Citation Nr: 18145348 Decision Date: 10/26/18 Archive Date: 10/26/18 DOCKET NO. 16-18 242 DATE: October 26, 2018 ORDER Entitlement to a rating higher than 10 percent for cervical spine strain is denied. Entitlement to a rating higher than 10 percent for musculoskeletal headaches is denied. Entitlement to a rating higher than 50 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for sleep apnea (OSA) is remanded. Entitlement to service connection for a prostate condition (BPH) is remanded. FINDINGS OF FACT 1. The Veteran’s cervical spine strain has been manifested by forward flexion limited to, at worst, 35 degrees with pain; without ankylosis or incapacitating episodes requiring medically prescribed bed rest. 2. For the period on appeal, the Veteran’s headaches did not manifest in a characteristic prostrating attack occurring on average once a month over the last several months. 3. For the period on appeal, the Veteran’s PTSD was not manifested by severe or serious impairment in establishing and maintaining effective or favorable relationships with people, with severe or pronounced impairment in the ability to obtain or retain employment, or occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 10 percent for cervical spine strain have not been met or more nearly approximated at any time during the appeal period. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5235-5243. 2. The criteria for a rating higher than 10 percent for headaches are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.124a, DC 8100. 3. The criteria for a rating higher than 50 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service November 20, 1985 to November 30, 2005 Service Connection. Ratings Disability evaluations are determined by comparing a veteran’s present symptomatology with criteria set forth in the VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). In deciding the Veteran’s higher evaluation claims, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 22 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the Court held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the “staging” of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126. Hart appears to extend Fenderson to all increased rating claims. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same “disability” or the same “manifestations” under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as “such a result would overcompensate the claimant for the actual impairment of his earning capacity.” Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board notes that the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Court previously indicated that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). However, the Court recently suggested that the plain language of 38 C.F.R. § 4.59 indicates that it is potentially applicable to the evaluation of musculoskeletal disabilities involving joint or periarticular pathology that are painful, whether or not evaluated under a diagnostic code predicated on range of motion measurements. See Correia v. McDonald, 28 Vet. App. 158 (2016); Southall-Norman v McDonald, 28 Vet. App. 346 (2016). In Sharp v. Shulkin, 29 Vet. App. 26, 34 (2017), the Court noted that the VA Clinician’s Guide instructs examiners when evaluating certain musculoskeletal conditions to obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from a Veteran. 1. Entitlement to a rating higher than 10 percent for cervical spine strain (neck disability) The Veteran reports that the symptoms related to his neck disability have increased, and he is entitled to a higher disability rating as a result. Disabilities of the spine are evaluated under the General Rating Formula for Rating Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a, DCs 5235-5242. The criteria for rating the Veteran’s disability are set forth as follows: Under the formula for rating spine disorders, a 10 percent evaluation is assigned for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or muscle spasm or guarding, or localized tenderness not resulting in abnormal gait or spinal contour, or vertebral body fracture with loss of 50 percent or more of height. A 20 percent evaluation is assigned for spinal fusion with forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, DCs 5235-5242. A 30 percent evaluation is assigned for spinal fusion with forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent evaluation is assigned for unfavorable ankylosis of the entire cervical spine, and a 100 percent evaluation contemplates unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, DCs 5235-5242. For purposes of VA compensation, normal forward flexion of the cervical spine is 0 to 45 degrees, extension is 0 to 45 degrees, left and right lateral flexion are 0 to 45 degrees, and left and right lateral rotation are 0 to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is to 340 degrees. 38 C.F.R. § 4.71a, DCs 5235-5242, Note 2. For purposes of evaluations under DC 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome (IVDS) that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, DCs 5243, Note 1. The record contains statements from the Veteran and others reporting increased pain. An April 2013 magnetic resonance imaging (MRI) documented a pinched nerve on the left side due to a large bone spur. See Medical Treatment Record (MTR), dated August 12, 2013. Private treatment records diagnose radiculopathy and document treatment for neck pain. See MTR, dated June 6, 2015. The Veteran is separately service connected for neurological impairment of the left upper extremity. See Rating Decision (RD), dated August 7, 2015. A September 2015 VA examiner diagnosed cervical spine strain and cervical spine IVDS involving the left medial nerve. See C&P Exam, dated September 30, 2015. The examination was conducted during a flare-up. Flare-ups were described as trouble rotating the head side to side; intense, unbearable neck pain; and left-sided numbness with pain and tingling which travels down the left arm. On examination, the examiner noted forward flexion to 35 degrees, extension to 45 degrees, right lateral flexion to 25 degrees, left lateral flexion to 30 degrees, right lateral rotation to 80 degrees, and left lateral rotation to 80 degrees; total range of motion was 295 degrees. The examiner noted pain at the same degrees of measurement which caused no functional loss. There was objective evidence of left cervical muscle tenderness. Based on the evidence of record, the Board finds that a disability rating higher than 10 percent for cervical strain is not warranted. In this regard, the Board notes that the Veteran’s cervical spine forward flexion has been limited to, at worst, 35 degrees. Further, there is no evidence that the Veteran suffers from additional limitation of flexion or ankylosis of the cervical spine. Therefore, a disability rating higher than 10 percent for a cervical spine disability is not warranted. 38 C.F.R. § 4.71a, DC 5237. The Board notes that the additional limitation the Veteran experiences due to pain and other factors on repetition was accounted for on examination as the Veteran was examined during a flare-up. Though the Veteran had additional pain on motion, the measurements remained consistent repetitive testing. 38 C.F.R. § 4.40, 4.45. There is no other evidence showing that the Veteran has more limitation of motion than that shown during the VA examination. Thus, with consideration of all pertinent disability factors, there remains no appropriate basis for assigning a schedular rating higher than 10 percent for functional impairment of the cervical spine. The Board notes that the Veteran is separately compensated for radiculopathy under DC 8610. Additionally, the Board has considered assigning the Veteran a disability rating under DC 5243, for intervertebral disc syndrome based on incapacitating episodes rather than limitation of motion. As the record shows no incapacitating episodes due to IVDS, a higher disability rating under this code is not applicable. 38 C.F.R. § 4.71a, DC 5243. Finally, consideration has been given to assigning staged ratings; however, at no time during the period on appeal has the Veteran’s cervical spine sprain warranted a disability rating higher than 10 percent. 2. Entitlement to a rating higher than 10 percent for headaches The Veteran seeks a rating higher than 10 percent for headaches. The appeal period before the Board begins on December 31, 2011, one year prior to the date VA received the claim for an increased rating. Gaston, 605 F.3d at 982. For the following reasons, the Board finds that an increased rating is not warranted. The Veteran’s headaches are analogously evaluated pursuant to 38 C.F.R. § 4.124a, DC 8100, for migraines. Under DC 8100, a 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on average once a month of the last several months. A 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Although the rating criteria do not define “prostrating,” according to Dorland’s Illustrated Medical Dictionary 1531 (32nd Ed. 2012), “prostration” is defined as “extreme exhaustion or powerlessness.” The term “productive of severe economic inadaptability” is not defined by VA regulations. The Court, however, has stated that this term is not synonymous with being completely unable to work and that the phrase “productive of” could be read to mean either “producing” or “capable of producing” economic inadaptability. Pierce v. Principi, 18 Vet. App. 440, 446-47 (2004). The Veteran underwent a VA examination in September 2015. See C&P Exam dated September 30, 2018. He reported constant headaches which manifested in dull pain present on both sides of the head. He treated them with Tylenol. The examiner indicated that the Veteran does not have characteristic prostrating attacks of migraine/non-migraine headache pain that occur once per month. The Veteran reported difficulty focusing or concentrating due to the headache. A review of the Veteran’s post-service medical treatment records relevant to the appeal period does not show that his headaches have differed from as described in the examinations noted above. A communication from the Veteran’s employer reports that he had four days of lost work in October 2015 due to neck and headache pain. See Third Party Correspondence, dated December 10, 2015. The Board notes that this communication was received after the September 2015 VA examination. However, as this report fails to show a history of several months of prostrating attacks and does not differentiate the Veteran’s headache pain from his neck pain, its probative value is limited. Based on a review of the evidence of record, the Board finds that an increased rating is not warranted. During this period, the Veteran reported constant daily headaches on examination which manifested as a dull pain. He later reported chronic, daily headaches which sometimes lasted hours with light sensitivity. See Correspondence, dated April 12, 2016. The Veteran describes his headache symptoms in conjunction with the symptoms of his neck disability; however, the evidence does not show that they resulted in extreme exhaustion or powerlessness together or separately. The Veteran reported that many times he has either missed work or simply did not report to work due to severe pain. However, he fails to provide information regarding the frequency of these incidents. To that end, both his lay descriptions of symptomology and the September 2015 examination report indicate headaches were of less severity than required to warrant a higher rating. The evidence did not show that the Veteran’s headaches manifested in or more nearly approximated characteristic prostrating attacks occurring on average once a month over the last several months. Thus, the criteria corresponding to a higher 30 percent rating were not met. 3. Entitlement to a rating higher than 50 percent for PTSD The Veteran asserts that his PTSD diagnosis affects him far more than accounted for by his current disability rating. PTSD is rated under 38 C.F.R. § 4.130, DC 9411. Under the Rating Formula, a 30 percent rating requires occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is awarded 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 inability to establish and maintain effective relationships. Id. 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; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Id. The United States Court of Appeals for the Federal Circuit held that 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.” Vasquez-Claudio v. Shinseki, 713 F3d 112, 11617 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather, “serve as examples of the type and degree of symptom, 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.’” Vasquez-Claudio, 713 F.3d at 11718; 38 C.F.R. § 4.130, DC 9411. Further, when evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission.” 38 C.F.R. § 4.126(a). The Board must also “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 examination.” Id. The record also contains Global Assessment of Functioning (GAF) scores assigned by clinicians, which reflect the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240 (1995). An examiner’s classification of the level of psychiatric impairment, by word or by a GAF score, is not determinative of the VA disability rating to be assigned. See Carpenter v. Brown, 8 Vet. App. 240 (1995). The percentage evaluation is based on all the evidence that bears on occupational and social impairment. Id; see also 38 C.F.R. § 4.126 (2017). The Board notes that effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by replacing references to DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition (DSM-IV) with the fifth edition of the DSM (DSM-5). See 38 C.F.R. § 4.125, amended by 79 Fed. Reg. 45099 (effective Aug. 4, 2014). The Board does not find that a rating higher than 50 percent for PTSD is warranted since the preponderance of the evidence does not more nearly approximate symptomatology resulting in deficiencies in most areas, to include work, school, family relations, judgment, thinking, or mood such that a higher 70 percent rating is warranted. At an August 2013 VA examination, the Veteran was diagnosed with PTSD and major depressive disorder. See CAPRI, dated August 15, 2013. A GAF score of 60, representing moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers) was noted. The examiner found the Veteran to have 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. Symptoms of PTSD included depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, feelings of detachment or estrangement from others, restricted range of affect, hypervigilance, decreased concentration; difficulty falling or staying asleep; irritability; and diminished interest in activities. The Veteran reported employment at Boeing beginning April 2006. He reported concentration problems at work. He noted that he keeps his personal life and work life separate. The Veteran reported feeling connected to his mother and somewhat to his children but noted that he is significantly detached from nearly everyone in his life. He reported this is because he is afraid of losing them. The Veteran had not participated in treatment for his PTSD. VA treatment records document mental health treatment from November 2014 to April 2015. See CAPRI, dated December 10, 2015. The Veteran was treated for irritability, traumatic memories, nightmares, disturbed sleep, and hypervigilance. He reported completion of a PhD at the end of 2014. In September 2015, the Veteran was again found to have 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 C&P Exam, dated September 24, 2015. The Veteran had no other diagnoses. He reported “very good” relationships with his mother and siblings and a “good” relationship with his adult children. He reported employment at Boeing since April 2015 after a six month lay-off. The Veteran denied current counseling and suicide attempts or psychiatric issues. Noted PTSD symptoms included anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a worklike setting. Based on his medical records and VA examinations, the Veteran’s symptoms more nearly approximate a 30 percent rating. However, lay statements from the Veteran and others combined with medical evidence indicates that his disability more nearly approximates a 50 percent rating. The Veteran reports chronic nightmares, low tolerance for and thoughts of harming people, avoidance of people and crowds, mood swings, increased difficulty with short and long-term memory, and hypervigilance. Lay statements in support of the Veteran’s claim note night terrors and sometimes extreme mood swings. A review of the totality of the evidence shows the Veteran exhibits difficulty in establishing effective social relationships (avoidance of people and crowds), disturbances of mood (sometimes extreme mood swings), hypervigilance, sleep disturbances, and memory problems more nearly approximating the criteria for a 50 percent rating. The Board finds that based on the symptomatology reported by the Veteran and lay observers and noted by VA examiners and other treatment providers, the Veteran’s total disability picture does not severely impair the Veteran’s ability to establish and maintain effective relationships with people or cause pronounced impairment in his ability to obtain or retain employment. The Veteran successfully obtained a PhD in 2014. Though his relationship with his fiancé was unsuccessful, he has good relationships with his family and reports no interpersonal issues at work. Excepting a 6-month period of unemployment, the Veteran has been employed at Boeing since April 2006. He denies suicidal ideation and is not shown to have obsessional rituals which interfere with routine activities, violent episodes, near-continuous panic or depression; or to neglect his personal appearance and hygiene. The Board finds the Veteran’s total disability picture indicates he generally has been able to maintain some personal relationships and has exemplary cognitive function, and as such, the Board finds the totality of the evidence does not rise to the level of occupational and social impairment with deficiencies in most areas. As the more probative evidence of record indicates a total disability picture that more closely approximates the symptoms provided for by a 50 percent rating under Diagnostic Code 9411, a rating higher than 50 percent for PTSD is not warranted. REASONS FOR REMAND The Veteran has not been provided VA examinations in support of his OSA and BPH claims. He should be afforded VA examinations. 1. Entitlement to service connection for sleep apnea The Veteran’s service treatment records (STRs) and separation examination reveal no complaints or findings of sleep disturbance during service. Private treatment records document complaints of sleep disturbance of unknown origin in 2009 and due to PTSD in 2013. A February 2015 sleep study diagnosed mild OSA with minimal frequency, duration, and disturbed sleep. The Veteran reported extreme difficulty sleeping at night due to dreams of war. See Correspondence, dated August 12, 2013, and NOD, dated November 1, 2013. The Veteran’s son reported incidences of night terrors. See Statement, dated August 12, 2013. The Veteran reported using Prazosin and taking over-counter-drugs in hopes of falling in a deep sleep so as not to dream. See Correspondence, dated April 12, 2016. A February 2015 sleep study diagnosed mild OSA. Although the Veteran reported sleep onset after one-hour, objective testing showed it to be 21 minutes. The examiner found sleep efficiency and latency to be normal, abnormal REM latency, and an arousal index of 10 with soft to moderate snoring. The Veteran’s OSA was found to minimally disturb sleep. Although sleep issues have been shown to be associated with PTSD, the Veteran has also been diagnosed with OSA. It is unclear if the OSA is related to service or is secondary to PTSD or part and parcel of the PTSD. 2. Entitlement to service connection for a prostate condition Private medical records generally document complaints of, or treatment for, acute prostatitis and BPH beginning October 2009. However, the record lacks competent medical opinion evidence as to the etiology of BPH. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of the OSA disability. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current OSA had its clinical onset during service or is related to any in-service disease, event, or injury. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that OSA disability is proximately due to, or the result of, the service-connected PTSD. The examiner should also provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that OSA is permanently aggravated by the Veteran’s service-connected PTSD. If applicable, the examiner should indicate if the OSA is part and parcel of the PTSD. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of any current prostate disability to include BPH. The examiner should review the record prior to examination. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current prostate disability to include BPH had its clinical onset during service or is related to any in-service disease, event, or injury. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. J. CONNOLLY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. E., Associate Counsel