Citation Nr: 18143795 Decision Date: 10/22/18 Archive Date: 10/22/18 DOCKET NO. 11-21 476 DATE: October 22, 2018 ORDER Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with alcohol and substance abuse in full remission from November 19, 2009, to June 30, 2013 is denied. Entitlement to an initial disability rating of 70 percent for PTSD with alcohol and substance abuse in full remission from July 1, 2013, thereafter, is granted. Entitlement to an effective date prior to November 19, 2009, for service connection for PTSD with alcohol and substance abuse in full remission, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected PTSD with alcohol and substance abuse in full remission is granted. REMANDED Entitlement to service connection for hypertension, to include as due to herbicide agent exposure, to include as secondary to service-connected PTSD is remanded. Entitlement to an initial disability rating in excess of 20 percent for diabetes mellitus, type II is denied. Entitlement to an effective date prior to September 2, 2015, for service connection for diabetes mellitus, type II is remanded. FINDINGS OF FACT 1. The competent evidence of record demonstrates that from November 19, 2009 to June 30, 2013, the Veteran’s PTSD with alcohol and substance abuse in full remission did not manifest in 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. 2. The competent evidence of record demonstrates that from July 1, 2013, thereafter, the Veteran’s PTSD with alcohol and substance abuse in full remission did not manifest in 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. 3. VA received a formal claim for service connection for PTSD on November 19, 2009. 4. The competent evidence of record demonstrates that the Veteran is unable to secure or maintain substantially gainful employment due to his service-connected PTSD with alcohol and substance abuse in full remission from July 1, 2013, thereafter. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability rating in excess of 50 percent from November 19, 2009 to June 30, 2013, for PTSD with alcohol and substance abuse in full remission have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for entitlement to an initial disability rating of 70 percent from July 1, 2013, for PTSD with alcohol and substance abuse in full remission have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.130, Diagnostic Code (DC) 9411. 3. The criteria for entitlement to an effective date prior to November 19, 2009, for service connection for PTSD with alcohol and substance abuse in full remission have not been met. 38 U.S.C. §§ 5101, 5110; 38 C.F.R. §§ 3.114, 3.151, 3.155, 3.400. 4. The criteria for entitlement to a TDIU rating have been met from July 1, 2013. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1966 to August 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from multiple rating decisions. An October 2010 rating decision granted the Veteran’s claim for service connection for PTSD and assigned a 50 percent disability rating, effective November 19, 2009. The rating decision also denied the Veteran’s claim for service connection for hypertension. An August 2017 rating decision assigned a 70 percent disability rating for the Veteran’s PTSD, effective June 30, 2015. A November 2011 rating decision denied the Veteran a total disability rating based on individual unemployability (TDIU). A September 2015 rating decision granted the Veteran’s claim for service connection for diabetes mellitus, type II and assigned a 20 percent disability rating, effective September 2, 2015. The Veteran disagreed with the initial disability ratings assigned, and it is presumed he is seeking the highest possible rating or maximum benefits available under the law. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). The issues of an initial rating in excess of 50 percent for PTSD with alcohol and substance abuse in full sustained remission, service connection for hypertension, to include as due to herbicide agent exposure, and a TDIU rating were remanded by the Board in January 2014. The issues of an initial disability rating for PTSD with alcohol and substance abuse in full remission in excess of 50 percent from November 19, 2009, and in excess of 70 percent from June 30, 2015, service connection for hypertension, to include as due to exposure to herbicide agents, to include as due to service-connected PTSD, and a TDIU rating were remanded by the Board in December 2017. Increased Ratings VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Diagnostic codes in the rating schedule identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. See 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not “duplicative or overlapping with the symptomatology” of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Because the level of disability may have varied over the course of the claim, the rating may be “staged” higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial-rating cases, where the appeal stems from a rating decision granting service connection with respect to the initial evaluation assigned the disability at issue, VA assesses the level of disability from the effective date of service connection. 38 U.S.C. § 5110; 38 C.F.R. § 3.400; Fenderson, 12 Vet. App. at 125. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Veteran’s PTSD has been rated under 38 C.F.R. § 4.130, DC 9411, which pertains to PTSD. Almost all mental health disorders, including PTSD, are evaluated under the General Rating Formula for Mental Disorders (Rating Formula), which assigns ratings based on particular symptoms and the resulting functional impairment. See 38 C.F.R. § 4.130, DC 9411. Under the General Rating Formula, a 50 percent rating requires 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 per 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 disability rating requires occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting; inability to establish and maintain effective relationships.) A 100 percent disability rating requires 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. The symptoms associated with each evaluation under the General Rating Formula do not constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the appropriate evaluation of a psychiatric disorder is not restricted to the symptoms set forth in the General Rating Formula. See id. Rather, VA must consider all symptoms of a claimant’s condition that affect his or her occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association’s DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed. 1994) (DSM-IV). Id. at 443. (The DSM-IV has been recently updated with a Fifth Edition (DSM-5), and VA has issued an interim final rule amending certain provisions in the regulations to reflect this update, including the Schedule for Rating Disabilities. 79 Fed. Reg. 45093. The amendments only apply to applications that are received by VA or are pending before the agency of original jurisdiction on or after August 4, 2014; they do not apply to appeals already certified to the Board or pending before the Board. Id.) If the evidence demonstrates that the claimant’s psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating in the General Rating Formula, then the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. In this regard, the Board must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126; Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (noting that the “frequency, severity, and duration” of a veteran’s symptoms “play an important role” in determining the disability level). The severity of the symptoms and the degree of occupational and social impairment they cause are independent factors. See Vazquez-Claudio, 713 F.3d at 116 (rejecting an interpretation of § 4.130 that would allow “a veteran whose symptoms correspond[ed] exactly to a 30 percent rating” to be granted a 70-percent rating solely because they affected most areas). In other words, there are two elements that must be met to assign a particular rating under the General Rating Formula: (1) symptoms equivalent in severity, frequency, and duration to the symptoms corresponding to a given rating, and (2) a level of occupational and social impairment corresponding to that rating that results from those symptoms. See id. at 118 (holding that, in determining whether a 70 percent rating is warranted, VA must make “an initial assessment of the symptoms displayed by the veteran, and if they are of the kind enumerated in the regulation, an assessment of whether those symptoms result in occupational and social impairment with deficiencies in most areas”). While VA considers the level of social impairment, it shall not assign an evaluation based solely on social impairment. 38 C.F.R. § 4.126. 1. Entitlement to an initial disability in excess of 50 percent for PTSD with alcohol and substance abuse in full remission from November 19, 2009 to June 30, 2013, is denied. For the time period from November 19, 2009 to June 30, 2013, the Veteran underwent a VA PTSD Examination in August 2010. The examination report noted that the Veteran’s symptoms include anger, irritability, anxiety, paranoia, isolation, nightmares, flashbacks, exaggerated startle response, hypervigilance, poor sleep without medication, significant trust issues, guilt, anxiousness, tension, and nervousness. The examination report found that the Veteran’s PTSD and alcohol abuse problem affect his marriage and prior job performance. These symptoms fall within the impairment level consistent with the 50 percent rating criteria. The Board finds that the Veteran is not entitled to an initial disability rating in excess of 50 percent from November 19, 2009 to June 30, 2013. The competent evidence of record does not demonstrate that the Veteran’s PTSD symptoms produced occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. There is also no showing that the Veteran experienced 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 during this time period. Additionally, the Veteran’s VA treatment records do not demonstrate the above functional impairment or symptoms. Therefore, the competent evidence of record does not describe symptoms that more nearly approximate a 70 percent disability rating during the time period from November 19, 2009 to June 30, 2013. Vazquez-Claudio v. Shinseki, 713 F. 3d 112 (Fed. Cir. 2013) (70 percent rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency, or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation). In sum, the preponderance of the evidence weighs against an assignment of an initial disability rating in excess of 50 percent from November 19, 2009 to June 30, 2013 for PTSD with alcohol and substance abuse in full remission. Thus, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 2. Entitlement to an initial disability of 70 percent PTSD with alcohol and substance abuse in full remission from July 1, 2013, thereafter, is granted. For the time period from July 1, 2013, thereafter, a July 2013 VA PTSD Examination was completed by a private licensed psychologist that noted the Veteran’s PTSD produces symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, near-continuous panic or depression, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, flattened affect, disturbances in motivation or mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, suicidal ideation, persistent danger or hurting self or others, neglect of personal appearance and hygiene. The examination report found that the Veteran’s PTSD produces occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Veteran underwent a VA PTSD Examination in June 2015. The examination report demonstrates that due to the Veteran’s PTSD, he experiences depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationship, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, neglect of personal appearance and hygiene. The examination report shows that the Veteran experiences occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Veteran also underwent a VA PTSD Examination in November 2017. The examination report demonstrates that due to the Veteran’s PTSD, he experiences depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, difficulty in understanding complex commands, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examination report also showed that the Veteran has intrusive thoughts that interfere with the ability to stay focused on the task at hand, has significant difficulty functioning around other people, has difficulty functioning as a team member, feels uncomfortable around others, cannot tolerated being around other people in any setting for more than a few minutes, his sleep is so disrupted he is fatigued at work, which makes concentration and focus on work assignments difficult, and has other mental health problems or symptoms that interfere significantly with the ability to work. Of note, the United States Court of Appeals for Veterans Claims (Court) has held that suicidal ideation generally rises to the level contemplated in a 70 percent evaluation. See Bankhead v. Shulkin, 29 Vet. App. 10, 21 (2017). The Court specified that VA must not require “more than thought or thoughts to establish the symptom of suicidal ideation,” and may not require that the Veteran have “been hospitalized or treated on an inpatient basis…” to establish suicidal ideation because that “imposes a higher standard than the criteria in the [Diagnostic Code] for mental disorders.” Bankhead, 29 Vet App. at 20. Moreover, the Court cautioned VA not to conflate the risk of “suicidal ideation, which VA generally considers indicative of a 70 [percent] evaluation, and his risk of self-harm, the persistent danger of which VA generally considers indicative of a 100 [percent] evaluation.” Id at 21. Thus, based on the competent evidence of record, including the examination conducted by the private licensed psychologist described above that showed suicidal ideation, the Board finds that the Veteran is entitled to an initial disability rating of 70 percent from July 1, 2013 as this is the first date these symptoms are documented. However, the competent evidence of record does not indicate that the Veteran’s PTSD symptoms manifested in 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. The Veteran’s VA treatment records do not describe PTSD symptoms that more nearly approximate a 100 percent disability rating during this time period. The preponderance of the evidence weighs in favor of an assignment of an initial disability rating of 70 percent from July 1, 2013 for PTSD with alcohol and substance abuse in full remission. The preponderance of the evidence weighs against an assignment of an initial disability rating in excess of 70 percent from July 1, 2013, thereafter. Thus, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 3. Entitlement to an effective date prior to November 19, 2009, for service connection for PTSD with alcohol and substance abuse in full remission, is denied. VA received a claim for service connection for PTSD on November 19, 2009. See Veteran’s Application for Compensation and/or Pension (VA Form 51-526). An October 2010 rating decision granted the Veteran’s claim for service connection for PTSD and assigned a 50 percent disability rating, effective November 19, 2009. VA previously denied the Veteran’s claim for service connection for PTSD in a May 2008 rating decision and an April 2000 rating decision. Thus, this matter involves a claim reopened after a final disallowance. Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5100; 38 C.F.R. § 3.400. If a claim for disability compensation is received within one year after separation from service, the effective date of entitlement is the day following separation or the date entitlement arose. 38 C.F.R. § 3.400(b)(2). Otherwise, it is the date of receipt of claim or the date entitlement arose, whichever is later. See 38 C.F.R. § 3.400. The Veteran’s VA treatment records indicate that he was diagnosed with PTSD in 2003 and earlier in 1984. The Veteran’s VA treatment records also indicate he participated in a PTSD Program at the Fort Thomas VA Medical Center from August 2007 to October 2007. However, as the date of receipt of the claim is later than the date entitlement arose, the effective date for service connection for PTSD remains November 19, 2009. As the Veteran separated from service in August 1969, the effective date cannot be one day after such separation, since a claim for diabetes was not filed within one year of service separation. See 38 C.F.R. § 3.400. Further, as the Veteran is seeking an earlier effective date for service-connected PTSD, the Board notes that although a July 13, 2010 amendment to the PTSD regulation liberalizes, in particular circumstances, the evidentiary standard for establishing an in-service stressor, it is not a liberalizing change for effective date purposes. 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114(a); but see Ervin v. Shinseki, 24 Vet. App. 318 (2011). Rather, the appropriate effective date should be determined under the general rule for effective dates, as applied above. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Accordingly, entitlement to an effective date prior to November 19, 2009 for an award of service connection for PTSD with alcohol and substance abuse in full remission, is denied. Because the law, and not the facts, is dispositive of the outcome of this issue, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Sabonis v. West, 6 Vet. App. 426, 430 (1994). 4. Entitlement to a total disability rating based on individual unemployability (TDIU) due PTSD with alcohol and substance abuse in full remission is granted. The Veteran maintains that he is unemployable, primarily due to his service-connected PTSD with alcohol and substance abuse in full remission. For the reasons discussed below, the competent evidence of record demonstrates that the Veteran’s service-connected PTSD produces unemployability. Certain percentage requirements must be satisfied in order to qualify for schedular consideration of entitlement to a TDIU rating. Specifically, if unemployability is the result of only one service-connected disability, this disability must be ratable at 60 percent or more. See 38 C.F.R. § 4.16(a). If it is the result of two or more service-connected disabilities, at least one must be ratable at 40 percent or more, with the others sufficient to bring the combined rating to 70 percent or more. Id. Disabilities of one or both upper extremities, or one or both lower extremities, including the bilateral factor, disabilities resulting from a common etiology or a single accident, and disabilities affecting a single body system such as orthopedic disabilities, will be considered as one disability for TDIU purposes. Id. Based on the decision above, the Veteran’s PTSD with alcohol and substance abuse in full remission was rated as 70 percent disabling from July 1, 2013. He is also service connected for diabetes mellitus, type II, effective September 2, 2015. Thus, the Veteran first met the schedular requirements for a TDIU rating on July 1, 2013. Total disability will be considered to exist 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. § 4.15. While the rating is based primarily upon the average impairment in earning capacity, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability, and to the effect of combinations of disability. Id. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment shall generally be deemed to exist when a Veteran’s earned 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). Marginal employment may also be established, on a facts found basis, when earned annual income exceeds the poverty threshold, including but not limited to employment in a protected environment such as a family business or sheltered workshop. Id. Consideration must be given in all claims to the nature of the employment and the reason for termination. Id. As the Veteran satisfies the criteria for schedular consideration for a TDIU rating from July 1, 2013, the only remaining consideration is whether his service-connected PTSD with alcohol and substance abuse in full remission renders him unable to obtain and maintain substantially gainful employment. Here, the Board finds that the Veteran’s service-connected PTSD with alcohol and substance abuse in full remission alone produces unemployability. In this regard, the Board has considered the Veteran’s educational and employment background. The evidence reflects that the Veteran graduated from high school and did not complete college coursework. See October 2017 Veterans Application for Increased Compensation Based on Unemployability (VA Form 21-8940). The Veteran engaged in locomotive engineer training from March 1998 to June 1998. Importantly, the ultimate question is not whether the Veteran can actually find employment, but whether, in light of his service-connected disability, he is capable of performing the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran provided that he last worked in 2006 for the Navy Surface Warfare Center in Crane, Indiana, he left his last job because of his disability, and he has not tried to obtain employment since he became too disabled to work. An August 2010 VA PTSD Examination indicated that the Veteran’s PTSD and alcohol abuse appears to affect his marriage and job performance and severe impairment of his social functioning. A private medical opinion from June 2013 provided that as a result of the Veteran’s symptoms from his service-connected PTSD, he is incapable of maintaining employment at any gainful level. The opinion was accompanied by an examination report that showed the Veteran has occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. A June 2015 VA PTSD Examination provided that the Veteran’s service-connected PTSD moderately-severely impairs his ability to perform day-to-day activities, especially in a work-setting. The examination report also indicated that his ability to interact with others is significantly impacted by irritability related to his PTSD, and he demonstrates marginal impulse control. The examination report further stated that the Veteran’s ability to accept supervision and criticism, flexibility, concentration, and memory are moderately impacted by his PTSD A November 2017 VA PTSD Examination noted that the Veteran has intrusive thoughts which interfere with the ability to stay focused on the task at hand, has significant difficulty functioning around other people, has difficulty functioning as a team member, feels uncomfortable around others, cannot tolerated being around other people in any setting for more than a few minutes, his sleep is so disrupted he is fatigued at work, which makes concentration and focus on work assignments difficult, and has other mental health problems or symptoms that interfere significantly with the ability to work. An additional private medical opinion from June 2018 concluded that the Veteran is totally and permanently precluded from performing work at a substantial gainful level due to the severity of his service connected PTSD with alcohol and substance abuse in full sustained remission since November 19, 2009, and which was later worsened by his diabetes mellitus, type II and the record supports this finding as far back as the date of filing. The Board carefully considered the Veteran’s statements, his education and employment background, and the limitations imposed on him as a consequence of his service-connected PTSD with alcohol and substance abuse in full remission. Considering the evidence indicating that the Veteran’s PTSD symptoms negatively impact his ability to obtain or maintain substantially gainful employment, that he has met the schedular requirements of a TDIU rating since July 1, 2013, and in the absence of any evidence that directly contradicts this conclusion, the Board finds that a TDIU rating is warranted from July 1, 2013 based solely upon the Veteran’s service-connected PTSD. Accordingly, a TDIU rating is granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). REASONS FOR REMAND 1. Entitlement to service connection for hypertension, to include as due to herbicide agent exposure, to include as secondary to service-connected PTSD is remanded. The Veteran’s claim was remanded by the Board in December 2017 for a new VA examination and opinion. The March 2018 VA medical opinion concerning a link between the Veteran’s hypertension and his presumed in-service exposure to herbicide agents on a direct basis is inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); D’Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination must be based on consideration of the claimant’s medical history and must describe the disability in sufficient detail so that the Board’s evaluation of the disability will be a fully informed one). The VA examiner provided, in part, that the Veteran’s hypertension was less likely than not related to his active service because there is no medical nexus for agent orange exposure to cause hypertension. The medical opinion provides no supporting rationale in terms of referencing the Veteran’s medical history, relevant medical literature, the clinical findings made on examination, or the symptomatology reflected in the medical and lay evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion comes from its reasoning); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion…must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). Here, the Veteran’s service personnel records reflect that he had service in the Republic of Vietnam. Additionally, the Veteran’s Certificate of Release or Discharge from Active Duty (DD Form 214) shows that he had over two years of foreign service and received the Vietnam Service Medal and Vietnam Campaign Medal. For purposes of establishing service connection for a disability resulting from exposure to herbicide agents, a veteran who had active military, naval, or air service in the Republic of Vietnam during the Vietnam Era, beginning on January 9, 1962, and ending on May 7, 1975, will be presumed to have been exposed to an herbicide agent during that service, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 U.S.C. § 1116(f); 38 C.F.R. §§ 3.307(a)(6)(iii), 3.309(e). Therefore, he is presumed to have been exposed to herbicide agents during service in the Republic of Vietnam during the Vietnam Era. The Veteran also stated that he was physically near Agent Orange during his active service, that he handled drums containing Agent Orange, and that he was splashed with Agent Orange during his handling of it. See November 2009 Veteran’s Application for Compensation and/or Pension (VA Form 21-526). Therefore, an addendum opinion must be obtained. 2. Entitlement to an initial disability rating in excess of 20 percent for diabetes mellitus, type II is denied. The VA Diabetes Mellitus Examinations in September 2015 and November 2017 are inadequate. See Barr, 21 Vet. App. at 312; D’Aries, 22 Vet. App. at 104. The examination reports do not indicate that the Veteran required one or more daily injection of insulin to treat his diabetes mellitus, type II. However, the Veteran’s VA treatment records appear to indicate that the Veteran’s diabetes mellitus, type II is being treated with insulin. The Board cannot make a fully-informed decision on whether the Veteran is entitled to a disability rating in excess of 20 percent for diabetes mellitus, type II because no VA examiner has considered the evidence contained in the Veteran’s VA treatment records concerning insulin use. Additionally, there may be relevant evidence contained in outstanding private treatment records as discussed below. The Board finds that a new VA examination is necessary to fully address the current severity of the Veteran’s diabetes mellitus, type II. Additionally, retrospective medical opinions are necessary to capture the severity of the Veteran’s diabetes mellitus, type II for the entire appeal period due to question of whether the Veteran’s VA treatment records show treatment with insulin. See Chotta v. Peake, 22 Vet. App. 80 (2008) (when there is an absence of medical evidence during a certain period of time, a retroactive medical evaluation may be warranted). The Veteran submitted an Application for Disability Compensation and Related Compensation Benefits (VA Form 21-526EZ) in September 2015. At that time, the Veteran identified Mercy Hospital Anderson in an Authorization to Disclose Information to the Department of Veterans Affairs (VA) (VA Form 21-4142). The Veteran’s claims folder indicates that VA attempted to acquire these private treatment records, but were informed that a fee was required. The Veteran was not informed that VA was unsuccessful in acquiring these private treatment records. A remand is required to allow VA to obtain authorization and request these records. 3. Entitlement to an effective date prior to September 2, 2015, for service connection for diabetes mellitus, type II is remanded. As the claim for an initial disability rating in excess of 20 percent for diabetes mellitus, type II is being remanded to obtain previously identified private treatment records, the Board finds that the earlier effective date issue is inextricably intertwined with the increased rating claim. See 38 C.F.R. § 4.16(a); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Accordingly, it must be remanded as well. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from April 2018 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for records from Mercy Anderson Hospital or any other physicians or facilities adequately identified by the Veteran concerning his treatment for diabetes mellitus, type II. Make two requests for the authorized records from Mercy Anderson Hospital or any other physicians or facilities adequately identified by the Veteran concerning his treatment for diabetes mellitus, type II, unless it is clear after the first request that a second request would be futile. 3. After the above development is completed, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected diabetes mellitus, type II. (a.) The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. (b.) To the extent possible, the examiner should identify any symptoms and functional impairments due to diabetes mellitus, type II alone and discuss the effect of the Veteran’s diabetes mellitus, type II on any occupational functioning and activities of daily living. (c.) The examiner should also provide a retrospective opinion, as can be ascertained from the Veteran’s self-reports as well as from any relevant VA treatment records and private treatment records, for the September 2015 and November 2017 VA examinations. For each examination, the examiner is asked to provide an opinion concerning whether the Veteran required the use of one or more daily injection of insulin. All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension is at least as likely as not related to his in-service exposure to herbicide agents in the Republic of Vietnam. All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Mussey, Associate Counsel