Citation Nr: 18144424 Decision Date: 10/24/18 Archive Date: 10/24/18 DOCKET NO. 16-04 729 DATE: October 24, 2018 ORDER Entitlement to a disability rating of 60 percent, but no higher, for service-connected chronic fatigue syndrome (CFS) is granted. Entitlement to a disability rating of 50 percent prior to September 30, 2015, and 70 percent from that date, for service-connected depressive disorder is granted. Entitlement to an effective date prior to December 5, 2012, for the grant of service connection for CFS is denied. Entitlement to an effective date prior to December 5, 2012, for the grant of service connection for depressive disorder is denied. REMANDED Entitlement to service connection for back disability is remanded. Entitlement to service connection for fibromyalgia is remanded. Entitlement to service connection for a bilateral hip condition is remanded. Entitlement to service connection for a respiratory condition, to include as secondary to service-connected depressive disorder is remanded. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. Entitlement to service connection for a digestive disorder is remanded. Entitlement to a disability rating in excess of 10 percent from December 19, 2014 to September 29, 2016, and compensable thereafter for service-connected pseudofolliculitis barbae is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. For the period on appeal, the Veteran’s CFS has manifested with debilitating fatigue, cognitive impairments, or a combination of other signs and symptoms which are nearly constant and restrict routine daily activities to less than 50 percent of the pre-illness level, or; which wax and wane, resulting in periods of incapacitation of at least six weeks total duration per year. 2. For the period on prior to September 30, 2015, the Veteran’s depressive disorder have approximated at least occupational and social impairment with reduced reliability and productivity. 3. For period since September 30, 2015, the Veteran’s depressive disorder approximated at least occupational and social impairment with deficiencies in most areas. At no time have the related symptoms resulted in total occupational and social impairment. 4. The Veteran was awarded service connection for CFS in a January 2016 rating decision. The Veteran filed an original claim for compensation on December 5, 2012, and modified this claim to include service connection for CFS prior to the first rating decision. 5. The Veteran was awarded service connection for depressive disorder in a January 2016 rating decision. The Veteran filed an original claim for compensation on December 5, 2012, and modified this claim to include service connection for depressive disorder prior to the first rating decision. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 60 percent, but no higher, for CFS have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2015); 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.88b, Diagnostic Code (DC) 6354 (2017). 2. The criteria for a disability rating of 50 percent prior to September 30, 2015, but no higher, for service-connected depressive disorder have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2015); 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.130, DC 9434 (2017). 3. The criteria for a disability rating of 70 percent from September 30, 2015, but no higher, for service-connected depressive disorder have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2015); 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.130, DC 9434 (2017). 4. The criteria for an effective date prior to December 5, 2012, for the award of service connection for CFS have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5108, 5110 (2015); 38 C.F.R. §§ 3.159, 3.400 (2017). 5. The criteria for an effective date prior to December 5, 2012, for the award of service connection for depressive disorder have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5108, 5110 (2015); 38 C.F.R. §§ 3.159, 3.400 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1985 to June 1992 in the United States Army. The Board acknowledges the Veteran’s claim for an earlier effective date regarding the disability rating for service-connected pseudofolliculitis barbae. Although the Veteran disagreed with the assignment of the 0 percent rating effective September 2016, the claim actually involves the propriety of the disability rating assigned during the entire appeal period. See Fenderson v. West, 12 Vet. App. 119 (1999). Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Separate DCs identify the various disabilities. VA should interpret 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. All reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. 1. Entitlement to an initial increased rating for service-connected CFS. The Veteran is currently in receipt of a 40 percent disability rating for service-connected CFS under DC 6354. 38 C.F.R. § 4.88b. DC 6354 provides ratings for CFS consisting of debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms. A 40 percent rating is assigned for signs and symptoms of CFS that are nearly constant and restrict routine daily activities to 50 to 75 percent of the pre-illness level, or the signs and symptoms wax and wane, resulting in periods of incapacitation of at least four but less than six weeks total duration per year. A 60 percent rating is assigned for signs and symptoms of CFS that are nearly constant and restrict routine daily activities to less than 50 percent of the pre-illness level, or signs and symptoms that wax and wane, resulting in periods of incapacitation of at least six weeks total duration per year. A 100 percent rating is assigned for signs and symptoms of CFS that are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care. A note to DC 6354 provides that, for the purpose of rating CFS, the condition will be considered incapacitating only while it requires bed rest and treatment by a physician. 38 C.F.R. § 4.88b. The Veteran is currently assigned a 40 percent initial disability rating for his service-connected CFS. The Veteran underwent an initial VA examination for CFS in February 2014. The Veteran’s symptoms were identified as debilitating fatigue, generalized muscle aches or weakness, fatigue lasting 24 hours or longer after exercise, and sleep disturbances. Cognitive impairments were also identified as an inability to concentrate and forgetfulness. All symptoms were described as nearly constant, with fatigue five to six days out of seven. Total duration of incapacitation periods over the previous 12 months were less than one week. Under the medical history portion of the disability questionnaire the Veteran’s debilitating fatigue was noted to reduce daily activity level to less than 50 percent of pre-illness level. Subsequently the VA examiner indicated that the symptoms restrict routine daily activities to 50 percent to 75 percent of the pre-illness level with no indication as to why this characterization was different than the medical history. In the Veteran’s notice of disagreement, he specifically requested a 60 percent rating and maintained that the characterization of his fatigue as reducing daily activity level to less than 50 percent of pre-illness level met that criteria. The Veteran also submitted multiple statements discussing the impact of his CFS symptoms on his daily activities, stating that his fatigue prevented significant levels of normal daily activity. There is a subsequent VA examination, conducted in September 2016, finding that the Veteran does not have a diagnosis of CFS. The Board finds this examination inadequate because it is contradicted by the contemporary competent medical evidence of record. The record also includes a private opinion from Dr. HS, submitted in February 2016, but this opinion is primarily focused on service connection rather than the current level of disability. Resolving all reasonable doubt in the Veteran’s favor, the Board finds that he is entitled to an initial 60 percent disability rating, but no higher, for his service-connected CFS. Specifically, the Board finds that the Veteran should be afforded the benefit of the doubt with regard to the results of his February 2014 VA examination. The examiner failed to explain the examination’s internal inconsistency where the Veteran’s debilitating fatigue was noted to reduce daily activity level to less than 50 percent of pre-illness level in the medical history portion, but also stated that symptoms restrict routine daily activities to 50 percent to 75 percent of the pre-illness level. Additionally, the Veteran’s subsequent competent statements describe impacts of the Veteran’s CFS on his daily activities that more closely approximate the criteria for a 60 percent disability rating. Considering the totality of the competent lay and medical evidence the Veteran’s symptoms more closely approximate a 60 percent disability rating, but no higher. There is no competent or credible evidence of record to indicate that the Veteran’s signs and symptoms of CFS are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care. Additionally, the medical evidence does not support a finding that CFS symptoms cause periods of incapacitation of at least six weeks total duration per year, defined as those requiring bed rest and treatment by a physician. 38 C.F.R. § 4.88b. 2. Entitlement to an initial increased rating for service-connected unspecified depressive disorder. The Veteran’s unspecified depressive disorder has been evaluated under the Rating Schedule for Mental Disorders. 38 C.F.R. § 4.130, DC 9434. A 50 percent rating is warranted if it is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for 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); and an inability to establish and maintain effective relationships. A 100 percent rating is assigned for 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 or minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives and own occupation or name. The symptoms listed in DC 9434 are not intended to 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. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Veteran’s VA treatment records include July 2013 health treatment identifying depressive disorder as the primary psychiatric disability. The Veteran mentions chronic suicidal thoughts but no plans or desires for actual self-harm due to his children and no current suicidal ideations. These thoughts, when they did occur, would resolve after several minutes. The Veteran also endorsed isolation as a primary symptom, stating that he does not have any friends and remains in his house. Additionally, the Veteran’s insight and judgment were both described as poor. The Veteran underwent an initial VA mental disorder examination in January 2014. The Veteran was diagnosed with a depressive disorder with symptoms noted to include depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The examiner characterized the depressive disorder as causing occupation 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. The Veteran’s relevant occupational and educational history noted that there were no mental health issues interfering with his work when he was working. The Veteran has received ongoing mental health counseling and treatment through the VA throughout the entire period on appeal. The Veteran’s VA medical treatment records indicate that there have been relatively stable reports in severity of the Veteran’s symptoms. There have been isolated instances of suicidal ideations that were characterized as “low risk” and there were no noted historical or current attempts associated with these ideations. In September 2015 the Veteran underwent a private examination, conducted by Dr. HH-G, a psychologist. Dr. HH-G used a Disability Benefits Questionnaire (DBQ) during the examination and identified the Veteran’s symptoms as depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression affecting the ability to function independently, chronic sleep impairment, mild memory loss, impairment of short and long term memory, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, persistent delusions or hallucinations, and persistent danger of hurting self or others. Dr. HH-G noted other symptoms of inability to enjoy the simplest of activities, restricted affect, social isolation, and paranoia. Dr. HH-G also included a substantive opinion to supplement the DBQ. The opinion discussed the symptoms noted on the DBQ and characterized the Veteran’s depressive disorder as manifesting with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The psychologist indicated that this severity in symptomatology “relates back to [the Veteran’s] original claim date of December 5, 2012.” Concurrent with the examination and opinion, the Veteran submitted statements from family members and friends discussing the impact of his psychiatric symptoms. The Veteran’s ex-wife, states that she witnessed his mental state worsen over the years and that “he became upset over everything, lashed out violently, and became mentally and emotionally abusive to her and in 1990 held a loaded gun to her head.” The Veteran’s brother, stated that the Veteran was “cold, distant, lost interest in all activities, [had] no motivation or energy, quiet, secretive, short tempered, mood swings and no longer attending church.” As to worsening symptoms he specifically cited mood swings and lack of interest in activities. A former significant other, stated that the Veteran’s mood swings, anger, and instability had worsened in the time she was with him. The Veteran’s sister described the Veteran as “quiet, reserved angry, defensive, easily upset, and prone to violent tendencies” which “worsened over time.” VA medical treatment records from October 2015 to the present also indicate that the Veteran regularly demonstrated symptoms such as depression, chronic sleep impairment with nightmares, anxiety, auditory and visual hallucinations, limited judgement and insight, paranoia, isolation, anhedonia, decreased motivation, outbursts of anger, and obsessive ritualistic behavior. The Board finds that the Veteran’s depressive disorder symptoms more closely approximate a 50 percent disability rating prior to September 30, 2015 (the date of the assessment by Dr. HH-G) and 70 percent thereafter. The only symptoms the Veteran displayed in his initial VA examination for his depressive disorder were depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. These symptoms, apart from disturbances of motivation and mood, are clearly contemplated by the criteria for a 30 percent rating. However, disturbances of motivation and mood are contemplated by the 50 percent rating criteria and the Veteran’s VA treatment records prior to this examination indicate additional, more serious, symptoms such as periodic suicidal ideations, ongoing social isolation, and impaired judgment/insight. While the VA examiner characterized the severity of the Veteran’s depressive disorder in terms of the 30 percent disability criteria, the Board finds that the overall disability picture during this period more closely approximates 50 percent. The Veteran’s VA treatment records subsequent to this examination did not include treatment for symptomatology that more closely approximated a disability rating in excess of 50 percent. The Veteran’s disability picture as documented by his VA mental health treatment remained consistent. The significant increase in the severity of the Veteran’s depressive disorder symptoms was not documented in competent evidence until the Veteran’s private evaluation in September 2015. This examination clearly demonstrates a disability picture contemplated by the 70 percent rating criteria. This worsening in symptoms is further corroborated by competent statements by the Veteran’s family and friends provided concurrent to the examination. While the opinion of Dr. HH-G indicated that this level of disability existed since the Veteran filed his original claim the Board finds this opinion less probative as it is a conclusory statement without supporting rationale and no medical evidence for the period prior to the examination was cited in support of the opinion. The most probative evidence of record for the period prior to September 2015 indicates that the Veteran’s depressive disorder symptoms remained relatively consistent in severity. At no time during the period on appeal did the Veteran’s depressive disorder symptoms manifest to a level of severity that more closely approximates total occupational and social impairment. Effective Date Prior to March 2015, VA would accept an informal claim-i.e., any communication or action indicating an intent to apply for one or more benefits, 38 C.F.R. § 3.155 (a) (2014)-as an original claim for effective date purposes. Standard Claims and Appeals Forms, 79 Fed. Reg. 57,660 (Sept. 25, 2014) amends inter alia, 38 C.F.R. § 3.155, entitled Informal claims. As the claim at issue here was filed prior to March 2015, the Board will consider whether there were any prior informal claims. To qualify as an informal claim, a written document must evince an intent to apply for benefits and identify the benefits sought. See MacPhee v. Nicholson, 459 F.3d 1323 (Fed. Cir. 2006); Brokowski v. Shinseki, 23 Vet. App. 79 (2009). 3. Entitlement to an earlier effective date for the grant of service connection for CFS prior to December 5, 2012. The Veteran seeks an earlier effective date for the grant of service connection for CFS. A claim of entitlement to service connection for CFS was received by VA through phone contact with the Veteran on December 5, 2012. Service connection was granted, effective December 5, 2012, in the January 2016 rating decision. Based on a review of the record, the Board finds no document that could serve as an informal claim prior to December 2012. The Veteran has not identified any prior claim or provided any specific argument regarding why he should be awarded an effective date earlier than December 2012. As there is no evidence of any prior claim, the Veteran is already in receipt of the earliest possible effective date as the effective date assigned is the date the Veteran’s claim was received. 4. Entitlement to an earlier effective date for grant of service connection for depressive disorder prior to December 5, 2012. The Veteran seeks an earlier effective date for the grant of service connection for depressive disorder. A claim of entitlement to service connection for depressive disorder was received by VA through phone contact with the Veteran on May 14, 2013 but was added to the Veteran’s December 2012 initial claim. Service connection was granted, effective December 5, 2012, in the January 2016 rating decision. Based on a review of the record, the Board finds no document that could serve as an informal claim prior to December 2012. The Veteran has not identified any prior claim or provided any specific argument regarding why he should be awarded an effective date earlier than December 2012. As there is no evidence of any prior claim, the Veteran is already in receipt of the earliest possible effective date as the effective date assigned is the date the Veteran’s claim was received. REASONS FOR REMAND 1. Entitlement to service connection for back disability is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a back condition because no VA examiner has adequately opined as to the nature of the Veteran’s current back condition diagnosis and whether any current back condition is etiologically related to service, or alternatively, pre-existed and was aggravated by service. The medical evidence of record is conflicting and mixed with regard to a diagnosed pathology for the Veteran’s claimed back condition. It is clear that the Veteran has back pain. However, the February 2014 VA examination is internally inconsistent as it indicates there is a diagnosis of Intervertebral Disc Syndrome (IVDS), an opinion that addresses degenerative joint disease (DJD), and an opinion that stated the Veteran had scoliosis that was not incurred in or aggravated by service. This examination and opinions are inadequate. The examiner does not address the stated diagnosis of IVDS, states that there is no DJD but offers an opinion discussing DJD, and seems to indicate that the Veteran had a preexisting back condition but did not use the correct standard in their analysis. Furthermore, the specific question of whether the Veteran had a preexisitng back condition was raised in a private opinion by Dr. HS. This opinion indicated that the Veteran’s “back condition was aggravated beyond normal progression due to serving in the armed forces.” Aggravation beyoned normal progression is the definition of aggravation used in analysis of a disability that clearly and unmistakably preexisted service. When analyzing such a condition, physicians are required to opine whether there is clear and unmistakable evidence that the Veteran’s preexisting condition was not aggravated by his active duty serivce. However, Dr. HS stated that the Veteran’s back condition was not evident prior to service and did not develop “until beginning rigorous military routines.” Therefore, on remand, the question of whether the Veteran had a preexisting back conditon that was aggravated by service must be clarified. Alternatively, the examiner must opine whether any back condition is at least as likely as not etiologically related to service. If no back condition is diagnosed, the examiner must opine whether the Veteran’s back pain is etiolofically related to service and discuss any functional impairment associated with such pain. 2. Entitlement to service connection for fibromyalgia is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for fibromyalgia because no VA examiner has adequately opined whether the Veteran has a current diagnosis of fibromyalgia that is etiologically related to service. The Veteran underwent a VA examination in in September 2016 for fibromyalgia. The examiner stated that the Veteran did not have, or ever had, a diagnosis of fibromyalgia. The examiner characterized the Veteran’s claim as an unverified claim of fibromyalgia and opined that the Veteran’s symptoms were “better explained by his underlying primary orthopedic conditions.” Subsequent to this examination the Veteran submitted a statement from his physician, Dr. AS, who has treated the Veteran since February 2, 2004. Dr. AS stated that he treated the Veteran for fibromyalgia and that his opinion was that the issue was service-connected because “he has no other known risk factors that may have precipitated his current condition.” No further rationale was provided. On remand a VA examination and opinion must be obtained to clarify whether the Veteran has a current fibromyalgia diagnosis that is etiologically related to service. 3. Entitlement to service connection for a hip condition is remanded. The Board cannot make a fully-informed decision on the issue of a hip condition because no VA examiner has opined as to the nature of any current hip conditions and whether any current hip condition is etiologically related to service, or alternatively, pre-existed and was aggravated by service. The medical evidence of record is conflicting and mixed with regard to a diagnosed pathology for the Veteran’s claimed hip condition, to include whether there are bilateral manifestations. It is clear that the Veteran has hip pain but the evidence is mixed as to whether such pain is bilateral. Additionally, the Veteran’s private treatment records include diagnoses of left and right hip changes consistent with Perthes’ Disease, a childhood disease, confirmed by diagnostic imaging. These changes were noted to be more prominent in the left hip. The post-service medical records also indicate that the Veteran underwent a total left hip replacement in 2013. In October 2014 the Veteran’s private physician, Dr. AS, diagnosed the Veteran with status post total hip replacement (left) secondary to Perthes Disease and opined that the Veteran “is entitled to benefits through compensation/physical” but provided no rationale. Dr. AS reiterated his opinion that he Veteran’s left hip replacement should be service-connected in an August 2017 opinion but again provided no rationale. Therefore, on remand the Veteran must be afforded a VA examination to determine the nature of any current hip condition and obtain an opinion as to whether such a condition preexisted and was aggravated by active duty service. Alternatively, the examiner must opine whether any hip condition is at least as likely as not etiologically related to active duty service. If no hip condition is diagnosed, the examiner must opine whether the Veteran’s hip pain is etiologically related to service and discuss any functional impairment associated with such pain. 4. Entitlement to service connection for a respiratory condition secondary to service-connected depressive disorder is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a respiratory condition because no VA examiner has adeqautely opined whether the Veteran’s respiratory condition is caused or aggravated by his servie-connected depressive disorder and associated symptoms. The Veteran underwent a VA examination for respiratory condition in which the examiner stated the Veteran does not have, or has had, a respiratory condition. However, the Veteran described to the examiner a 15 to 20 year history of an inability to “get a good breath.” Chest X-rays and pulmonary function testing did not show an abnormality how ever the examiner opined that the Veteran’s description of breathing issues were as likely as not anxiety related. Anxiety has been identified as a symptom of the Veteran’s service-connected depressive disorder. Therefore, an addendum opinion is needed to clarify whether the Veteran’s breathing difficulties are a separate disability or a symptom of anxiety. 5. Entitlement to service connection for OSA, to include as secondary to service-connected depressive disorder is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for OSA because no VA examiner has opined whether the Veteran’s diagnosed OSA is etiologically related to active duty service or secondary to his service-connected depressive disorder. The Veteran underwent a VA examination for OSA in July 2016. The Board finds that the opinion offered was inadequate because it was limited to the specific etiological relationship between OSA and Gulf War contaminent exposure. Thus, on remand an addendum opinion is needed to address OSA on a direct basis to active duty service. Alternatively, the Veteran’s representative has asserted that OSA is secondary to the Veteran’s service-connected depressive disorder. Cited are August 2016 mental health records indicating that the Veteran does not use his continuous positive airway pressure (CPAP) machine due to smothering sensation and medical literature indicating that the Veteran’s depressive disorder and OSA “are comorbid and the depressive disorder caused and permanently aggravates the Veteran’s OSA.” As the representatitve is not a medical professional his opinions based on the literature are not competent. However, an addendum opinion must be obtained to to address this evidence. 6. Entitlement to service connection for a digestive disorder is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a digestive disorder because no VA examiner has adequately opined whether the Veteran has a digestive disorder etiologically related to active duty service. In a July 2014 VA examination the examiner stated that the Veteran did not have, or ever had, a diagnosed intestinal condition. However, the examiner also indicated that the Veteran had diarrhea following meals for approximately 15 to 20 years attributable to a non-surgical/non-infectious intestinal conditions. Therefore, on remand an addendum opinion must be obtained to clarify whether the Veteran has a current digestive disorder/intestinal condition and, if so, indicate whether any such condition is etiologically related to active duty serivce. 7. Entitlement to a disability rating in excess of 10 percent for the period from December 19, 2014 to September 29, 2016 and noncompensable thereafter for service-connected pseudofolliculitis barbae is remanded. The Veteran’s most recent VA examination for service-connected pseudofolliculitis barbae was conducted in September 2016. However, the Board finds the examination inadequate as it failed to address the Veteran’s private treatment records for pseudofolliculitis barbae. In a May 2015 statement, the Veteran asserted that the pseudofolliculitis barbae disability has increased in severity since the Veteran was last adequately examined by VA. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of service-connected pseudofolliculitis barbae disability. 8. Entitlement to TDIU is remanded. The Veteran raised the issue of entitlement to a TDIU in a March 2018 statement. Rice v. Shinseki, 22 Vet. App. 447 (2009). The AOJ should develop the issue, to include having the Veteran complete a VA Form 21-8940. The matters are REMANDED for the following action: 1. Provide the Veteran with a VA Form 21-8940, Application for TDIU and request that he submit the completed form, with all appropriate information. Thereafter, take all appropriate action on the TDIU claim, to include obtaining any necessary examinations or opinions. 2. After completion of the above, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any back conditions. The examiner must clarify and identify all diagnoseable back conditions. For any diagnosed back condition, the examiner must opine whether the Veteran had a back condition that clearly and unmistakably (undebatable) preexisted the Veteran’s service. If the examiner finds it did clearly and unmistakably preexist service, the examiner must opine whether it was clearly and unmistakably not aggravated by service. If the examiner finds that it either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. The examiner should consider, and discuss as necessary, the opinion of Dr. HS regarding a preexisting back condition and the February 2014 VA examination. If a back condition is not diagnosed, is it at least as likely as not that there is objective evidence of back pain? If so, does the objectively confirmed back pain reach the level of functional impairment of earning capacity? In answering this question, the examiner should ask the Veteran to explain the effect of pain. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any fibromyalgia. The examiner must clarify and determine whether the Veteran has a current diagnosis of fibromyalgia. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. In rendering this opinion, the examiner should consider, and discuss as necessary, the diagnosis and opinion of Dr. AS. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any hip conditions. The examiner must clarify and identify all diagnoseable hip conditions. For any diagnosed hip condition, the examiner must opine whether the Veteran had a hip condition that clearly and unmistakably (undebatable) preexisted the Veteran’s service. If the examiner finds it did clearly and unmistakably preexist service, the examiner must opine whether it was clearly and unmistakably not aggravated by service. If the examiner finds that it either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, the examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. In rendering this opinion, the examiner should consider, and discuss as necessary, the diagnosis of Perthes Disease and the opinion of Dr. AS. If a hip condition is not diagnosed, is it at least as likely as not that there is objective evidence of hip pain? If so, does the objectively confirmed hip pain reach the level of functional impairment of earning capacity? In answering this question, the examiner should ask the Veteran to explain the effect of pain. 5. Obtain an addendum opinion from an appropriate clinician (with an examination if deemed necessary) regarding whether the Veteran has a diagnosed respiratory condition that is separate from his service-connected disabilities. If a separate respiratory condition is identified is it at least as likely as not related to proximately due to or aggravated by service-connected disability, specifically the anxiety symptoms of the Veteran’s service-connected depressive disorder. The examiner is informed that aggravation here is defined as any increase in disability 6. Obtain an addendum opinion from an appropriate clinician (with an examination if deemed necessary) regarding whether the Veteran’s OSA is at least as likely as not related to active duty service or proximately due to or aggravated by service-connected disability, specifically service-connected depressive disorder. In rendering these opinions, the clinician must address the statements regarding noticing sleep issues shortly after separation from active duty and the medical literature submitted by the Veteran’s representative regarding associations between psychiatric disorders and OSA. 7. Obtain an addendum opinion from an appropriate clinician (with an examination if deemed necessary) regarding whether the Veteran has a current digestive/intestinal disorder that is at least as likely as not related to service. In rendering this opinion, the clinician must address the Veteran’s statements regarding experiencing diarrhea following meals for 15 to 20 years. (Continued on the next page)   8. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected pseudofolliculitis barbae. 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. 9. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined TDIU claim. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. M.E. Larkin Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P.S. McLeod