provided the April 2015 back opinion. The electronic file and a copy of this Remand must be made available to the examiner. The examiner should note in the examination report that the electronic file and the Remand have been reviewed. If the April 2015 VA examiner is not available, the electronic file should be provided to an appropriate medical professional so as to render the requested opinion. If the examiner determines that a VA examination is necessary, one should be scheduled. The examiner is must provide opinions as to the following: a) Is it at least as likely as not (50 percent probability or greater) that any diagnosed back disability, to include spondylolisthesis L-5 sacrum, is causally related to service, to include as due to his job duties as a heavy equipment operator? b) Is it at least as likely as not (50 percent probability or greater) that any diagnosed back disability, to include spondylolisthesis L-5 sacrum, is due to a vibration injury sustained during the course of his job duties as a heavy equipment operator? The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion as it is to find against it. A complete rationale for any opinions expressed should be set forth. If the examiner cannot provide an above opinion without resorting to speculation, (s)he should explain why an opinion cannot be provided (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). The examiner is reminded to consider and address the lay statements submitted by the Veteran and his family members regarding the nature and onset of his disabilities and the symptoms he has experienced since service. 4. Return the file to the VA contract examiner who provided the July 2017 diabetes mellitus opinion. The electronic file and a copy of this Remand must be made available to the examiner. The examiner should note in the examination report that the electronic file and the Remand have been reviewed. If the July 2017 VA contract examiner is not available, the electronic file should be provided to an appropriate medical professional so as to render the requested opinion. If the examiner determines that another VA examination is necessary, one should be scheduled. The examiner must provide opinions as to the following: a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s diabetes mellitus is proximately due to his service-connected PTSD or aggravated (permanently worsened beyond its natural progression) by service-connected PTSD? b) Is it at least as likely as not (50 percent or greater possibility) that the Veteran’s PTSD caused the Veteran to overeat and not exercise, which led to weight gain, which led to the development of diabetes mellitus? Please address the medical treatise submitted by the Veteran in support of this theory of entitlement to service connection. The term “at least as likely as not” does not mean within the realm of possibility, but rather that the evidence both for and against a conclusion is so evenly divided that it is as sound to find in favor of a certain conclusion as it is to find against it. All findings, conclusions, and the rationale for all opinions expressed should be provided in a report. Please note that an examiner’s report that (s)he cannot provide and opinion without resort to speculation is inadequate unless the examiner provides a rationale for that statement. 5. Return the file to the VA contract examiner who provided the July 2017 drug and alcohol addiction/abuse opinion. The electronic file and a copy of this Remand must be made available to the examiner. The examiner should note in the examination report that the electronic file and the Remand have been reviewed. If the July 2017 VA contract examiner is not available, the electronic file should be provided to an appropriate medical professional so as to render the requested opinion. If the examiner determines that a VA examination is necessary, one should be scheduled. The examiner must provide opinions to the following: a) Has the Veteran had a drug/alcohol addiction or abuse problem during the pendency of this appeal, i.e. since January 2015? If not, how long has the problem been in remission? b) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s drug/alcohol addiction began in service? c) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s drug/alcohol addiction or abuse is proximately due to service-connected PTSD? d) Is it at least as likely as not (50 percent or greater probability) that nonservice-connected drug/alcohol addiction or abuse is aggravated by service-connected PTSD? Aggravation is defined as a permanent worsening of the nonservice-connected disability beyond that due to the natural disease process as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. This addendum opinion should address the theory that the Veteran used drugs and alcohol to self-medicate and cope with his PTSD symptoms, which led to addiction/abuse. The addendum should address the treatise submitted by the Veteran’s attorney in support of that theory. Also, the addendum should address the Veteran’s theory that his drug and alcohol abuse was caused or aggravated by his pain of the knees and back. All findings, conclusions, and the rationale for all opinions expressed should be provided in a report. Please note that an examiner’s report that (s)he cannot provide and opinion without resort to speculation is inadequate unless the examiner provides a rationale for that statement. G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. M. Lunger, Associate Counsel