Citation Nr: 18149022
Decision Date: 11/08/18	Archive Date: 11/08/18

DOCKET NO. 15-46 681
DATE:	November 8, 2018
ORDER
New and material evidence has been received to reopen the claim of entitlement to service connection for a lumbar spine disability; the appeal to reopen the previously denied claim is granted.  
Entitlement to service connection for a left shoulder condition is denied.
Entitlement to service connection for a right shoulder condition is denied.
Entitlement to service connection for degenerative disc disease of the cervical spine is denied.
Entitlement to service connection for a left hip condition is denied.
Entitlement to service connection for a left leg and knee condition is denied.
Entitlement to service connection for obstructive sleep apnea is granted.
Entitlement to service connection for hypertension is denied.
Entitlement to service connection for headaches is granted.
Entitlement to a rating in excess of 10 percent for tinnitus is denied.
Entitlement to a rating in excess of 20 percent for diabetes mellitus is denied.
Entitlement to a separate 20 percent rating for peripheral neuropathy of the right upper extremity secondary to the Veteran’s diabetes mellitus is granted.  
Entitlement to a rating in excess of 20 percent for peripheral neuropathy of the left upper extremity is denied.
Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left lower extremity is denied.
Entitlement to a rating in excess of 10 percent for peripheral neuropathy of right lower extremity is denied.
Entitlement to a rating in excess of 10 percent for peripheral neuropathy the left lower femoral nerve is denied.
Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right lower femoral nerve is denied.
Entitlement to a compensable rating for bilateral hearing loss is denied. 
Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied.
Entitlement to an effective date prior to January 23, 2015 for the grant of service connection for peripheral neuropathy of the right lower extremity is denied.
Entitlement to an effective date prior to January 23, 2015 for the grant of service connection for peripheral neuropathy of the left upper extremity is denied. 
Entitlement to an effective date prior to January 23, 2015 for the gran of service connection for peripheral neuropathy of the left lower femoral nerve is denied.
Entitlement to an effective date prior to January 23, 2015 for the grant of service connection for peripheral neuropathy of the right lower femoral nerve is denied.
Entitlement to a total disability rating based on individual unemployability (TDIU) is granted.
REFERRED
The issue of entitlement to service connection for coronary artery disease status post stent placement secondary to herbicide exposure was raised in a June 2016 statement and is referred to the Agency of Original Jurisdiction (AOJ) for adjudication.
REMANDED
Entitlement to service connection for a lumbar spine disability is remanded.
FINDINGS OF FACT
1. In an unappealed rating decision dated January 1997 service connection for a lumbar spine disability was denied. 
2. New and material evidence has been received to reopen the claim of entitlement to service connection for a lumbar spine disability.  
3. The evidence is insufficient to show that the Veteran had a left shoulder disorder during the appeal period. 
4. The evidence is insufficient to show that the Veteran had a right shoulder disorder during the appeal period.  
5. The evidence is insufficient to show the Veteran’s cervical spine disorder had its onset in service, manifested to a compensable degree within one year of separation, or is otherwise related to service. 
6. The evidence is insufficient to show the Veteran’s left hip disorder had its onset in service, manifested to a compensable degree within one year of separation, or is otherwise related to service.
7.  The evidence is insufficient to show the Veteran’s left knee/leg disorder had its onset in service, manifested to a compensable degree within one year of separation, or is otherwise related to service.
8. The evidence is sufficient to show that the Veteran’s obstructive sleep apnea is aggravated by his service-connected PTSD.  
9. The evidence is insufficient to show that the Veteran’s hypertension had its onset in service, manifested to a compensable degree within one year of separation, or is otherwise related to service. 
10. Resolving reasonable doubt in the Veteran’s favor, the evidence is sufficient to show that the Veteran’s headaches are secondary to his service-connected tinnitus and PTSD. 
11. The 10 percent rating currently in effect is the maximum schedular rating for service-connected tinnitus.
12. The Veteran’s diabetes mellitus required insulin and restricted diet; regulation of activities is not shown. 
13. The Veteran’s diabetic peripheral neuropathy of the right upper extremity manifested in numbness and tingling in the hands.  
14. The Veteran’s peripheral neuropathy of the left upper extremity manifested in no worse than mild incomplete paralysis.  
15. The Veteran’s peripheral neuropathy of the right sciatic nerve manifested in no worse than mild incomplete paralysis 
16. The Veteran’s peripheral neuropathy of the left sciatic nerve manifested in no worse than mild incomplete paralysis. 
17. The Veteran’s peripheral neuropathy of the left femoral nerve manifested in no worse than mild incomplete paralysis. 
18. The Veteran’s peripheral neuropathy of the right femoral nerve manifested in no worse than mild incomplete paralysis. 
19. For the entire appeal period, the Veteran’s hearing loss manifested in hearing impairment corresponding to no worse than acuity Level I in the right ear and acuity Level I in the left ear.  
20. The Veteran’s PTSD is manifested in no worse than occupational and social impairment with deficiencies in most areas such as work, school, family relations and mood due to difficulty adapting to stressful circumstances and inability to establish and maintain effective relationships.
21. The evidence is insufficient to show a worsening of the Veteran’s peripheral neuropathy within one year prior to January 23, 2015. 
22. The evidence is insufficient to show a worsening of the Veteran’s peripheral neuropathy within one year prior to January 23, 2015. 
23. The evidence is insufficient to show a worsening of the Veteran’s peripheral neuropathy within one year prior to January 23, 2015. 
24. The evidence is insufficient to show a worsening of the Veteran’s peripheral neuropathy within one year prior to January 23, 2015. 
25. The evidence is sufficient to show that the Veteran’s service-connected disabilities make him unable to secure and follow a substantially gainful occupation.   
CONCLUSIONS OF LAW
1. The criteria for whether new and material evidence was received to reopen the claim of entitlement to service connection for a lumbar spine disability have been met.  38 U.S.C. § 5108; 38 C.F.R. § 3.156.
2. The criteria for entitlement to service connection for a left shoulder disorder have not been met.  38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), (c).
3. The criteria for entitlement to service connection for a right shoulder disorder have not been met.  38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), (c).
4. The criteria for entitlement to service connection for degenerative disc disease of the cervical spine have not been met.  38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), (c), 3.307, 3.309.
5. The criteria for entitlement to service connection for a left hip disorder have not been met.  38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), (c), 3.307, 3.309.
6. The criteria for entitlement to service connection for a left leg and knee disorder have not been met.  38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), (c), 3.307, 3.309.
7. The criteria for entitlement to service connection for obstructive sleep apnea have been met.  38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), (c), 3.310.
8. 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), (c), 3.307, 3.309.
9. The criteria for entitlement to service connection for headaches have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), (c), 3.310.
10. A rating in excess of 10 percent for tinnitus is not warranted.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.87, Diagnostic Code 6260.
11. The criteria for a rating in excess of 20 percent for diabetes mellitus have not been met.  38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.119, DC 7913.
12. The criteria for a separate 20 percent rating for diabetic peripheral neuropathy of the right upper extremity have been met.  38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.119, 4.124a, DCs 7913, 8513. 
13. The criteria for entitlement to a rating in excess of 20 percent for peripheral neuropathy of the left upper extremity have not been met.  38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.124a, DC 8513.
14. The criteria for entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right sciatic nerve have not been met.  38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.124a, DC 8520.
15. The criteria for entitlement to a rating in excess of 10 percent for peripheral neuropathy of left sciatic nerve have not been met.  38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.124a, DC 8520.
16. The criteria for entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left femoral nerve have not been met.  38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.124a, DC 8526.
17. The criteria for entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right femoral nerve have not been met.  38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.124a, DC 8526.
18. The criteria for entitlement to a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.85, 4.86, DC 6100.
19. The criteria for entitlement to a rating in excess of 70 percent for PTSD have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.126, 4.130, DC 9411.
20. The criteria for entitlement to an effective date prior to January 23, 2015 for the assignment of a separate evaluation for peripheral neuropathy of the left lower femoral nerve have not been met.  38 U.S.C. §§ 1155; 5107; 38 C.F.R. §§ 3.400(o), 4.1, 4.10, 4.124a, DC 8526. 
21. The criteria for entitlement to an effective date prior to January 23, 2015 for the assignment of a separate evaluation for peripheral neuropathy of the right lower extremity have not been met.  38 U.S.C. §§ 1155; 5107; 38 C.F.R. §§ 3.400(o), 4.1, 4.10, 4.124a, DC 8520.
22. The criteria for entitlement to an effective date prior to January 23, 2015 for the assignment of a separate evaluation for peripheral neuropathy of the left upper extremity have not been met.  38 U.S.C. §§ 1155; 5107; 38 C.F.R. §§ 3.400(o), 4.1, 4.10, 4.124a, DC 8513.
23. The criteria for entitlement to an effective date prior to January 23, 2015 for the assignment of a separate evaluation for peripheral neuropathy of the right lower femoral nerve have not been met.  38 U.S.C. §§ 1155; 5107; 38 C.F.R. §§ 3.400(o), 4.1, 4.10, 4.124a, DC 8526.
24. The criteria for entitlement to TDIU have been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.314, 3.321, 3.340, 4.16.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from March 1968 to March 1970.
Service Connection
Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303.  To establish service connection for a disability, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.  Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).
Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017).
For certain disorders, including hypertension and arthritis, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service.  See 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309.
When a disease listed at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service.  See 38 C.F.R. § 3.303(b).  However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint.  See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).
Service connection may also be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury.  38 C.F.R. § 3.310(a).  Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability.  38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995).
Service connection may also be granted for specific diseases associated with exposure to herbicide agents.  38 C.F.R. § 3.309(e).  If a veteran was exposed to a herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, despite any lack of evidence of such disease during service provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; Type II diabetes; Hodgkin's disease; ischemic heart disease; all chronic B-cell leukemias; multiple myeloma; non-Hodgkin's lymphoma; Parkinson's disease; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers; and soft-tissue sarcoma.  This presumption is rebuttable by affirmative evidence to the contrary.  38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a).
A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 shall be presumed to have been exposed during such service to an herbicide agent unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service.  38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6).  For the purposes of § 3.307, the term herbicide agent means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era.  38 C.F.R. § 3.307(a)(6)(i).  A veteran must have been present on the landmass or inland waterways of Vietnam at some point during his or her military duty to be entitled to the presumption of herbicide exposure.  Haas v. Peake, 525 F.3d 1168 (2008).  As the Veteran served in Vietnam, herbicide exposure to presumed. 
1. Whether new and material evidence was received to reopen the claim of entitlement to service connection for a lumbar spine disability.
The Veteran’s lumbar spine claim was originally denied in a January 1997 rating decision.  The Veteran did not appeal this decision and it became final.  38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(a), (b).  A May 2015 rating decision declined to reopen the claim.  
A previously denied claim may be reopened by the submission of new and material evidence.  38 U.S.C. § 5108; 38 C.F.R. § 3.156.  Evidence is new if it has not been previously submitted to agency decision makers.  38 U.S.C. § 5108; 38 C.F.R. § 3.156(a).  Evidence is material if it, either by itself or considered in conjunction with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim.  Id.  New and material evidence cannot be cumulative or 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.  Id.
When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed.  Fortuck v. Principi, 14 Vet. App. 173, 179-80 (2003); Justus v. Principi, 3 Vet. App. 510 (1992).  Furthermore, in Shade v. Shinseki, 24 Vet. App. 110, 117 (2010), the United States Court of Veterans Appeals (Court) clarified that the phrase “raises a reasonable possibility of substantiating the claim” is meant to create a low threshold that enables, rather than precludes, reopening.  Specifically, the Court stated that reopening is required when the newly submitted evidence, combined with VA assistance and considered with the other evidence of record, raises a reasonable possibility of substantiating the claim.  Id.
The January 1997 rating decision denied service connection based on a finding that the Veteran’s lumbar spine disability did not have its onset in service and was not related to service.  Evidence received since the previous denial includes the Veteran’s July 2007 statement that his service connected scars of the upper back due to shrapnel wounds caused arthritis in his lower back.  The evidence is new in that it was not previously considered.  It is also material insofar as it asserts a secondary theory of entitlement that has not been previously considered.  See Shade, 24 Vet. App. at 117-18.  Thus, the Board finds that the additional evidence is both new and material, and the claim for entitlement to service connection for a lumbar spine disability is reopened.
2. Entitlement to service connection for a left shoulder disability.
The Veteran claims entitlement to service connection for a left shoulder disability. 
To be considered for service connection, a claimant must first have a disability.  In Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992), the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability.  The Court has held that this requirement “is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim.” McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); but see Romanowsky v. Shinseki, 26 Vet. App. 289, 293-94 (2013) (holding that “when the record contains a recent diagnosis of a disability prior to a veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency.”).  
Notably, in the February 1970 separation report of medical history the Veteran endorsed both “yes” and “no” in response to painful or “trick” shoulder or elbow.  However, the Veteran’s clinical evaluation showed a normal shoulder.  A July 1970 VA examination report indicated the Veteran’s left shoulder was normal.  Although the Veteran’s post-service medical treatment records note shoulder joint pain, there is no evidence of a current disability due to disease or injury (underlying pathology), which is required for an award of service connection.  Thus, service connection for a left shoulder disability is denied.  
3. Entitlement to service connection for a right shoulder disability.
The Veteran claims entitlement to service connection for a right shoulder disability.  
To be considered for service connection, a claimant must first have a disability. Brammer, 3 Vet. App. at 225.  Notably, in the February 1970 separation report of medical history the Veteran endorsed both “yes” and “no” in response to painful or “trick” shoulder or elbow.  However, the evidence shows the Veteran underwent a right shoulder surgery after a dislocation in 1999.  See January 2008 VA Examination Report.  Although the Veteran’s medical treatment records note shoulder joint pain, there is no evidence of a current diagnosis that had its onset in service.  Entitlement to service connection for a right shoulder disability is not warranted. 
4. Entitlement to service connection for degenerative disc disease of the cervical spine.
The Veteran asserts his cervical spine disability had its onset in service.  
As the evidence shows a current disability of degenerative disc disease of the cervical spine, the issue that remains disputed is whether the Veteran’s cervical spine disability had its onset in service, manifested to a compensable degree within one year of separation, or is otherwise related to service.  See January 2008 VA Examination Report.  The preponderance of the evidence is against the claim. 
The Veteran’s service treatment records are silent for complaints of or treatment for a neck disability.  
During the January 2008 general VA examination, the Veteran reported a history of chronic neck pain and a history of neck injuries.  The Veteran had cervical disc surgery with fusion in 2005.  
During the May 2015 VA examination, the Veteran reported that he first injured his neck in 2004 after he was hit in the head with a forklift and reported he later headbutted his son-in-law.  The examiner opined that the Veteran’s current neck condition was less likely as not related to service.  The examiner reasoned that the Veteran had an injury when he fell off the horizontal bars in service but that his neck pain did not start until 2004.  
The Board finds the May 2015 VA examination and opinion probative to the question at hand.  The examiner considered an accurate history, to include the Veteran’s contentions regarding the onset of his symptoms.  The opinion was definitive and supported by a rationale that considered the lay and medical evidence.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).  
Significantly, the Veteran has not presented or identified any contrary medical opinion that supports the claim for service connection.  VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter.  Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991).  The Board finds that the most persuasive evidence of record shows that the current cervical spine disability is not related to service.
The Veteran is competent to testify to facts or circumstances that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011).  It is also well established that lay persons without medical training, such as the Veteran, are not competent to provide medical opinions on matters requiring medical expertise.  See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis).  Whether the Veteran’s current cervical spine disability is related to service requires medical expertise to determine.
The Board has also considered whether the service connection is warranted on a presumptive basis.  However, the evidence does not show – and the Veteran does not assert – that his degenerative disc disease of the cervical spine manifested to a compensable degree within one year of separation. See 38 C.F.R. §§ 3.307, 3.309.  Notably, the Veteran asserted that he first had neck pain in 2004 – over 30 years after separation.   
Therefore, the Board finds that the most probative evidence of record shows that the Veteran’s cervical spine condition is not related to service and did not manifest to a compensable degree within one year of service.  Entitlement to service connection for a cervical spine disability is not warranted.  In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine.  However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable.  See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990).
5. Entitlement to service connection for a left hip disability. 
The Veteran claims entitlement to service connection for a left hip disability. 
The evidence shows a current diagnosis of degenerative arthritis of the hip and hip arthralgia.  See January 2008 General VA Examination Report.  The issue that remains disputed is whether the Veteran’s left hip condition had its onset in service, manifested to a compensable degree within one year of separation, or is otherwise related to service.  The preponderance of the evidence is against the claim. 
The Veteran’s service treatment records are silent for complaints of or treatment for a left hip disability.  And there is no evidence of record showing the Veteran’s current hip disability had its onset in service.  
Although no VA examination was accorded to the Veteran, the Board finds that no such development is warranted based upon the facts of this case.  In pertinent part, there is medical evidence which diagnoses the current disability but the record does not remotely suggest that his hip condition is due to or incurred during service.  Only the Veteran’s contentions indicate a relationship with service, which is insufficient to trigger an examination since in these circumstances the validity of the assertions would require competent medical evidence.
The Board has also considered whether service connection is warranted on a presumptive basis.  However, the evidence does not show that the Veteran’s hip disability manifested to a compensable degree within one year of separation.  38 C.F.R. §§ 3.307, 3.309.
Service connection for a left hip condition is not warranted.  As the preponderance of the evidence is against the Veteran’s claim, the doctrine of reasonable doubt does not apply. Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
6. Entitlement to service connection for a left leg and knee disability.
The Veteran claims entitlement to service connection for a left leg and knee disability.  
The evidence does not show a diagnosis of a left leg disorder due to disease or injury (underlying pathology).  As there is no left leg disorder there is no legal basis for the grant of service connection.  Brammer, 3 Vet. App. at 225.  
However, the evidence shows a diagnosis of degenerative joint disease of the left knee.  See September 2013 VA Treatment Notes.  The issue that remains disputed is whether the Veteran’s left knee condition had its onset in service, manifested to a compensable degree within one year of separation or is otherwise related to service.  The preponderance of the evidence is against the claim.  
The Veteran’s service treatment records are silent for complaints of or treatment for a left knee condition.  During his February 1970 separation examination, the Veteran did report having “trick” or locked knee.  The medical service provider indicated the Veteran’s pain in the right knee was related to a shrapnel wound. 
Notably, a July 1970 VA examination report stated there was evidence of small metallic fragments in the soft tissue of the left thigh.  However, the medical evidence shows that the Veteran was treated for and is service-connected for shrapnel fragments of the right leg.  In addition, the Veteran’s post service treatment records continually indicate that he complained of residuals symptoms from shrapnel wounds to the right leg.  As such, the Board finds the July 1970 VA examination report indicating metallic fragments in the soft tissue of the left thigh must be an error.   
September 1996 treatment imaging tests showed the Veteran had normal knees bilaterally.  See September 1996 VA Examination Report.  During the January 2008 VA general examination, film studies were negative for a left knee condition.  
An August 2013 VA examination indicates the Veteran reported that while trying to move a chair he twisted and felt his left knee pop.  A physical examination showed left knee effusion, bone contusions, and a partial tear of the left medial meniscus.  
Although the evidence shows a current left knee diagnosis, there is no evidence of record showing that the Veteran’s left knee condition is related to service.  The Veteran was not afforded a VA examination because the evidence was insufficient to trigger an examination.  See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i) (2017).
The Board has also considered whether service connection is warranted on a presumptive basis.  However, the evidence does not show – and the Veteran does not assert – that his degenerative joint disease of the left knee manifested to a compensable degree within one year of separation.  See 38 C.F.R. §§ 3.307, 3.309.
Service connection for a left knee or leg disability is not warranted.  As the preponderance of the evidence is against the Veteran’s claim, the doctrine of reasonable doubt does not apply. Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
7. Entitlement to service connection for obstructive sleep apnea.
The Veteran asserts that his sleep apnea is related to service.  A March 2006 sleep study showed a diagnosis of obstructive sleep apnea.  The issue that remains disputed is whether the Veteran’s sleep apnea is related to service. 
In a January 2017 medical opinion private physician, Dr. H.S., opines that it is at least as likely as not that the Veteran’s PTSD and his prescribed sedating antihistamine and his atypical antipsychotic medication and symptoms of chronic sleep impairment aided in the development of and permanently aggravates the Veteran’s sleep apnea.  Dr. H.S.’s opinion was based on a review of the medical evidence and an examination of the Veteran.  He also cites to medical literature regarding the relationship between PTSD and sleep apnea for his opinion.  As such, the opinion is probative to the issue. 
Notably, the May 2015 VA psychological evaluation report also indicates that examiner reported a relationship between the Veteran’s sleep apnea and PTSD also.  Specifically, the examiner indicated that the Veteran’s reported anxiety symptoms and sleep disturbance are conceptualized to be part of his PTSD.  However, his sleep apnea and chronic pain may exacerbate existing sleep disturbance as well as anxiety symptoms.  
Thus, service connection for sleep apnea is granted. 
8. Entitlement to service connection for hypertension.
The Veteran asserts that his hypertension is related to service.
The evidence shows a diagnosis of hypertension.  See VA Treatment Records.  The issue that remains disputed is whether the Veteran’s hypertension is related to service, manifested to a compensable degree within one year of separation, or is otherwise related to service.  The preponderance of the evidence is against the claim. 
Service treatment records are silent for complaints of or treatment for hypertension.  The Veteran’s blood pressure was within normal limits at separation.  A July 1970 VA examination showed the Veteran’s blood pressure was within normal limits.  
A March 1997 VA examination showed an elevated blood pressure of 153/92.  The January 2008 VA examination report indicated the Veteran had a noted history of elevated blood pressure over the previous year.  His records showed no specific history of hypertension noted.  The Veteran was started on medication for blood pressure control in April 2007.  
While the evidence shows a diagnosis of hypertension, there is no evidence to show that the Veteran’s hypertension had its onset in service or is otherwise related to service.  The Veteran was not afforded a VA examination because the evidence was insufficient to trigger an examination.  See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i) (2017).
The Board has also considered whether service connection is warranted on a presumptive basis.  However, the evidence does not show – and the Veteran does not assert – that his hypertension manifested to a compensable degree within one year of separation.  See 38 C.F.R. §§ 3.307, 3.309.
As the preponderance of the evidence is against the Veteran’s claim, the doctrine of reasonable doubt does not apply. Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
9. Entitlement to service connection for headaches.
The Veteran claims entitlement to service connection for headaches.
The evidence shows a diagnosis of headaches.  See VA Treatment Records.  This issue that remains disputed is whether the headaches had their onset in service or is related to a connected disability.  To this end, the evidence is conflicting.
A March 2008 VA treatment note indicated that the Veteran reported having headaches daily without improvement.  The Veteran reported that the headaches were related to a concussion he from February 2006 when he fought his son in law.  The medical service provider noted, “However, the Veteran was exposed to RPGs, grenades etc. and was dazed/saw stars during the Vietnam war.”  The Veteran also described partial seizures that started in 2002.  
Social Security Administration (SSA) records show the Veteran had post- concussion symptoms including a daily headache, and cognitive difficulties following a February 2006 head injury.  See April 2008 SSA Records. 
In a February 2017 medical opinion private physician, Dr. H.S., opined as likely as not the Veteran’s headaches are caused by a combination of tinnitus and PTSD.  The examiner opined that during the VA examination when the Veteran was diagnosed with tinnitus and noted that his tinnitus can be very annoying at time.   Dr. H.S. further noted that it is known that damage to the auditory system resulting in tinnitus can cause headaches.  Dr. H.S. further noted that medical research stated that patients with mental health conditions are more likely to develop headaches because pain and mood are regulated by the same part of the brain.  Dr. H.S. reported that the Veteran indicated that when he gets tinnitus flares he gets a headache, which increases the volume of the ringing in his ears.  The Veteran also reported that increased stress, anxiety, and depression symptoms will bring on a headache. 
Based on the conflicting evidence, the Board resolves reasonable doubt in the Veteran’s favor. 
Entitlement to service connection for headaches is granted. 
Increased Rating
Disability evaluations are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4.  The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1.  The assignment of a particular Diagnostic Code (DC) depends wholly on the facts of the particular case.  Butts v. Brown, 5 Vet. App. 532, 538 (1993).
The Veteran is presumed to be seeking the maximum possible evaluation.  AB v. Brown, 6 Vet. App. 35 (1993).  When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating.  38 C.F.R. § 4.7.  At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found – a practice known as “staged” ratings.  Fenderson v. West, 12 Vet. App. 119 (1999).  The evaluation of the same disability under various diagnoses, known as “pyramiding,” is to be avoided.  38 C.F.R. § 4.14.
10. Entitlement to a rating in excess of 10 percent for tinnitus.
The Veteran asserts that an increased rating in excess of 10 percent for the service-connected tinnitus is warranted.
Tinnitus is evaluated under 38 C.F.R. § 4.87, Diagnostic Code 6260, which was revised effective June 13, 2003, to clarify the existing VA practice that only a single 10 percent rating is assigned for tinnitus, whether the sound is perceived as being in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260 (2017). 
In Smith v. Nicholson, 19 Vet. App. 63 (2005) the Court held that the pre-1999 and pre-June 13, 2003 versions of Diagnostic Code 6260 required the assignment of dual ratings for bilateral tinnitus.  VA appealed this decision to the United States Court of Appeals for the Federal Circuit (Federal Circuit), and stayed the adjudication of tinnitus rating cases affected by the Court’s decision in Smith.  In Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006), the Federal Circuit concluded that the Court erred in not deferring to VA’s interpretation of its own regulations, 38 C.F.R. § 4.25(b) and Diagnostic Code 6260, which limits a veteran to a single disability rating for tinnitus, regardless whether the tinnitus is unilateral or bilateral. 
The Veteran has already been assigned the maximum rating of 10 percent, under Diagnostic Code 6260, and there is no legal basis upon which to award a higher or separate schedular evaluation for tinnitus.
The Board has considered all arguments advanced on behalf of the Veteran and recognizes his feeling that a higher rating is warranted. Even providing full credence to the Veteran’s assertions, there is no legal basis upon which to assign a higher or separate schedular evaluation for tinnitus.  Sabonis v. Brown, 6 Vet. App. 426 (1994).  A rating in excess of 10 percent for tinnitus is not warranted.
Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record.  See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).
11. Entitlement to a rating in excess of 20 percent for diabetes mellitus.
The Veteran asserts that his diabetes mellitus with peripheral neuropathy of the right upper extremity is more disabling than reflected in his current 20 percent rating.   
Under Diagnostic Code 7913, a 10 percent rating is warranted for diabetes mellitus that is manageable by restricted diet only.  A 20 percent rating is warranted for diabetes mellitus requiring insulin and a restricted diet, or an oral hypoglycemic agent and a restricted diet.  A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities.  A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated.  A 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated.  38 C.F.R. § 4.119, Diagnostic Code 7913.
Competent medical evidence is required to establish “regulation of activities,” namely, avoidance of strenuous occupational and recreational activities, for a 40 percent rating under DC 7913.  Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007).  Notably, the Veteran must be required to avoid strenuous occupational and recreational activities.  The restriction on both types of activities is a means of showing the severity of the disability.  Id. at 363. In addition, the Court held that medical evidence is required to show the need for regulation of activities.  Id. at 364.  
Compensable complications of diabetes mellitus are to be rated separately unless they are part of the criteria used to support a 100 percent evaluation under Diagnostic Code 7913.  Noncompensable complications are deemed to be part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913.
The May 2015 VA examination report indicates the Veteran was prescribed oral hypoglycemic agents and an insulin injection more than once per day.  The examiner checked the box indicating that the Veteran had “regulation of activities” and explained that the Veteran modifies his diet to eat low carbohydrate meals.  The examiner further indicated that the Veteran must watch how much he works with his hands because repetitive use of his hands causes his neuropathy to flare up.  The examiner further noted that the Veteran must watch how long he can walk because of the neuropathy in his feet.  The evidence shows that the Veteran did not have hospitalizations for episodes of ketoacidosis or hypoglycemic reactions in the previous 12 months.  There was no evidence of progressive unintentional weight loss or loss of strength attributable to the Veteran’s diabetes. 
Regarding functional impact, the Veteran reported that his left upper extremity neuropathy results in weakness after repetitive use of his hand.  He reported dropping things frequently such as work tools and dishes.  The examiner noted that in an occupation setting, the Veteran would need to take breaks when his neuropathy symptoms flare up.  The Veteran also reported having trouble walking long distances because of foot neuropathy.  As such, in an occupational setting, he would need to take breaks from standing or walking as needed for foot pain. 
The evidence shows that for the entire appeal period the Veteran’s diabetes mellitus symptoms more nearly approximate the criteria for a 20 percent rating. The Veteran’s diabetes required insulin and restricted diet, but regulation of activities is not shown.
In the March 2017 Brief the Veteran’s attorney argues that the May 2015 VA examination shows the Veteran did require regulation of activities and thus a 40 percent rating is warranted.  The Board rejects this argument.  The examiner did check the box indicating that the Veteran had “regulation of activities” and explained that the Veteran modifies his diet to eat low carbohydrate meals.  The examiner further indicated that the Veteran must watch how much he works with his hands because repetitive use of his hands causes his neuropathy to flare up.  The examiner further noted that the Veteran must watch how long he can walk because of the neuropathy in his feet.  As previously noted “regulation of activities,” is defined as the avoidance of strenuous occupational and recreational activities.  The evidence does not show that the Veteran was medically required to avoid strenuous occupation and recreational activities due to his diabetes.  His limitations of walking and standing are related to his diabetes-induced peripheral neuropathy, which is separately compensated pursuant DC 7913.  In addition, VA treatment records show the Veteran was advised to consider weight loss and regular exercise on numerous occasions.  Thus, the Board finds that the Veteran’s diabetes mellitus did not require regulation of activities within the meaning of DC 7913.
A rating in excess of 20 percent for diabetes mellitus is not warranted.   
As previously noted, compensable complications of diabetes mellitus are to be rated separately unless they are part of the criteria used to support a 100 percent evaluation under Diagnostic Code 7913.  The Veteran has been assigned separate evaluations for his left upper and bilateral lower extremities.  The AOJ included the Veteran’s peripheral neuropathy of the right upper extremity symptoms were contemplated by the Veteran’s 20 percent evaluation for diabetes mellitus evaluation under DC 7913.   
Peripheral neuropathy of the right upper extremity is rated pursuant to 8513, which provides ratings for major and minor extremities.  The Veteran’s service treatment records indicate he is right handed.  Under Diagnostic Code 8513, for the major extremity, the rating schedule provides a 20 percent rating for mild incomplete paralysis, a 40 percent rating for moderate incomplete paralysis, and a 70 percent rating for severe incomplete paralysis of all radicular groups. Where there is complete paralysis of the major extremity, a 90 percent rating is assigned. 38 C.F.R. § 4.124a.
The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration.  Id.  When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a.  The terms “mild,” “moderate” and “severe” are not defined in VA regulations, and the Board must arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6.
During the May 2015 VA examination, the Veteran reported rare numbness and tingling in the right hand about once a month.  The Veteran denied constant pain or intermittent pain in the bilateral upper extremities.  He showed numbness and mild parasthesia in the bilateral upper extremities.  A neurological examination showed the Veteran had normal strength in the upper extremities.  The Veteran’s deep tendon reflexes in the upper extremities were normal.  Light touch testing results were mostly normal in the upper extremities but showed decreased sensation in the left hand/fingers.  Position sense testing was normal in the upper extremities.  The Veteran showed mild incomplete paralysis of the right ulnar nerve.  
As previously noted, 38 C.F.R. § 4.124a provides that when the neurological involvement is wholly sensory, the rating should be for the mild, or at most the moderate degree.  Here, the Veteran’s reports of tingling and numbness are sufficient to show sensory involvement and the physical examination showed mild incomplete paralysis of the right ulnar nerve.  Thus, a separate rating based on mild incomplete paralysis of the right upper extremity secondary to the Veteran’s diabetes mellitus is warranted    
12. Entitlement to a rating in excess of 20 for peripheral neuropathy of the left upper extremity.
The Veteran asserts that his peripheral neuropathy of the left upper extremity is more disabling than reflected in his 20 percent rating.  
Under DC 8513, for the minor extremity, the rating schedule provides a 20 percent rating for mild incomplete paralysis, a 30 percent rating for moderate incomplete paralysis, and a 40 percent rating for severe incomplete paralysis of all radicular groups. Where there is complete paralysis of the minor extremity, an 80 percent rating is assigned. 38 C.F.R. § 4.124a.
During the May 2015 VA examination, the Veteran reported numbness and tingling in the left hand off and on throughout the day, especially after repetitive use.  He reported rare numbness and tingling in the right hand about once a month.  The Veteran denied constant pain or intermittent pain in the bilateral upper extremities.  He showed numbness and mild parasthesia in the bilateral upper extremities.  A neurological examination showed the Veteran had normal strength in the upper extremities.  The Veteran’s deep tendon reflexes in the upper extremities were normal.  Light touch testing results were mostly normal in the upper extremities but showed decreased sensation in the left hand/fingers.  Position sense testing was normal in the upper extremities.  Vibration sensation was normal in the right upper extremities and decreased in the left upper extremity.  Cold sensation was normal in the upper extremities.  There was no evidence of muscle atrophy.  The Veteran showed mild incomplete paralysis of the left median nerve and mild incomplete paralysis of the right ulnar nerve.  
The medical evidence of records shows that for the entire appeal period, Veteran’s peripheral neuropathy of the left upper extremity manifested in no worse than mild incomplete paralysis.  The Veteran’s reported symptoms are most sensory.  As moderate incomplete paralysis is not shown, a rating in excess of 20 percent for peripheral neuropathy of the left upper extremity is not warranted.  
13. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right lower extremity.
The Veteran asserts that his peripheral neuropathy of the right lower extremity is more disabling than reflected in his current 10 percent rating. 
The Veteran’s peripheral neuropathy of the right upper extremity is rated pursuant to DC 8520. DC 8520 provides ratings for paralysis of the sciatic nerve.  DC 8520 provides that mild incomplete paralysis is rated 10 percent disabling; moderate incomplete paralysis is rated 20 percent disabling; moderately severe incomplete paralysis is rated 40 percent disabling; and severe incomplete paralysis, with marked muscular atrophy, is rated 60 percent disabling. Complete paralysis of the sciatic nerve, the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost, is rated 80 percent disabling. 38 C.F.R. § 4.124a.
During a May 2015 VA examination, the Veteran reported that his peripheral neuropathy in the feet started about 5 years ago.  The Veteran reported constant numbing and tingling in both feet.  He reported burning pain occurring at night in the bilateral feet.  The Veteran denied constant pain in the lower extremities.  He showed mild intermittent pain in bilateral lower extremities.  He also showed moderate numbness and parasthesia/dysesthesias in the bilateral lower extremities.  A neurologic examination showed the Veteran had normal strength in the lower extremities.  The Veteran’s deep tendon reflexes in the lower extremities were absent.  Light touch testing results were normal in the lower extremities.  Position sense testing was normal in the right lower extremity and decreased in the left lower extremities.  Vibration sensation was decreased in the bilateral lower extremities.  Cold sensation was decreased in the lower extremities.  There was no evidence of muscle atrophy.  The Veteran showed trophic skin changes in both legs resulting in decreased hair growth and smooth/shiny skin.  The Veteran showed mild incomplete paralysis of the left and right sciatic and femoral nerves.  
The medical evidence of record shows that for the entire appeal period, Veteran’s peripheral neuropathy of the right sciatic nerve manifested in no worse than mild incomplete paralysis.  The Veteran reported sensory symptoms and decreased sensation but also had full strength.  There was also no evidence of muscle atrophy.  As moderate incomplete paralysis of the sciatic nerve is not shown, a rating in excess of 10 percent for peripheral neuropathy of the right lower extremity is not warranted.  
14. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of left lower extremity.
The Veteran asserts that his peripheral neuropathy of the left lower extremity is more disabling than reflected in his current 10 percent rating. 
As noted above, the Veteran’s peripheral neuropathy of the right upper extremity is rated pursuant to DC 8520 for the sciatic nerve.  See 38 C.F.R. § 4.124a, DC 8520.  
During a May 2015 VA examination, the Veteran reported that his peripheral neuropathy in the feet started about 5 years ago.  He reported constant numbing and tingling in both feet.  He also reported burning pain occurring at night in the bilateral feet.  The Veteran denied constant pain in the lower extremities.  He showed mild intermittent pain in bilateral lower extremities.  He also showed moderate numbness and parasthesia/dysesthesias in the bilateral lower extremities.  A neurologic examination showed the Veteran had normal strength in the lower extremities.  The Veteran’s deep tendon reflexes in the lower extremities were absent.  Light touch testing results were normal in the lower extremities.  Position sense testing was normal in the right lower extremity and decreased in the left lower extremities.  Vibration sensation was decreased in the bilateral lower extremities.  Cold sensation was decreased in the lower extremities.  There was no evidence of muscle atrophy.  The Veteran showed trophic skin changes in both legs resulting in decreased hair growth and smooth/shiny skin.  The Veteran showed mild incomplete paralysis of the left and right sciatic and femoral nerves.  
The medical evidence of record shows that for the entire appeal period, Veteran’s peripheral neuropathy of the left sciatic nerve manifested in no worse than mild incomplete paralysis.  The Veteran reported sensory symptoms and decreased sensation but also had full strength.  There was also no evidence of muscle atrophy.  As moderate incomplete paralysis of the sciatic nerve is not shown, a rating in excess of 10 percent for peripheral neuropathy of the left lower extremity is not warranted.  
15. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the left lower femoral nerve.
The Veteran asserts that his peripheral neuropathy of the left lower femoral nerve is more disabling than reflected by his current 10 percent rating. 
Peripheral neuropathy of the femoral nerve is rated pursuant to DC 8526.  Under DC 8526, mild incomplete paralysis of the femoral nerve is rated 10 percent disabling; moderate incomplete paralysis is rated 20 percent disabling; severe incomplete paralysis is rated 30 percent disabling; and complete paralysis is rated 40 percent disabling.
During a May 2015 VA examination, the Veteran reported constant numbing and tingling in both feet.  He also reported burning pain occurring at night in the bilateral feet.  The Veteran denied constant pain in the lower extremities.  He showed mild intermittent pain in bilateral lower extremities.  He also showed moderate numbness and parasthesia/dysesthesias in the bilateral lower extremities.  A neurologic examination showed the Veteran had normal strength in the lower extremities.  The Veteran’s deep tendon reflexes in the lower extremities were absent.  Light touch testing results were normal in the lower extremities.  Position sense testing was normal in the right lower extremity and decreased in the left lower extremities.  Vibration sensation was decreased in the bilateral lower extremities.  Cold sensation was decreased in the lower extremities.  There was no evidence of muscle atrophy.  The Veteran showed trophic skin changes in both legs resulting in decreased hair growth and smooth/shiny skin.  The Veteran showed mild incomplete paralysis of the left and right sciatic and femoral nerves.  
The medical evidence shows that for the entire appeal period, Veteran’s peripheral neuropathy of the left sciatic nerve manifested in no worse than mild incomplete paralysis.  The Veteran reported sensory symptoms and decreased sensation but also had full strength.  There was also no evidence of muscle atrophy.  As moderate incomplete paralysis of the femoral nerve is not shown, a rating in excess of 10 percent for peripheral neuropathy of the left femoral nerve is not warranted.  
16. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right lower femoral nerve.
The Veteran asserts that his peripheral neuropathy of the right lower femoral nerve is more disabling than reflected by his current 10 percent rating. 
As previously noted, peripheral neuropathy of the femoral nerve is rated pursuant to DC 8526.  During a May 2015 VA examination, the Veteran reported constant numbing and tingling in both feet.  He also reported burning pain occurring at night in the bilateral feet.  The Veteran denied constant pain in the lower extremities.  He showed mild intermittent pain in bilateral lower extremities.  He also showed moderate numbness and parasthesia/dysesthesias in the bilateral lower extremities.  A neurologic examination showed the Veteran had normal strength in the lower extremities.  The Veteran’s deep tendon reflexes in the lower extremities were absent.  Light touch testing results were normal in the lower extremities.  Position sense testing was normal in the right lower extremity and decreased in the left lower extremities.  Vibration sensation was decreased in the bilateral lower extremities.  Cold sensation was decreased in the lower extremities.  There was no evidence of muscle atrophy.  The Veteran showed trophic skin changes in both legs resulting in decreased hair growth and smooth/shiny skin.  The Veteran showed mild incomplete paralysis of the left and right sciatic and femoral nerves.  
The medical evidence of record shows that for the entire appeal period, Veteran’s peripheral neuropathy of the left sciatic nerve manifested in no worse than mild incomplete paralysis.  The Veteran reported sensory symptoms and decreased sensation but also had full strength.  There was also no evidence of muscle atrophy.  As moderate incomplete paralysis of the femoral nerve is not shown, a rating in excess of 10 percent for peripheral neuropathy of the right femoral nerve is not warranted.  
17. Entitlement to a compensable rating for bilateral hearing loss.
The Veteran asserts that his bilateral hearing loss is more disabling than reflected in his current noncompensable rating.  
The assigned evaluation for hearing loss is determined by mechanically applying the rating criteria to certified test results under Diagnostic Code (DC) 6100.  See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992).  Under DC 6100, ratings for hearing loss are determined in accordance with the findings obtained on audiometric examination.  Evaluations of hearing impairment range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests, together with the average hearing threshold level as measured by puretone audiometry tests in the frequencies 1000; 2000; 3000; and 4000 Hertz (cycles per second).  To evaluate the degree of disability from hearing impairment, the rating schedule establishes eleven auditory acuity levels designated from Level I for essentially normal acuity through Level XI for profound deafness.  38 C.F.R. § 4.85, DC 6100.  As set forth in the regulations, Tables VI, VIa, and VII are used to calculate the rating to be assigned.  See 38 C.F.R. § 4.85, DC 6100.
If the use of speech discrimination is not appropriate, then Table VIA is the appropriate source of the Roman numeral designation, which is based solely on puretone threshold average. 38 C.F.R. § 4.85(c).  Puretone threshold average is the average of the puretone thresholds at the 1000, 2000, 3000, and 4000 Hertz (Hz) frequencies. 38 C.F.R. § 4.85(d).
Hearing tests will be conducted without hearing aids, and the results of above-described testing are charted on Table VI and Table VII.  See 38 C.F.R. § 4.85.
Alternatively, VA regulations provide that in cases of exceptional hearing loss, when the puretone thresholds at each of the four specified frequencies (1,000, 2,000, 3,000 and 4,000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral.  Each ear will be evaluated separately.  38 C.F.R. § 4.86(a).  The provisions of 38 C.F.R. § 4.86(b) further provide that, when the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever would result in the higher numeral, and that numeral will be elevated to the next higher numeral.  
The Veteran was afforded a VA audiological evaluation in January 2012.  The pure tone thresholds, in decibels, were as follows: 
			HERTZ		
	1000	2000	3000	4000	AVERAGE
RIGHT	15	15	45	50	31.25
LEFT	20	20	35	60	33.75

Average puretone threshold for the right ear was 31.25 and 33.75 for the left.  Speech audiometry revealed speech recognition ability of 96 percent in the right ear and 96 percent in the left ear.  Regarding functional impact the Veteran reported that he did not think that his hearing loss would interfere with his ability to work.   
The results of the May 2015 audiogram show no worse than Level I acuity in the right ear and Level I acuity in the left ear.  Application of the above-noted findings to Table VII result in a 0 percent disability rating under 38 C.F.R. § 4.85, DC 6100.  
The Board finds the VA examiner’s finding highly probative to the question at hand.  The examiners were audiologists and possessed the necessary education, training, and expertise to provide the requested opinions.  See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993).  In addition, the VA examiners conducted the audiological evaluation in compliance with the VA Handbook of Standard Procedures and Best Practices for Audiology Compensation and Pension Examinations.
The Board in no way discounts the difficulties that the Veteran experiences because of his hearing loss.  The Veteran is competent to testify to facts or circumstances that can be observed and described by a lay person.  38 C.F.R. § 3.159(a)(2); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011).  However, it must be emphasized, as previously noted, that the disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designation assigned after audiometry results are obtained.  Hence, the Board must base its determination on the results of the pertinent audiological evaluations of record.  See Lendenmann v. Principi, 3 Vet. App. 345 (1992).  In other words, the Board is bound by law to apply VA’s rating schedule based on the Veteran’s audiometry results.  See 38 U.S.C. § 1155; 38 C.F.R. § 4.1.  
Under these circumstances, the Board finds that a compensable rating for hearing loss is not warranted.
18. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD).
The Veteran asserts that his PTSD is more disabling than reflected in his current 50 percent rating.  
PTSD and major depressive disorder are evaluated under VA’s General Rating Formula for Mental Disorders.  Under the formula, a 50 percent 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 understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.  38 C.F.R. § 4.130, DC 9411.
A 70 percent rating is warranted where 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; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships.  38 C.F.R. § 4.130, DC 9411.  The criteria for a 70 percent rating for PTSD are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood.  Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001).
A 100 percent rating is warranted when 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; memory loss for names of close relatives, own occupation, or own name.  38 C.F.R. § 4.130, DC 9411.
Ratings are assigned according to the manifestation of symptoms. However, the use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating.  Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002).  
The United States Court of Appeals for the Federal Circuit has acknowledged the “symptom-driven nature” of the General Rating Formula and that “a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.”  Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116 (Fed. Cir. 2013).  The Federal Circuit has explained that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating.”  Id. at 117.
When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the veteran’s capacity for adjustment during periods of remission.  38 C.F.R. § 4.126(a).  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 during the examination. Id.  However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation based on social impairment.  38 C.F.R. § 4.126(b).
A December 2014 rating decision proposed to decrease the Veteran’s PTSD evaluation. A July 2015 rating decision decreased the Veteran’s PTSD evaluation from 70 percent to 50 percent effective September 1, 2015.  In January 2015, the Veteran filed an increased rating claim for his PTSD.  The July 2015 rating decision continued the reduction to 50 percent effective September 1, 2015.  Based on the procedural history.  The Board will first consider whether the reduction of the Veteran’s PTSD evaluation from 70 percent to 50 percent was proper.       
When reduction in the evaluation of a service-connected disability is contemplated and the lower evaluation would result in a reduction or discontinuance of compensation payments, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons.  The beneficiary must be notified at his latest address of record of the contemplated action and furnished detailed reasons therefor.  The beneficiary must be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at the present level.  38 C.F.R. § 3.105(e).
In addition, 38 C.F.R. § 3.344 provides that rating agencies will handle cases affected by change of medical findings or diagnosis, to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension.  It is essential that the entire record of examination and the medical-industrial history be reviewed to ascertain whether the recent examination is full and complete, including all special examinations indicated as a result of general examination and the entire case history.  
Examinations which are less thorough than those on which payments were originally based will not be used as a basis for reduction.  Ratings for diseases subject to temporary or episodic improvement will not be reduced based on any one examination, except in those instances where all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated.  Moreover, where material improvement in the physical or mental condition is clearly reflected, the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life.  38 C.F.R. § 3.344(a).
However, the provisions of 38 C.F.R. § 3.344(c) specify that the above considerations are required for ratings which have continued for long periods at the same level (five years or more), and do not apply to disabilities which have not become stabilized and are likely to improve.  Therefore, reexaminations disclosing improvement, physical or mental, in these disabilities will warrant a reduction in rating.  38 C.F.R. § 3.344.
In the present case, the 70 percent rating was in effect from September 9, 2004. Regardless of whether the disability rating has been in effect for at least 5 years, the Board must not only determine “that an improvement in a disability has actually occurred but also that improvement actually reflects an improvement in the veteran’s ability to function under the ordinary conditions of life and work.”  Murphy v. Shinseki, 26 Vet. App. 510, 517 (2014); Faust v. West, 13 Vet. App. 342, 349 (2000); Brown, 5 Vet. App. at 421.
Thus, it is well established that VA cannot reduce a veteran’s disability evaluation without first finding, inter alia, that the service-connected disability has improved to the point that he or she is now better able to function under the ordinary conditions of life and work.  Murphy v. Shinseki, 26 Vet. App. 510, 517 (2014); Faust v. West, 13 Vet. App. 342, 349 (2000); Brown, 5 Vet. App. at 421.
An October 2014 VA psychological evaluation shows the Veteran had a diagnosis of other specified trauma and stressor related disorder, and an unspecified depressive disorder.  The examiner noted that the Veteran continues to have symptoms of PTSD related to his war experiences but currently they are not sufficient under the DSM 5 (lacks one symptom under criterion D) for the full diagnosis, but they do constitute a trauma stressor disorder related to those experiences.  
The Veteran had occupational and social impairment with reduced reliability and productivity.  The examiner noted that most of the Veteran’s impairment seems related to his PTSD symptoms of irritability and anxiety.  The Veteran reported generally getting along with his wife of 43 years.  He is active in his church and reported studying to eventually get a license to become a minister.  He reported socializing with church members and generally getting along with other.  He reported that he liked to keep busy but finds it harder now because of his physical limitations due to pain.  
The Veteran reported the following symptoms: depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and neglect of personal appearance and hygiene.  The Veteran further reported that his main symptoms had been irritability (without violence) and problems with anxiety.  Notably, the proposed reduction was based on the results of the October 2014 VA psychological evaluation. 
The Veteran was afforded an additional psychological evaluation in May 2015.  During the evaluation the Veteran showed diagnoses of PTSD and unspecified depressive disorder. The Veteran showed occupational and social impairment with reduced reliability and productivity.  
The Veteran reported the following symptoms: emotional numbing, anger, sleep disturbance (Vietnam related nightmares), avoidance behaviors, dissociative experiences, low frustration tolerance, anger, psychological reactivity triggers, intrusive images/thoughts, altered beliefs regarding self/world/others, hypervigilance (gun by the bed/sitting with back to the wall), anxiety (trouble breathing), worry, suspiciousness, chronic sleep impairment, and disturbances of motivation and mood.  He also reported depressive symptoms and intermittent suicidal ideation without plan or intent.   
The examination was negative for gross impairment in thought processes or communication, persistent delusions or hallucinations, spatial disorientation, impaired judgment, grossly inappropriate behavior, and persistent danger of hurting self or others.  The examiner noted that the Veteran was oriented to person, place, time, and purpose.  His attention and concentration were fair.  His speech was normal.  He denied current suicidal ideation or intent.  There was no homicidal ideation evidenced.  There were no auditory or visual hallucinations reported.  There was no delusional content shown.  His insight was fair and judgment appropriate.  Regarding severity, the Veteran reported an increase in depressive symptoms, which he attributes mostly to physical status and overall pain.  The examiner noted that overall, psychiatric symptoms appear to have worsened.  However, the changes appear to be a result of diminished physical functional abilities and inherent reciprocal relationship between physical symptoms and psychological symptoms.   
In an October 2016 letter, the Veteran’s wife indicated that the Veteran’s PTSD symptoms are severe and have gotten progressively worse over time.  She reported the Veteran suffers from symptoms of depression and anxiety that cause him to become withdrawn.  He experiences intense flashbacks and nightmares, avoids crowds, confuses easily, and often lacks the ability to focus or be present with people when they are with him.  She reported that his depression and anxiety are constant and impede his ability to complete day to day chores and activities.   She reported he is regularly disoriented.  His memory and concentration are hindered.  She further reported that he has thoughts and feeling of suicide.  Also of record are lay statements from the Veteran’s friends endorsing similar symptoms.  
The Veteran also submitted a December 2016 Disability Benefits Questionnaire (DBQ).  The Veteran showed occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, and/or mood.  The Veteran reported he is unable to maintain healthy social relationships due to PTSD.  He reported social anxiety, panic attacks, intimacy issues, isolation, and avoidance.  He indicated he is easily irritated in social situations, has trust issues, and difficulty communicating and getting along with others.   
The Veteran also endorsed the following symptoms: depressed mood, anxiety, panic attacks more than once a week, near-continuous panic or depression, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, speech intermittently illogical, obscure, or irrelevant, difficulty understanding complex commands, impaired judgement, impaired abstract thinking, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficult adapting to stressful circumstances, inability to establish and maintain effective relationships, suicidal ideation, obsessional rituals, impaired impulse control, persistent delusions or hallucinations, neglect of personal appearance or hygiene, intermittent inability to perform activities of daily living, and disorientation to time or place.  
In a December 2016 letter, VA psychiatrist, Dr. H.W.H., indicated that she had been treating the Veteran since April 2010.  She indicated that the Veteran has continued problems of hyperarousal, hypervigilance, anger outbursts, sporadic rage, exacerbated startle response, nightmares, and avoidance behaviors.  
The Veteran’s VA treatment records indicate that he consistently denied suicidal and homicidal ideation.  He consistently reported feeling depressed, irritable, anxious, and angry.  While treated he consistently presented as neatly groomed and appropriately dressed.  He also reported interrupted sleep.  The Veteran was consistently oriented to person, place, and time.  Regarding hallucinations, the Veteran reported seeing shadows in his periphery and sometimes hearing his name called.
The Board turns first to whether the reduction in the Veteran’s PTSD evaluation from 70 percent to 50 percent was proper.  Based on the medical records, the most probative evidence does not show an improvement in the Veteran’s ability to function under the ordinary conditions of life and work due to his PTSD.  While the October 2014 VA psychological evaluation suggests that the Veteran’s mental health symptoms were less severe the May 2015 VA examiner noted that the Veteran’s mental health symptoms had worsened in conjunction with his physical ailments.  In sum, the preponderance of the evidence does not indicate that an improvement in the Veteran’s PTSD has occurred and that the improvement reflects an improvement in the veteran’s ability to function under the ordinary conditions of life and work.  See Brown, 5 Vet. App. at 421.  Thus, restoration of the 70 percent rating is warranted.
Turning now to the Veteran’s increased rating claim, the evidence shows that for the entire appeal period, the Veteran’s PTSD more nearly approximates the criteria for a 70 percent rating.  The evidence does not show total occupational and social impairment.  There is no evidence of gross impairment in thought processes or communication. The Veteran generally denied delusions but reported visual and auditory hallucinations.  There is no evidence of grossly inappropriate behavior.  There is also no evidence he is in persistent danger of hurting self or others.  The evidence consistently shows that the Veteran can complete activities of daily living.  The objective evidence also shows that the Veteran has been able to consistently maintain personal hygiene.  The Veteran consistently reported being able to get along with his wife and reported consistent involvement in his church.  As such, the Veteran’s symptoms more nearly approximate the criteria for a 70 percent rating, a 100 percent rating is not warranted.   
In reaching the above decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine does not apply. Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
Effective Date
The Veteran filed an increased rating claim for diabetes mellitus in January 2015.  A July 2015 rating decision assigned separate ratings for the Veteran’s diabetes complications including peripheral neuropathy of the left upper extremity, peripheral neuropathy of the right lower extremity, peripheral neuropathy of the left lower femoral nerve, and peripheral neuropathy of the right lower femoral nerve effective January 23, 2015.  The Veteran’s attorney asserts that the assigned of evaluations should be given an effective date of January 23, 2014.  See March 2017 Appellate Brief.
The Board notes that the effective date of an award of increased compensation is the earliest date as of which it is factually ascertainable that an increase in disability has occurred, if the claim is received within one year from such date; otherwise, it is the date of receipt of the claim.  38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2); see also Hazan v. Gober, 10 Vet. App. 511 (1997).  The Veteran’s increased rating claim for diabetes mellitus was received January 23, 2015.  In this regard, this decision will consider whether an increased rating is warranted for any portion of the one-year period prior to the date of claim (i.e., January 23, 2014 to January 23, 2014).  See Gaston v. Shinseki, 603 F.3d 979, 984 (Fed. Cir. 2010) (holding that 38 U.S.C. § 5110(b)(2) and its implementing regulation “require[e] that an increase in a veteran’s service-connected disability must have occurred during the one year prior to the date of the veteran's claim to receive the benefit of an earlier effective date.”).
Notably, the Veteran’s medical treatment records within the year prior to January 2015 do not show complaints of or treatment for peripheral neuropathy.  The Veteran underwent a VA examination for his diabetes and neurological symptoms in May 2015.  The May 2015 VA examination report showed a worsening in the Veteran’s diabetes complications resulting in the assignment of separation ratings for peripheral neuropathy of the left upper extremity, peripheral neuropathy of the right lower extremity, peripheral neuropathy of the left lower femoral nerve, and peripheral neuropathy of the right lower femoral nerve.  
19. Entitlement to an effective date prior to January 23, 2015 for the grant of service connection for peripheral neuropathy of the left lower femoral nerve.
A review of the evidence dated within one year of the Veteran’s increased rating claim for diabetes indicates that there is no basis for a separate compensable rating for the left lower femoral nerve prior to January 23, 2015.  As there is no medical evidence during the one-year period before he filed his claim showing a worsening of his peripheral neuropathy symptoms, the effective date must be the date of receipt of the claim.  38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). 
An effective date prior to January 23, 2015 is not warranted.  
20. Entitlement to an effective date prior to January 23, 2015 for the grant of service connection for peripheral neuropathy of the right lower extremity. 
A review of the evidence dated within one year of the Veteran’s increased rating claim for diabetes indicates that there is no basis for a separate compensable rating for peripheral neuropathy of the right lower extremity prior to January 23, 2015.  As there is no medical evidence during the one-year period before he filed his claim showing a worsening of his peripheral neuropathy symptoms, the effective date must be the date of receipt of the claim.  38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). 
An effective date prior to January 23, 2015 is not warranted.  
21. Entitlement to an effective date prior to January 23, 2015 for the grant of service connection for peripheral neuropathy of the left upper extremity. 
A review of the evidence dated within one year of the Veteran’s increased rating claim for diabetes indicates that there is no basis for a separate compensable rating for peripheral neuropathy of the left upper extremity prior to January 23, 2015.  As there is no medical evidence during the one-year period before he filed his claim showing a worsening of his peripheral neuropathy symptoms, the effective date must be the date of receipt of the claim.  38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). 
An effective date prior to January 23, 2015 is not warranted.  
22. Entitlement to an effective date prior to January 23, 2015 for the grant of service connection for peripheral neuropathy of the right lower femoral nerve.
A review of the evidence dated within one year of the Veteran’s increased rating claim for diabetes indicates that there is no basis for a separate compensable rating for peripheral neuropathy of the right lower femoral nerve prior to January 23, 2015.  As there is no medical evidence during the one-year period before he filed his claim showing a worsening of his peripheral neuropathy symptoms, the effective date must be the date of receipt of the claim.  38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). 
An effective date prior to January 23, 2015 is not warranted.  
23. Entitlement to a total disability rating based on individual unemployability (TDIU).
The Veteran asserts that he is unable to work due to his service connected disabilities.    
Schedular TDIU may be assigned when the disabled person is determined to be unable to secure or follow a substantially gainful occupation as a result of service-connected disability or disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more.  See 38 C.F.R. § 4.16(a). 
Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability.  38 C.F.R. § 4.16(a).
It is the policy of the VA that all veterans who are unable to secure and follow a substantially gainful occupation due to a service connected disability shall be rated totally disabled and that veterans who fail to meet the schedular criteria for a total disability rating shall be considered for such a rating on an extraschedular basis.  38 C.F.R. § 4.16(b).  The Board is precluded from awarding TDIU on an extra-schedular basis in the first instance, but must ensure that the claim is referred to the Director of VA’s Compensation Service.  Bowling v. Principi, 15 Vet. App. 1, 10 (2001).
When determining whether the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disability, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but it may not be given to his age or to any impairment caused by nonservice-connected disabilities.  38 C.F.R. §§ 3.341, 4.16, 4.19.
The Veteran is currently service connection for PTSD rated as 50 percent disabling, diabetes mellitus rated as 20 percent disabling, peripheral neuropathy of the left upper extremity rated as 20 percent disabling, tinnitus rated as 10 percent disabling, peripheral neuropathy of the left lower extremity rated as 10 percent disabling, peripheral neuropathy of the right lower extremity rated as 10 percent disabling, peripheral neuropathy of the left lower femoral nerve rated as 10 percent disabling, peripheral neuropathy of the right lower femoral nerve rated as 10 percent disabling, scars rated of the right knee and leg rated as noncompensable, scars of the left upper back rated as noncompensable, and bilateral hearing loss rated as noncompensable.  The Veteran’s combined disability rating is 80 percent.  Thus, he meets the schedular requirements for TDIU.  In addition, the preponderance of the evidence shows that the Veteran’s service-connected disabilities make him unable to secure and follow a substantially gainful occupation.   
A February 2007 SSA decision found that the Veteran was limited due to his PTSD.  In an October 2007 letter, Dr. R.L.W. of Evansville Neurology reported that he treats the Veteran for post-concussion syndrome.  Dr. R.L.W. indicated that Veteran is too disabled from any occupation because of his persistent symptoms.  Dr. R.L.W. further noted that his opinion was based on the Veteran’s subjective complaints.
During the January 2008 VA examination, the Veteran reported he has not worked since 2006.  He reported that he worked in the oil fields off and on for about 34 years.  He reported that he quit working in the oil fields in 1999 after a shoulder injury.  He reported working for temporary services off and on until 2004.   He worked as a forklift driver between 2004 and 2006.  
During the January 2008 VA psychiatric evaluation, the Veteran reported he suffered a head injury in February 2006 which caused a seizure problem.  As a result, he reported he was unable to resume employment.  The Veteran also asserted that his unemployability is due to his PTSD symptoms.  He reported that his anger, concentration, and flashbacks have impaired his ability to work.  He stated that although he has not been fired, he quit several jobs because of his anger problems.  The examiner concluded that although it is likely that the Veteran’s anger and difficulties in managing social interactions causes impairment at work, it has not caused extended unemployment.  The examiner also concluded that the primary reason for his unemployment is his February 2006 head injury.  
In a March 2011 and March 2012 letters, VA physician H.W.H. indicated she has been treating the Veteran since April 2010 for PTSD.  She reported the Veteran has continued problems of hyperarousal, hypervigilance, angry outbursts, sporadic rage, exacerbated startle response, nightmares, and avoidance behaviors.  She asserts that he is not able to engage in social interactions with others without experiencing heighted anxiety that would make is extremely difficult for him to function in any type of position.  Additionally, the Veteran has sporadically severe headaches due to previous head trauma that contributed to his overall dysfunctional status in a workplace setting.  
Notably, the Veteran’s March 2011 application for TDIU indicates his highest level of education was a GED.   
During the May 2015 VA diabetes examination, the Veteran reported that his left upper extremity neuropathy results in weakness after repetitive use of his hand.  He reported dropping things frequently such as work tools and dishes.  The examiner noted that in an occupation setting, the Veteran would need to take breaks when his neuropathy symptoms flare up.  The Veteran also reported having trouble walking long distances because of foot neuropathy.  As such, in an occupational setting, he would need to take breaks from standing or walking as needed for foot pain.  Similarly, the May 2015 neurological examination indicates the Veteran upper extremity peripheral neuropathy is worse with repetitive use and makes using tools difficult.  
A December 2016 mental health DBQ indicates that the Veteran’s PTSD symptoms continuously impair his ability to work effectively and efficiently.  
In a January 2017 employment assessment, vocational consultant, Dr. S.B., concluded that the Veteran s totally and permanently precluded from working at a substantial level due to the severity of his service-connected disabilities.  Dr. S.B. reviewed the claims file in detail and noted the Veteran’s documented history of mental health symptomology including agitation, nightmares, low energy, low motivation, memory issues, hallucinations and anxiety.  
The evidence consistently shows that the severity of the Veteran’s mental health symptoms including his impaired sleep, difficulty interacting with others, and lack of motivation and mood substantially impact his ability to work.  In addition, the Veteran’s highest level of education was completion of a GED.  The majority of the Veteran’s previous work experience include physically vigorous work such as working in oil fields and as a forklift operator.  The Veteran’s service-connected physical disabilities including his diabetes, peripheral neuropathy of the bilateral upper and lower extremities, and service-connected headaches also preclude him from participating in a highly physical occupation.  In sum, the evidence shows that Veteran’s service-connected disabilities make him unable to secure and follow a substantially gainful occupation.  TDIU is granted. 
REASONS FOR REMAND
1. Entitlement to service connection for a lumbar spine disability.
As the Veteran’s lumbar spine claim has been reopened, it must be remanded for additional development.  The Veteran asserts that his lumbar spine disability is secondary to his service-connected scars of the upper back.  Remand for an addendum opinion on secondary service connection is warranted. 
The matter is REMANDED for the following action:
1. Return the claims file to examiner who provided the May 2015 opinion (or another qualified examiner if unavailable), to provide and addendum opinion as to whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran’s lumbar spine disability was caused by or aggravated by (i.e., permanently worsened beyond the natural progression) by his service-connected scars of the upper back.
The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached.
2. Readjudicate the appeal. 
 
R. FEINBERG
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	J.A. Williams, Associate Counsel