Citation Nr: 18144638 Decision Date: 10/25/18 Archive Date: 10/24/18 DOCKET NO. 16-06 514 DATE: October 25, 2018 ORDER New and material evidence having been received, the claim for entitlement to service connection for right shoulder condition is reopened; to this extent, the claim is granted. New and material evidence having been received, the claim for entitlement to service connection for migraines is reopened; to this extent, the claim is granted. Entitlement to service connection for right shoulder condition is denied. Entitlement to service connection for sleep disorder also claimed as sleep apnea is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for migraines is denied. Entitlement to an increased evaluation in excess of 50 percent for post-traumatic stress disorder is denied. REMANDED Entitlement to service connection for acid reflux is remanded. FINDINGS OF FACT 1. By a May 2006 rating decision, the Regional Office (RO) denied the Veteran’s claims for service connection for right shoulder condition and service connection for migraines; he was advised of the RO’s decision, and of his appellate rights. 2. The Veteran did not initiate an appeal of the RO’s May 2006 decision within one year; nor was new and material evidence received within a year. 3. Additional evidence received since the RO’s May 2006 decision is not cumulative or redundant of the evidence of record at the time of that decision, relates to unestablished facts necessary to substantiate the claims for service connection for right shoulder condition and service connection for migraines, and raises a reasonable possibility of substantiating the claims. 4. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of right shoulder condition. 5. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of sleep apnea. 6. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of hypertension. 7. The probative evidence of record demonstrates that the Veteran’s cluster headache condition is neither proximately due to nor aggravated beyond its natural progression by his service-connected PTSD, and is not otherwise related to an in-service injury, event, or disease. 8. The Veteran’s symptoms more nearly approximated the symptomatology associated with a 50 percent rating. CONCLUSIONS OF LAW 1. The Regional Office’s May 2006 rating decision to deny service connection for right shoulder condition and service connection for migraines is final. 38 U.S.C. §§ 7105 (2012); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103 (2017). 2. New and material evidence has been received to reopen the Veteran’s claims for service connection for right shoulder condition and service connection for migraines. 38 U.S.C. §§ 1131, 5108 (2012); 38 C.F.R. §§ 3.303, 3.156 (2017). 3. The criteria for entitlement to service connection for right shoulder condition have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 4. The criteria for entitlement to service connection for sleep disorder, also claimed as sleep apnea, have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.306. 5. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.306, 3.307. 6. The criteria for entitlement to service connection for migraines have not been met. 38 U.S.C. §§ 1101, 1110 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2017). 7. The criteria for entitlement to an increased evaluation in excess of 50 percent for posttraumatic stress disorder have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1999 to August 2003. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from a June 2013 rating decision. The Veteran did not request a Board hearing. New and Material Evidence A decision of the RO becomes final and is not subject to revision on the same factual basis unless a notice of disagreement is filed within one year of the notice of decision. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108 (2012); see Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a) (2017). Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if preexisting such service, was aggravated thereby. 38 U.S.C. §§ 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). Generally, to establish entitlement to service connection, a veteran must show evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the current disability and an in-service injury or disease. All three elements must be proved. See generally Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). 1. Whether new and material evidence has been submitted to reopen entitlement to service connection for right shoulder condition The issue of entitlement to service connection for right shoulder condition was originally denied in a May 2006 rating decision because the RO was unable to establish a link between the Veteran’s right shoulder strain and service. Since the May 2006 rating decision, the Veteran was afforded a VA examination in March 2013 and submitted VA treatment records from September 2009 to July 2012. The VA treatment records are new in that they were not of record at the time of the May 2006 rating decision. However, they are not material as they do not show treatment or complaint of a right shoulder condition. The March 2013 VA examination is new because it was not of record at the time of the March 2006 rating and it is material because it provides a nexus opinion as to the Veteran’s right shoulder condition and his military service. As the evidence submitted is new and material, the claim for entitlement to service connection for right shoulder condition is reopened. 2. Whether new and material evidence has been submitted to reopen entitlement to service connection for migraines The issue of entitlement to service connection for migraines was originally denied in a May 2006 rating decision because the RO was unable to establish a link between the Veteran’s migraines and service. Since the May 2006 rating decision, the Veteran was afforded a VA examination in March 2013 and submitted VA treatment records from September 2009 to July 2012. The March 2013 VA examination and VA treatment records are new because they were not of record at the time of the May 2006 rating. The March 2013 VA examination is material because it provides a nexus opinion as to the Veteran’s migraines and his military service. The VA treatment records are material because they provide diagnoses. As the evidence submitted is new and material, the claim for entitlement to service connection for migraines is reopened. Service Connection Under applicable law, service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (a) (2017). Establishing service connection generally requires competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d) (2017). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App. 370, 374 (2002). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. 3. Entitlement to service connection for right shoulder condition The Veteran contends that his right shoulder condition is due to injuring his shoulder during night jungle training in service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of right shoulder condition and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The March 2013 VA examiner evaluated the Veteran and determined that, while he experienced subjective symptoms of his right shoulder popping out, he did not have a diagnosis of a right shoulder condition. Further, despite VA treatment records from January 2005 to April 2006 and from September 2009 to July 2012, VA treatment records do not contain a diagnosis of a right shoulder condition. The Veteran contends in his July 2013 NOD that the March 2013 VA examination was inadequate. The March 2013 VA examiner performed a physical examination of the Veteran, performed diagnostic tests to determine the presence of a right shoulder condition diagnosis, reviewed the Veteran’s claims file, and considered the Veteran’s lay statements. The examiner’s opinion is consistent with VA treatment records which do not show a right shoulder condition diagnosis. Consequently, the Board gives more probative weight to the March 2013 VA examiner’s findings. There is no persuasive evidence that the Veteran has symptoms that result in any functional impairment. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that a “disability” under 38 U.S.C. § 1110 refers to functional impairment of earning capacity). While the Veteran believes he has a current diagnosis of right shoulder condition, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Thus, service connection for right shoulder condition is not warranted. 4. Entitlement to service connection for sleep disorder also claimed as sleep apnea The Veteran contends that his sleep apnea is due to his service-connected PTSD. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of a service-connected disability. The Board concludes that the Veteran does not have a current diagnosis of sleep apnea and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The August 2014 VA examiner evaluated the Veteran and determined that, while he experienced subjective symptoms of difficulty sleeping and fatigue, he did not have a diagnosis of sleep apnea. Further, despite consistent treatment from January 2005 to December 2009, February 2011 to March 2013, and March 2014 to December 2014, VA treatment records do not contain a diagnosis of sleep apnea. An October 2014 sleep study noted the Veteran had fragmented sleep and intermittent snoring without meeting the diagnostic criteria for obstructive sleep apnea. See October 2014 VA treatment record. While the Veteran believes he has sleep apnea, he is not competent to provide a diagnosis in this case. This issue is also medically complex, as it requires knowledge of the interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the medical evidence. Indeed, sleep disturbances have been associated with the Veteran’s service connected PTSD. Thus, as the Veteran does not have a current diagnosis for sleep apnea, service connection for sleep apnea is not warranted. 5. Entitlement to service connection for hypertension The Veteran contends that his hypertension is due to his service-connected PTSD. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of a service-connected disability. The Board concludes that the Veteran does not have a current diagnosis of hypertension and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The August 2014 VA examiner evaluated the Veteran and determined that, while he states he was previously diagnosed with hypertension and takes Verapamil, he did not have a diagnosis of hypertension. The examiner stated the Veteran was prescribed Verapamil, an anti-hypertensive medication, in 1995 for his cluster headaches. Further, despite consistent treatment from January 2005 to December 2009, February 2011 to March 2013, and March 2014 to December 2014, VA treatment records do not contain a diagnosis of hypertension. While the Veteran believes he has hypertension, he is not competent to provide a diagnosis in this case. This issue is also medically complex, as it requires knowledge of the interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the medical evidence. Thus, as the Veteran does not have a current diagnosis of hypertension, service connection for hypertension is not warranted. 6. Entitlement to service connection for migraines The Veteran contends that his headaches are due to his service-connected PTSD. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, a service-connected disability. The Board concludes that, while the Veteran has a current diagnosis of cluster headaches, the preponderance of the evidence is against finding that the Veteran’s cluster headaches are proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The March 2013 VA examiner opined that the condition of cluster headaches is not related to the Veteran’s PTSD. The rationale was that review of the medical literature does not include PTSD as a risk factor for cluster headaches. See March 2013 VA examination. There are no findings in the record that PTSD permanently aggravates any headache pattern and there are no findings upon examination that headaches are caused by the Veteran’s service-connected PTSD. Id. While the Veteran believes his cluster headaches condition is proximately due to or the result of his service-connected disability, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the March 2013 VA examination. Service connection may also be granted on a direct basis, but the preponderance of the evidence is also against finding that the Veteran’s cluster headaches condition is related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service treatment records from October 2002 show that the Veteran was seen for headaches after he fell backwards and hit his head on concrete. However, the March 2013 VA examiner opined that the Veteran’s cluster headaches condition is not at least as likely as not related to an in-service injury, event, or disease, including experiencing headaches in service after hitting his head on concrete. The rationale was the Veteran’s file reveals no evidence of a cluster type headache pattern exists. See March 2013 VA examination. The Veteran had periodic medical reviews in which headache was not present, and the Veteran did not have a chronic headache condition at the time of discharge. Id. While the Veteran believes his cluster headaches condition is related to an in-service injury, event, or disease, including experiencing headaches in service, he is not competent to provide a nexus opinion in this case. This issue is medically complex due to other potential etiologies. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the March 2013 VA examination. Thus, service connection for cluster headaches is not warranted. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2017); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2017); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2017); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10 (2017). Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran’s condition. Schafrath at 594; See also 38 C.F.R. §§ 4.1, 4.2. The Veteran is seeking an increased rating for his service-connected posttraumatic stress disorder (PTSD) which is currently rated in accordance with the criteria set forth in the Schedule for Rating Disabilities, 38 C.F.R. Part 4, Diagnostic Code 9411 (2017) as 50 percent. A 70 percent evaluation is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and the inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. Furthermore, as the United States Court of Appeals for the Federal Circuit recently explained, evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms [,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation...requires an ultimate factual conclusion as to the Veteran’s level of impairment in ‘most areas.’” Vazquez-Claudio at 117-18; 38 C.F.R. § 4.130, DC 9411. Additionally, consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. 7. Entitlement to an increased evaluation in excess of 50 percent for post-traumatic stress disorder After a review of the record, the Board finds that the impact of the Veteran’s service-connected generalized anxiety disorder with substance abuse disorder on his occupational and social functioning does not warrant an evaluation in excess of 50 percent. The Veteran does not exhibit occupational and social impairment with deficiencies in most areas of the type and degree contemplated by a 70 percent rating. VA treatment records from February 2011 through July 2012 show the Veteran exhibited an affect within normal limits, nervous mood, difficulty sleeping, logical thought process and thought content, and intact judgment and insight. He did not exhibit suicidal ideations and homicidal ideations, or audio hallucinations or visual hallucinations. See VA treatment records. He experienced anxiety, irritability, panic attacks, and did not make friends easily. See November 2011 Statement in Support of Claim. He constantly checks windows and doors to ensure they are locked and sleeps with a weapon next to the bed. Id. The Veteran was afforded a VA examination in March 2013. The examiner opined that the Veteran has occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. See March 2013 VA examination. The Veteran’s symptoms included anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, disturbances of motivation and mood, and difficulty adapting to stressful circumstances, including work or a worklike setting. Id. The examiner noted the Veteran endorsed increased symptoms when he is alone and driving as he was also a driver when his trauma occurred. Id. The Veteran related he has some issues with behavior at work, including fighting and arguing with co-workers and customers. Id. In the July 2013 Notice of Disagreement, the Veteran stated he goes out of the way to avoid people and crowds, and has difficulty adapting to stressful circumstances. He stated he often gets angry and “cusses” people out at work. See July 2013 Notice of Disagreement. VA treatment records from March 2014 show the Veteran presented with a constricted affect, nervous mood, and had logical thought form and thought content. He did not have suicidal ideations or homicidal ideations. See VA treatment records. He stated he does not sleep well and has violent dreams. Id. July 2014 VA treatment records show the Veteran continued to have nightmares and night sweats. December 2014 treatment records state the Veteran did not have suicidal thoughts or homicidal thoughts. The Board finds that the preponderance of the evidence is against a finding of entitlement to an increased rating. The Veteran’s symptoms are primarily manifested by anxiety, irritability, anger but not violent, sleep difficulty, panic attacks, and disturbances of motivation and mood. While the 2013 VA examiner noted that the Veteran exhibited some difficulty adapting to stressful circumstances, the examiner’s overall assessment of the impact of the Veteran’s symptoms on his occupational and social functioning was consistent with a lower rating. The Veteran’s record contains no other references to symptoms which are similar to those listed in the 70 percent or 100 percent criteria. The Veteran did not exhibit suicidal ideation or obsessional rituals which interfere with routine activities. He did not exhibit speech that was intermittently illogical, obscure, or irrelevant. The Veteran does not exhibit near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively. He does not exhibit impaired impulse control with violent episodes or spatial disorientation. The Veteran appeared for his mental health appointments with good grooming and did not show neglect of personal appearance and hygiene. At the March 2013 VA examination, it was noted the Veteran has been married for 13 years and has two children. He does not isolate from his children. He regularly visits his family and they visit him. The Veteran attends church but is not involved with any other groups. He is employed at Lowe’s for the past 9 years. He reported some issues with behavior at work, including arguing and fighting with co-workers and customers but this did not interfere with his keeping his job. The examiner opined the Veteran’s occupational and social impairment reflected occupation and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational task, which is consistent with that of a 30 percent rating. The foregoing findings clearly show the Veteran retains the ability to establish and maintain effective relationships as shown by his relationships with his spouse, children, family, work, and association with his church. This is consistent with a 50 percent rating. In summary, the Board finds that the 50 percent disability rating assigned for the Veteran’s PTSD contemplates the frequency, severity, and duration of his symptoms. REASONS FOR REMAND 1. Entitlement to service connection for acid reflux is remanded. The Veteran contends that his acid reflux is due to his service-connected PTSD. The record contains an August 2014 VA examination in which the examiner opined that the Veteran’s acid reflux is not at least as likely as not proximately due to or the result of the Veteran’s service-connected PTSD. The VA examiner reasoned that PTSD and GERD often co-exist, but PTSD does not cause GERD and cites the article Gastro-esophageal Reflux Disease and Psychological Comorbidity but does not give a rationale regarding why the Veteran’s GERD is not connected to his service-connected PTSD in this instance. Additionally, the aggravation component of the theory of secondary service connection was not specifically addressed. As such, a supplemental addendum opinion—based on full review of the record and supported by stated rationale—is needed to fairly decide the issue on appeal. See 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2016); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s acid reflux is at least as likely as not caused OR aggravated by his service-connected PTSD. A fully articulated medical rationale for each opinion expressed must be set forth in the medical report. The medical professional should discuss the particulars of this Veteran’s medical history and the relevant medical sciences that apply to this case, which may reasonably make clear the medical guidance in the study of this case. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Alexia E. Palacios-Peters, Associate Counsel