Citation Nr: 18144532 Decision Date: 10/25/18 Archive Date: 10/24/18 DOCKET NO. 16-18 541 DATE: October 25, 2018 ORDER Entitlement to service connection, to include on a secondary basis, for coronary artery disease (CAD) is granted. Entitlement to service connection, to include on a secondary basis, for hypertension is granted. Entitlement to service connection, to include on a secondary basis, for obstructive sleep apnea (OSA) is granted. Entitlement to service connection for skin cancer is denied. Entitlement to an effective date earlier that July 28, 2014 for the grant of service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to an initial 70 percent disability rating, but no higher, for PTSD is granted subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. REMANDED Entitlement to service connection, to include on a secondary basis, for headaches is remanded. Entitlement to an initial rating in excess of 10 percent disabling for right ankle disability is remanded. FINDINGS OF FACT 1. CAD has been shown to be etiologically related to the Veteran’s PTSD. 2. Hypertension has been shown to be etiologically related to the Veteran’s PTSD. 3. OSA has been shown to be etiologically related to the Veteran’s PTSD. 4. The Veteran does not have a diagnosed skin cancer disorder. 5. The Veteran filed an original claim for entitlement to service connection for PTSD on July 28, 2014. 6. The Veteran’s PTSD more nearly approximated occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking or mood due to such symptoms as suicidal ideation, impaired impulse control, such as unprovoked irritability with periods of violence, difficulty in adapting to stressful circumstances, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, and memory loss. 7. The Veteran is service connected for the following disabilities: PTSD rated 70 percent disabling as of July 28, 2014; right ankle disability rated 10 percent disabling as of June 13, 2012; and bilateral varicose veins rated non-compensable. Pursuant to this decision, the Veteran is also service connected for CAD, hypertension and OSA with ratings to be assigned by the Agency of Original Jurisdiction (AOJ). 8. The Veteran is unable to secure and follow substantially gainful employment as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for CAD have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 3.159, 3.303, 3.310 (2018). 2. The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 3.159, 3.303, 3.310 (2018). 3. The criteria for entitlement to service connection for OSA have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 3.159, 3.303, 3.310 (2018). 4. The criteria for entitlement to service connection for skin cancer have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 3.159, 3.303 (2018). 5. The criteria for an effective date earlier than July 28, 2014, for the award of service connection for PTSD have not been met. 38 U.S.C. §§ 5101(a), 5107, 5110 (2012); 38 C.F.R. §§ 3.1(p), 3.104, 3.151, 3.156, 3.160, 3.400 (in effect prior to March 24, 2015). 6. The criteria for an initial 70 disability percent rating, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1-4.7, 4.15, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411 (2018). 7. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1970 to May 1995. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 rating decision by a Department of Veterans Affairs Regional Office (RO). The Board observes that additional evidence has been added to the claims file following the last adjudication by the RO in the April 2016 statement of the case (SOC), including a December 2016 brief filed by the representative, disability benefits questionnaires (DBQs) and medical opinion letters prepared by the Veteran’s private physicians. The Board notes that the December 2016 brief included a waiver of consideration of evidence by the regional office. Additionally, as the Veteran’s substantive appeal was received in April 2016, which is after February 2, 2013, an automatic waiver of evidence submitted by the claimant or his representative is presumed. The Board notes that additional VA treatment records were also received following the April 2016 SOC, including an April 2015 VA examination of the right ankle. The Board observes that the April 2016 SOC lists the April 2015 VA examination as evidence of record that was considered. In any event, with regard to the service connection issues granted in this decision, there is no risk of prejudice to the Veteran from proceeding without a waiver. Finally, with regard to the service connection claim for skin cancer, the Board has reviewed these records and observes that they are not pertinent to that issue of service connection in the decision below. The Board further notes that in a December 2016 brief, the representative asserted that the evidence of record showed the PTSD symptoms prevented the Veteran from maintaining substantially gainful employment. As such, a claim for a TDIU has been raised by the record and is part of the current appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Lastly, the Board notes that an August 2013 rating decision granted service connection for right ankle disability and denied service connection for blood clots and diabetes mellitus II. The denial of the service connection claim for diabetes was based on a finding that new and material evidence had not been received. In July 2014, the Veteran filed a timely notice of disagreement. A SOC was issued in May 2015 addressing all three issues. In June 2015, the Veteran filed a VA Form 9, Substantive Appeal, with regard to the denial of his diabetes claim, “and any other AO presumptive listed in the SOC.” The June 2015 Form 9 further requested a Board hearing. An April 2016 VA Form 8 certified all three issues to the Board under a separate docket number. The Board finds that the inclusion of the increased rating claim for right ankle disability was incorrectly included in the separate appeal stemming from the August 2013 rating decision and was properly perfected from the appeal stemming from the May 2015 rating decision currently before the Board. As such, the issues of entitlement to service connection for diabetes and blood clots will be decided by the Board at a later time following the requested hearing. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Lay evidence presented by a Veteran concerning continuity of symptoms after service may not be deemed to lack credibility solely because of a lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (2006). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. CAD, Hypertension and OSA The Veteran seeks entitlement to service connection for a heart condition, hypertension and OSA. Specifically, the Veteran asserts that the above-mentioned disorders are secondary to his service-connected PTSD. Initially, the Board notes that the Veteran’s STRs are silent as to any diagnosed heart condition, hypertension or OSA. With regard to the claim for a heart condition, the STRs do show that the Veteran complained of chest pain (February 1975, September 1985, and September 1991). However, those reports of chest pain were found related to probable bronchitis, costochondritis and musculoskeletal issues, respectively. Post-service records show that in May 2012, the Veteran was diagnosed with coronary artery disease (CAD) status post stenting and chest pains, hypertension and OSA. In a December 2016 letter, Dr. HS opined that the Veteran’s service-connected PTSD aided in the development and permanently aggravated his diagnosed CAD. In support of this opinion, Dr. HS noted the Veteran’s PTSD symptoms including depressed mood, anxiety, chronic sleep impairment, mild memory loss, difficulty in adapting to stressful circumstances, and impaired impulse control. Dr. HS further noted that symptoms of anxiety and depression stimulated an unhealthy heart rate resulting in constant long-term stress thereby damaging the heart. In addition, medical research was also noted to show that anxiety disorders played a major role in the development of heart disease, and that medical literature showed a clear correlation between PTSD and cardiovascular disease including CAD and stroke. In another December 2016 letter, Dr. HS opined that the Veteran’s service-connected PTSD aided in the development and permanently aggravated his diagnosed hypertension. In support of this opinion, Dr. HS noted the above-mentioned PTSD symptoms and further noted medical research that had shown mental health conditions predictive of later incidence of hypertension. Dr. HS further noted that the incidence of hypertension was higher in persons with high or intermediate depressive symptoms. Based on the medical literature, Dr. HS found that a relationship between hypertension and PTSD was undisputed, that symptoms of anxiety and depression stimulated an unhealthy heart rate resulting in constant long-term stress thereby increasing high blood pressure due to an increased heart rate and constricted blood vessels. Finally, a December 2016 DBQ shows a diagnosis for OSA and persistent daytime hypersomnolence. The physician, Dr. HS, noted that the diagnosed OSA required the use of a CPAP machine. The Veteran reported non-compliance with his CPAP machine about half the time as use of the machine caused anxiety and panic attacks. As a result, the Veteran reported that he would “rip off the mask... in the middle of the night.” Due to the Veteran’s inability to use the CPAP machine every night, Dr. HS found that the Veteran’s service-connected PTSD aggravated the OSA condition as the Veteran suffered from frequent daytime sleepiness and had to take frequent naps. Dr. HS further noted medical literature that found an association between PTSD and OSA, including a finding that PTSD promoted the development of OSA. Dr. HS further noted that medical literature supported a finding of a comorbid relationship between the two conditions. Based on the above, Dr. HS opined that it was “as likely as not his [PTSD] aided in the development of his OSA and has permanently aggravated his OSA.” In the present case, there is sufficient evidence the Veteran meets the threshold criterion for service connection of a current disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Specifically, the medical evidence shows diagnoses for CAD, hypertension and OSA. Therefore, the remaining question is whether those disabilities are related to service. After a review of the evidence of record, the Board finds that service connection for CAD, hypertension and OSA is warranted. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury; or, for any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of nonservice-connected condition. 38 C.F.R. § 3.310(a), (b). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In this regard, the Board finds the December 2016 medical opinion letters and DBQ the most probative evidence of record. Dr. HS noted review of the entire claims file, provided positive nexus opinions finding that the claimed conditions were caused and/or aggravated by the Veteran’s service-connected PTSD, and provided a detailed rationale for the medical opinions rendered. Importantly, there is no medical evidence to the contrary. As such, the only competent medical evidence of record supports a finding that the diagnosed CAD, hypertension and OSA are secondary to the Veteran’s service-connected PTSD. Thus, all three Shedden requirements have been met and the claims are granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 2. Skin Cancer The Veteran filed a service connection claim for skin cancer in July 2014. Initially, the Board notes that the service treatment records (STRs) are silent as to any treatment or diagnosis for skin cancer. Additionally, in-service examinations noted normal skin and the Veteran denied any skin disease, including in May 1970, March 1974, February 1978, February 1984, September 1990, April 1994, and March 1995. Post-service medical records include an October 1995 general examination noting the Veteran was negative for a skin condition. A July 2003 VA medical record noted that the Veteran did not have any skin cancer. An assessment for diabetes did note reddish blotches and hyperpigmented that appeared to be necrobiosis lipoidica related to diabetes. Finally, since filing his claim, private treatment records dating from November 2008 to December 2012 noted no skin conditions including rashes. A necessary element for establishing entitlement to service connection is the existence of a current disability; it is the cornerstone of a claim for VA disability compensation. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). For VA purposes, a current disability exists when a claimant has a disability at the time a claim is filed or at some point during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he/she files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim). Here, the Veteran has consistently claimed entitlement to service connection for skin cancer. However, the evidence of record does not show any diagnosed skin cancer. Moreover, since filing his claim in July 2014, the evidence of record does not show any diagnosed skin condition. Importantly, the Veteran has not offered any lay evidence with regard to this claim on appeal. Accordingly, absent a diagnosis for skin cancer, the Board finds that the probative evidence is against the Veteran’s claim for service connection. Although the Veteran is entitled to the benefit-of-the-doubt where the evidence is in approximate balance, the benefit-of-the-doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for service connection. The claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Effective Date The Veteran filed a service connection claim for PTSD in July 2014. A May 2015 rating decision granted service connection for PTSD effective July 28, 2014; the date the Veteran filed his claim. The Veteran asserts entitlement to an earlier effective date. The Board notes that on March 24, 2015, VA amended its adjudication regulations to require that all claims governed by VA’s adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57660 (Sept. 25, 2014). The amendments, however, are only effective for claims and appeals filed on or after March 24, 2015. As the appeal in this case was filed prior to that date, the amendments are not applicable in this instance and the regulations in effect prior to March 24, 2015 will be applied in this case. Generally, except as otherwise provided, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity 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 later. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400. That is, the effective date of an award “shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor.” 38 U.S.C. § 5110(a). The Veteran seeks an effective date earlier than July 28, 2014 for the award of service connection for PTSD. However, the evidence of record reflects that the Veteran filed his service connection claim on July 28, 2014. There is no earlier communication expressing a desire to file a claim prior to that date of record. Moreover, he had not provided an explanation as to why he believes he is entitled to an earlier date. Accordingly, the Board concludes that July 28, 2014 is the proper effective date for the grant of service connection for PTSD. There is no legal basis for an earlier effective date. In reaching this decision the Board has considered the doctrine of reasonable doubt. However, the preponderance of the evidence is against the Veteran’s claim and the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Increased Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings 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. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, and the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. PTSD In July 2014, the Veteran filed a service connection claim for PTSD which was granted in a May 2015 rating decision. The Veteran appealed the initial 50 percent assigned rating. Specifically, the Veteran asserts his PTSD more nearly approximates a 70 percent rating. The Veteran’s PTSD is rated pursuant to 38 C.F.R. § 4.130, DC 9411. Under the rating criteria, a 50 percent rating is assigned for a psychiatric disorder manifested by 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. Id. A 70 percent rating is assigned for PTSD manifested by 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), or an inability to establish and maintain effective relationships. Id. A maximum 100 percent rating is assigned for PTSD manifested by total occupational and social impairment due to such symptoms as gross impairment in thought process 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, and memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. If the evidence shows that the veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (2002); Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). The Board notes that the evidence of record is limited as the Veteran has not been shown to have undergone treatment for his PTSD. After filing his claim in July 2014, the Veteran underwent a VA examination in January 2015. During that examination, the Veteran’s diagnosed PTSD was found manifested by occupational and social impairment with reduced reliability and productivity. The examiner noted current symptoms including: depressed mood; anxiety; mild memory loss, such as forgetting names, directions or recent events; difficulty in adapting to stressful circumstances, including work or a worklike setting; and impaired impulse control, such as unprovoked irritability with periods of violence. The Veteran was noted as appropriately attired, responsive and cooperative. He was found oriented to all spheres. The Veteran did report nightmares “every once in a while, not every week.” In addition, the Veteran endorsed suicidal ideation in the past, but not recently. The evidence of record also includes a November 2016 DBQ conducted by Dr. HGG. During an interview, Dr. HGG noted that the Veteran reported being socially isolated and withdrawn and that he needed assistance with performing activities of daily living. The diagnosed PTSD was found manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking and/or mood. No other psychiatric disorder was diagnosed. The following symptoms were found: depressed mood; anxiety; suspiciousness; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss such as forgetting names, directions or recent events; impairment of short and long term memory; memory loss for names of close relatives, own occupation or own name; flattened effect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; suicidal ideation; persistent delusions or hallucinations; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Finally, Dr. HHG noted that the severity of the Veteran’s symptoms dated back to July 2014. After a review of the evidence of record, the Board finds that an increased initial rating of 70 percent is warranted. Specifically, during the entire period on appeal, the Board finds that the evidence establishes that the Veteran’s PTSD has been manifested by symptoms including: suicidal ideation; impaired impulse control, such as unprovoked irritability with periods of violence; difficulty in adapting to stressful circumstances; and memory loss. The above-mentioned symptoms are specifically contemplated by a higher 70 percent rating. The Board recognizes the November 2016 DBQ in which Dr. HHG checked the boxes for: memory loss for names of close relatives, own occupation or own name; persistent delusions or hallucinations; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Even though these symptoms were checked on the DBQ form, Dr. HHG summarized that the Veteran’s overall functioning more nearly approximated the criteria for occupational and social impairment with deficiencies in most areas. Further, the discussion of the Veteran’s symptomatology does not reflect that he is totally both socially and occupationally impaired. As noted by Dr. HHG, the Veteran has been in a relationship with his significant other since his spouse died. Thus, total social impairment has not been shown. In sum, the Board finds that an initial 70 percent disability rating is warranted, but no higher. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.130; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. §§ 3.340(a)(1), 4.15. “Substantially gainful employment” is that employment “which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides.” Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). “Marginal employment shall not be considered substantially gainful employment.” 38 C.F.R. § 4.16(a). In determining whether unemployability exists, consideration may be given to the veteran’s level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. A total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16(a). As noted above, in a December 2016 brief, the representative asserted that evidence of record showed that the PTSD symptoms prevented the Veteran from maintaining substantially gainful employment. Accordingly, a claim for a TDIU has been raised by the record. During the pendency of the appeal, the Veteran has been service connected for the following disabilities: PTSD rated 70 percent disabling; right ankle disability rated 10 percent disabling as of June 13, 2012; and bilateral varicose veins rated non-compensable. Pursuant to this decision, the Veteran is also service connected for a heart condition, hypertension and OSA with ratings to be assigned by the Agency of Original Jurisdiction (AOJ). The Board notes the Veteran has met the schedular rating criteria as of July 28, 2014. During the period on appeal, the evidence of record includes a January 2015 VA PTSD examination which noted current symptoms including: depressed mood; anxiety; mild memory loss, such as forgetting names, directions or recent events; difficulty in adapting to stressful circumstances, including work or a worklike setting; and impaired impulse control, such as unprovoked irritability with periods of violence. The Veteran underwent a VA ankle examination in April 2015. The Veteran reported that he experienced less stability and that his ankle felt like it rolled outward causing increased pain. The Veteran also reported flare-ups during which he would have to sit and wait for the pain to pass. The examiner noted abnormal ROM that caused functional loss including difficulty walking and pushing on gas pedals. During ROM testing, pain was noted in dorsiflexion and plantar flexion. There was also objective evidence of localized tenderness on palpation of the ankle located in the lateral ankle inferior to the lateral malleolus. The examiner did note that he was unable to assess whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time as that would require mere speculation. Other contributing factors of a right ankle disability included deformity, disturbance of locomotion and interference with standing. A reduction of muscle strength was noted. The examiner also noted that ankle instability or dislocation was suspected. The Veteran reported that he could no longer run any distance. The Veteran also reported that he used to farm which included driving tractors. The examiner found the Veteran could no longer perform those functions. The Veteran further reported that he could only drive for about 15 miles and then had to get out and walk around and at times he used his left foot on the accelerator. With regard to employability, the examiner found the Veteran could perform sedentary work such as phone and other office type activities during which he would have to get up and move around every 45 minutes and that he would have to elevate his foot while sitting. Finally, a December 2016 DBQ found the Veteran’s OSA manifested by persistent daytime hypersomnolence. The physician found that the Veteran’s excessive daytime sleepiness would interfere with a normal work day. After a review of the evidence of record, the Board finds that the totality of the record indicates the functional impairments caused by the Veteran’s service-connected disabilities render him unable to secure or follow a substantially gainful occupation. First, the evidence of record indicates the functional impairments caused by the service-connected disabilities would likely prevent the Veteran from obtaining or maintaining an occupation involving physical labor. This includes his right ankle disability and OSA which render him unfit to operate heavy machinery or vehicles. In addition, right ankle symptoms make it difficult for the Veteran to lift heavy objects or to work on his feet for a normal work day. Second, the Board finds the service-connected PTSD would likely prevent the Veteran from following a substantially gainful sedentary occupation. First, the evidence of record indicates the Veteran has struggled with anger, irritability and difficulty in adapting to stressful circumstances, including work or a worklike setting. During this period on appeal, the Veteran’s PTSD was also found manifested by memory loss such as forgetting directions. The Board finds that the combined persistent functional effects would likely prevent the Veteran from being able to work around others, be effectively supervised, sustain the focus and attention to learn necessary skills, or to complete a full, productive work schedule in a substantially gainful occupation. Accordingly, based on the evidence of record, the Board finds the functional effects of the Veteran’s service-connected disabilities have rendered him unable to secure and follow a substantially gainful occupation throughout the appeal period. Therefore, entitlement to a TDIU is warranted. REASONS FOR REMAND 1. Headaches The Veteran asserts entitlement to service connection for headaches. The claims file includes an April 2008 private medical record in which the Veteran reported a one-week history of right-sided headaches. The Veteran further reported that his headaches occurred mostly at night and would wake him from sleep. The physician assessed the Veteran with new onset headaches with mental status changes. In October 2012, the Veteran reported increased frequency and severity of his headaches. In addition, the physician noted that the Veteran was referred to neurology due to multiple symptoms of transient ischemic attack including headaches. Accordingly, the medical evidence suggests that the Veteran’s headache condition may be secondary to his service-connected PTSD and/or CAD. At a January 2015 VA examination, the Veteran was diagnosed with migraines including migraine variants with 2013 listed as the date of diagnosis. The Veteran reported the onset of his headaches approximately one and a half years prior with pain located on the right side. The examiner opined that the diagnosed headache condition was “less likely than not (less than 50% probability)” etiologically related to service. While the examiner noted a date of diagnosis of 2013, as noted above, the medical evidence shows a diagnosis for new onset right-sided headaches as of April 2008. Accordingly, the VA examination was based, at least in part, on an inaccurate factual predicate. Moreover, no opinion as to secondary service connection was provided. Accordingly, a remand is necessary and further assistance to the Veteran is required in order to comply with the duty to assist as mandated by 38 U.S.C. § 5103A, and to afford the Veteran an adequate VA examination. Barr v. Nicholson, 21 Vet. App. 303 (2007). 2. Right Ankle The Veteran last underwent a VA examination in April 2015. The examiner noted abnormal ROM that caused functional loss including difficulty walking and pushing on gas pedals. Pain was also noted in dorsiflexion and plantar flexion during ROM testing. However, the examiner did not provide ROM testing results. The Veteran’s right ankle disability is rated pursuant to 38 C.F.R. § 4.71a, DC 5271, which provides a 10 percent rating for moderate limited ankle motion and a 20 percent rating for marked limited ankle motion. While the schedule of ratings does not provide any information as to what manifestations constitute “moderate” or “marked” limitation of ankle motion, guidance can be found in VBA’s M21-1 Adjudication Procedures Manual. Specifically, the M21-1 states that moderate limitation of ankle motion is present when there is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, while marked limitation of motion is demonstrated when there is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. See VBA Manual M21-1, III.iv.4.A.6.m. Normal range of motion for the ankle is defined as follows: dorsiflexion from zero to 20 degrees; and plantar flexion from zero to 45 degrees. See 38 C.F.R. § 4.71, Plate II. Accordingly, in order to properly rate the Veteran’s right ankle disability, a new VA examination providing ROM testing results is necessary. The matter is REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran’s VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. Then, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed headache condition. The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed headache condition is etiologically related to his period of service? (b) Is it at least as likely as not (50 percent or greater probability) that any diagnosed headache condition was caused by the Veteran’s service-connected disabilities, to include heart condition and PTSD? Please explain why or why not. (c) Is it at least as likely as not (50 percent or greater probability) that any diagnosed headache condition was permanently worsened beyond normal progression (aggravated) by the Veteran’s service-connected disabilities, to include heart condition and PTSD? Please explain why or why not. If the examiner finds that the disability was aggravated by the service-connected disability, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred. The examiner should review pertinent documents in the Veteran’s claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 3. After the development in #1 has been completed, schedule the Veteran for an examination by an appropriate examiner to determine the current nature and severity of his service-connected right ankle disability. (Continued on the next page)   The examiner should review pertinent documents in the Veteran’s claims file and this Remand in connection with the examination. All indicated studies should be completed, and all pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The examiner should conduct range of motion studies for both the right and left ankle, and assess any functional impairment due to such factors as pain and weakness, and express this functional impairment in terms of further loss of motion. The examiner should test the range of motion in active motion, passive motion, weight-bearing, and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Lamb, Associate Counsel