Citation Nr: 18149453 Decision Date: 11/09/18 Archive Date: 11/09/18 DOCKET NO. 16-15 161A DATE: November 9, 2018 ORDER Whether new and material evidence has been received to reopen a claim for service connection for asthma is granted. Whether new and material evidence has been received to reopen a claim for service connection for erectile dysfunction is granted. Whether new and material evidence has been received to reopen a claim for service connection for tremors is granted. Whether new and material evidence has been received to reopen a claim for service connection for muscle tension headaches is granted. Whether new and material evidence has been received to reopen a claim for service connection for an acquired psychiatric disability is granted. Whether new and material evidence has been received to reopen a claim for service connection for depression is granted. Entitlement to service connection for asthma is denied. Entitlement to service connection for sleep apnea, including as secondary to a service-connected disability, is granted. Entitlement to service connection for Wolff-Parkinson-White syndrome is denied. Entitlement to service connection for erectile dysfunction as secondary to a service-connected disability is granted. Entitlement to service connection for muscle tension headaches is granted. Entitlement to service connection for an acquired psychiatric disorder is granted. Entitlement to service connection for depression is denied. Entitlement to an increased rating in excess of 10 percent for hypertension is denied. REMANDED Entitlement to service connection for tremors as secondary to a service-connected disability is remanded. FINDINGS OF FACT 1. In October 2010, the RO denied service connection for asthma, muscle tension headaches, tremors, erectile dysfunction and the Veteran did not perfect an appeal. 2. The evidence submitted since the RO’s October 2010 rating decision is not cumulative or redundant and raises a reasonable possibility of substantiating the underlying claim for service connection for asthma, muscle tension headaches, tremors, and erectile dysfunction. 3. In May 2013, the RO denied service connection for an acquired psychiatric disorder and depression and the Veteran did not perfect an appeal. 4. The evidence submitted since the RO’s May 2013 rating decision is not cumulative or redundant and raises a reasonable possibility of substantiating the underlying claim for service connection for an acquired psychiatric disorder and depression. 5. Resolving reasonable doubt in the Veteran’s favor, the evidence establishes an acquired psychiatric disorder is related to service. 6. The preponderance of the evidence is against finding that the Veteran’s asthma is related to service. 7. Sleep apnea is attributable to a service-connected disability. 8. The preponderance of the evidence shows that the Veteran does not have a current diagnosis of Wolff-Parkinson-White syndrome. 9. Erectile dysfunction is attributable to a service-connected disability. 10. Muscle tension headaches are attributable to a service-connected disability. 11. The Veteran does not have a depression diagnosis. 12. Throughout the rating period on appeal, the Veteran has required continuous medication for control of hypertension; his documented diastolic pressure has predominantly been less than 110 and his systolic pressure has predominantly been less than 200. CONCLUSIONS OF LAW 1. The October 2010 rating decision is final regarding the issue of service connection for asthma, muscle tension headaches, tremors, erectile dysfunction. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. 2. New and material evidence has been received since the RO’s October 2010 rating decision sufficient to reopen the Veteran’s claim of service connection for asthma, muscle tension headaches, tremors, and erectile dysfunction. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The May 2013 rating decision is final regarding the issue of service connection for an acquired psychiatric disorder and depression. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. 4. New and material evidence has been received since the RO’s May 2013 rating decision sufficient to reopen the Veteran’s claim of service connection for an acquired psychiatric disorder and depression. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. The criteria for service connection for an acquired psychiatric disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303, 3.307, 3.309. 6. The criteria for service connection for asthma have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303, 3.307, 3.309. 7. The criteria for service connection for sleep apnea as secondary to the service-connected acquired psychiatric disability have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 8. The criteria for service connection for Wolff-Parkinson-White syndrome have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 9. The criteria for service connection for erectile dysfunction as secondary to service-connected acquired psychiatric disability have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 10. : The criteria for service connection for muscle tension headaches as secondary to service-connected acquired psychiatric disability have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 11. The criteria for service connection for depression have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 12. The criteria for an evaluation in excess of 10 percent for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.104, Diagnostic Code 7101. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from August 1989 to August 1993. The Veteran has not indicated service in the Gulf after August 1990. See October 2007 Compensation Claim. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from October 2014 and June 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. New and Material Evidence 1. Whether new and material evidence has been received to reopen a claim for service connection for asthma. 2. Whether new and material evidence has been received to reopen a claim for service connection for erectile dysfunction. 3. Whether new and material evidence has been received to reopen a claim for service connection for tremors. 4. Whether new and material evidence has been received to reopen a claim for service connection for muscle tension headaches. 5. Whether new and material evidence has been received to reopen a claim for service connection for an acquired psychiatric disability. 6. Whether new and material evidence has been received to reopen a claim for service connection for depression. Governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing and, after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. Rating actions from which an appeal is not timely perfected become final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. A final decision cannot be reopened unless new and material evidence is presented. 38 U.S.C. § 5108. In general, if new and material evidence is presented or secured with respect to a finally adjudicated claim, VA shall reopen and review the claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether new and material evidence has been submitted, the Board must consider the specific reasons for the prior denial. Evans v. Brown, 9 Vet. App 273, 283 (1996); Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). The provisions of 38 C.F.R. § 3.156(a) create a low threshold, with the phrase “raises a reasonable possibility of substantiating the claim” enabling rather than precluding reopening and not constituting a third requirement that must be met before the claim is reopened. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). In an October 2010 rating decision, the RO denied the Veteran’s claim for service connection for asthma, muscle tension headaches, tremors, and erectile dysfunction. The Veteran timely filed a notice of disagreement (NOD) in April 2011 seeking a de novo review and a Statement of the Case (SOC) was issued in September 2012. The Veteran did not timely file a VA Form 9 substantive appeal and, as a result, the October 2010 rating decision is final. In a May 2013 rating decision, the RO denied the Veteran’s claim for an acquired psychiatric disorder, to include schizoaffective disorder, bipolar type, posttraumatic stress disorder, and bipolar disorder and for depression. The Veteran did not file an NOD and, as a result, the May 2013 rating decision is final. Pertinent evidence received since the October 2010 and May 2013 rating decisions includes VA medical treatment records, VA examinations, private medical treatment records, private examinations, and arguments from the Veteran and his attorney. This evidence is presumed credible for the purpose of determining whether new and material evidence has been submitted. See Justus v. Principi, 3 Vet. App. 510 (1992). The Board finds that the evidence submitted since the October 2010 and May 2013 rating decisions is new and material. Specifically, the private medical treatment records and examinations indicate a nexus between the claimed disabilities and either the Veteran’s service or another disability. This evidence is new in that it was not previously considered by agency decisionmakers. It is also not cumulative or redundant of the evidence previously of record. Moreover, it raises a reasonable possibility of substantiating the claims. Accordingly, reopening of the claims of entitlement to service connection for asthma, muscle tension headaches, tremors, erectile dysfunction, an acquired psychiatric disorder, and depression is warranted. Service Connection To establish entitlement to service connection, there must be: (1) competent and credible evidence confirming the Veteran has the claimed disability or at least has since filing the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection may be established on a secondary basis for a disability that is 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 (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a)-(b). When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 7. Entitlement to service connection for an acquired psychiatric disorder. The Veteran contends that his acquired psychiatric disorder is related to service, or in the alternative, aggravated by his service-connected hypertension. Service treatment records (STRs) are silent for complaints of, treatment for, or a diagnosis of a psychiatric disability while the Veteran was in active service. A review of the post-service medical evidence of record shows that the Veteran has received mental health treatment at the VA Medical Center. The VA treatment records show that the Veteran has been diagnosed with posttraumatic stress disorder (PTSD), bipolar disorder, and schizoaffective disorder, bipolar type with PTSD traits. The Veteran was afforded a VA psychiatric examination in June 2014 and was diagnosed with schizoaffective disorder, bipolar type. The examiner noted that this diagnosis “reflects the history of paranoia, mania, depressive episodes, irritability, mood swings, and anger outbursts that have been documented in the psychiatric records.” See June 2014 VA examination at 1. The examiner opined that the Veteran’s mental disorder was less likely than not proximately due to or the result of his service-connected hypertension. The examiner noted that scholarly articles show that mental illness is a risk factor for hypertension but that none were found to suggest or imply that hypertension is a causal factor in developing mental illness. The Board notes that this examination did not provide an opinion as to whether the Veteran’s mental disorder was aggravated by his service-connected hypertension or was directly related to his active service. The Veteran submitted a January 2011 private mental status examination from Dr. J.G., who reported that he reviewed Social Security Administration records and records. The Veteran reported initially seeking private treatment for depression in the 1990s before receiving VA treatment starting in 2005. The examiner diagnosed the Veteran with bipolar disorder, most recent episode depressed. The Veteran also submitted a May 2016 private disability benefits questionnaire (DBQ) in September 2017. Dr. R.W. diagnosed the Veteran with schizoaffective disorder, bipolar type. The Veteran denied any occupational or social problems prior to service. He also reported alcohol abuse which developed and progressed during his time in the military and described it as a form of self-medication to cope with his mental problems which began in service. Dr. R.W. stated that his examination suggested that the Veteran had schizoaffective disorder which most likely began in service and continues uninterrupted to the present. Dr. R.W. attached a thorough assessment of the Veteran’s mental health which concluded that his schizoaffective disorder began in service. Dr. R.W. based this opinion on examination of the Veteran, review of the Veteran’s records, evidence-based research. Also of record are two lay statements from the Veteran’s The statements all note that they knew the Veteran before his service and that upon leaving service they all noticed significant changes in the Veteran’s personality. Based on the foregoing, the Board finds that the evidence for and against the claim is at least in equipoise. Therefore, reasonable doubt must be resolved in favor of the Veteran. Accordingly, entitlement to service connection for an acquired psychiatric disability is warranted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. App. 49 (1990). 8. Entitlement to service connection for asthma. The Veteran contends that service connection is warranted for asthma, as related to smoke and jet fumes from his service in Desert Storm. The Veterans STRs do not reflect any complaints, findings, treatment, or diagnosis of respiratory disorders. In his August 1993 separation examination, the Veteran’s lungs and chest were marked as normal and the Veteran himself did not endorse shortness of breath or asthma in the Report of Medical History. In a June 2010 VA examination, it was noted that, in April 2010, the Veteran had recently complained of increasing shortness of breath since January 2010 and was diagnosed with dyspnea possibly secondary to hyperactive airways and questionable asthma. The Veteran complained of occasional dry cough and shortness of breath on exertion and spontaneously. The Veteran stated that he had not been diagnosed with asthma but was being evaluated for asthma. He contended that he developed breathing problems and attributed it to one of his hypertensive medications. The examiner again diagnosed the Veteran with dyspnea secondary to hyperactive airways and questionable asthma and opined that it was not caused by hypertension, noting that the exact cause of hyperactive airway disease and asthma is unknown but hypertension is not among the genetic and environmental factors known to trigger attacks. There is no competent evidence that indicates a link between the service-connected hypertension, to include medications, and the asthma. On this basis, the Board finds secondary service connection is not warranted and there is not a duty to further assist regarding this aspect of the claim. 38 C.F.R. §§ 3.159, 3.310. The Veteran underwent a VA respiratory examination in April 2011. The Veteran denied productive cough, sputum production or hemoptysis, but complained of intermittent anorexia in the summertime “with the heat.” He also complained of dyspnea on exertion “with anything that I do” and reported 2-3 asthmatic attacks daily during which the Veteran cannot function. The Veteran was diagnosed with asthma. The VA examiner noted that there was no mention of asthma or asthma-like symptoms in the Veteran’s military records, including his separation examination, and the Veteran was diagnosed with asthma approximately 20 years after military service. Therefore, the examiner concluded, no chromic issue with asthma can be established in the Veteran following his military service. As a result, the examiner opined that the Veteran’s asthma was not caused by or the result of exposure to jet smoke and fumes from his duties as an Aviation Electronic Technician during military service. Here, the most probative and credible evidence are the VA examinations, which are consistent with the medical evidence of record and establish that the Veteran’s asthma is not related to his service, including exposure to any smoke and jet fumes. The VA examiner explained the reasons for her conclusions based on an accurate characterization of the evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (stating that factors for assessing the probative value of a medical opinion are the physician’s access to the claims folder and the thoroughness and detail of the opinion). Thus, her opinions are highly probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) The Board acknowledges the Veteran’s contentions that his asthma is related to his active military service, as he was exposed to smoke and jet fumes. However, to the extent that the Veteran attempts to link his asthma to service, the Board finds that these statements are not competent evidence and no probative value on this issue of nexus as the Veteran has not been shown to possess the medical training or expertise needed to provide such opinions. To the extent that any probative value was to be given, the general lay assertions are outweighed by the specific, reasoned opinions of the April 2011 VA examination report and the clinical evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Based on the above, the Board finds that the preponderance of the evidence is against the claim. The claim for entitlement to service connection for a respiratory disability must be denied. There is no reasonable doubt to be resolved. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 9. Entitlement to service connection for sleep apnea, including as secondary to a service-connected disability. The Veteran contends that his sleep apnea is related to service or to his now service-connected acquired psychiatric disorder. Private treatment records show that in 2011, the Veteran complained of frequent night awakening, snoring, and daytime sleepiness. A July 2011 sleep study found that the Veteran had sleep apnea and he was put in a CPAP machine. With respect to secondary service connection, the Board notes that this decision granted service connection for an acquired psychiatric disability. The Veteran’s representative submitted a March 2017 private disability benefits questionnaire wherein the private examiner, Dr. M.B., opined that it was as likely as not that the Veteran’s schizoaffective disorder aided in the development of and permanently aggravated his obstructive sleep apnea. She based her opinion on an interview with the Veteran, review of his medical records, review of the supporting literature, and her experience. Dr. M.B. noted that research has shown that psychiatric disorders are commonly associated with obstructive sleep apnea and that a study found that subjects with psychiatric disorders have a higher prevalence of sleep apnea. Based on a review of the evidence, the Board concludes that service connection for sleep apnea as secondary to service-connected acquired psychiatric disability is warranted. The evidence shows that he currently has a diagnosis of sleep apnea. When affording him the benefit-of-the-doubt, the evidence supports a finding that service connection for the Veteran’s sleep apnea as secondary to his service-connected acquired psychiatric disability is warranted. In concluding that service connection on a secondary basis is warranted, of particular importance to the Board is the March 2017 opinion from Dr. M.B. As Dr. M.B.’s opinion was formed after interviewing the Veteran as well as reviewing his records, and is supported by a rationale discussing the relationship between psychiatric disorders and sleep apnea, the Board accords it great probative value. It is also uncontradicted. Taking into account this opinion and in affording the Veteran the benefit of the doubt, the evidence supports a finding that the Veteran’s sleep apnea is aggravated by his now service-connected acquired psychiatric disability. Thus, after considering all of the evidence of record, the Board concludes that a finding of service connection is warranted. Service connection for sleep apnea is, therefore, granted. 10. Entitlement to service connection for Wolff-Parkinson-White syndrome. The Veteran contends that he currently suffers from Wolff-Parkinson-White syndrome (WPW) that is the result of military service or as secondary to service-connected hypertension. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that §§ 1110 and 1131’s requirement of the existence of a present disability for VA compensation purposes cannot be considered arbitrary); see also McClain v. Nicholson, 21 Vet. App. 319, 323 (2007) (holding that the requirement of a current disability is met when a claimant has a disability at the time a claim for VA compensation is filed or during the pendency of that claim). Consequently, the evidence of record must show that the Veteran currently has the disability for which benefits are being claimed. The medical evidence of record shows that the Veteran’s service treatment records (STRs) do not contain any complaints of, treatment for, or diagnoses of any cardiac condition, including WPW, in service. Additionally, relevant post-service medical records do not document diagnoses for any of these conditions. The Veteran was afforded a VA examination in May 2015 for his claimed WPW. The examiner diagnosed the Veteran with supraventricular arrhythmia, but noted that the Veteran did not have WPW. The examiner noted that the Veteran’s private treatment records contained a WPW pattern on an EKG but did not specifically confirm a diagnosis of WPW. In his review of the Veteran’s medical records, the VA examiner also did not see a definitive diagnosis of WPW. Moreover, the examiner sated that even if the Veteran were eventually diagnosed with WPW, WPW is considered a congenital abnormal pathway, meaning that the Veteran was born with it and it was not known to be caused from hypertension. As a result, the examiner noted that it was less likely than not that the Veteran’s reputed WPW was proximately due to or the result of his service-connected hypertension. In the absence of proof of a present disability (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it; without this minimum level of proof, there can be no valid claim). Therefore, as the evidence of record shows that the Veteran does not have WPW, the Board concludes that service connection is not warranted, and no further discussion of the remaining elements is necessary. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) (“A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service.”); see also Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006) (finding that the absence of any one element will result in denial of service connection). Accordingly, to the extent that the medical evidence addresses whether the Veteran has WPW, the preponderance of the evidence indicates that he does not. The Veteran is competent to report his current symptoms, but his reports must be weighed against the medical evidence of record. See Grover v. West, 12 Vet. App. 109, 112 (1999); Jandreau, supra. To the extent that the Veteran has indicated that he has WPW, the medical evidence showing an absence of such a disability is of greater probative weight than the Veteran’s reports made during the course of his claim, as the examiner have the medical knowledge upon which to determine if there is a medical disability with a pathology. Although lay persons are competent to provide opinions on some medical issues, see, e.g. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue of whether the Veteran currently has WPW falls outside the realm of common knowledge of a lay person. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992) (stating that a layperson can provide an account of symptoms but not a diagnosis that requires medical knowledge). Consequently, the Veteran’s statements as to a current diagnosis or the etiology of any of these conditions are not probative. As the preponderance of the evidence is against a finding that the Veteran has a current diagnosis of WPW or during any period relevant to the appeal, the benefit of the doubt rule does not apply. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 11. Entitlement to service connection for erectile dysfunction as secondary to a service-connected disability. The Veteran contends that his erectile dysfunction is related to his acquired psychiatric disability, which is now service-connected. On review of the evidence, the Board finds that service connection is warranted. The Veteran underwent a VA examination in July 2010 for his service-connected hypertension and related symptoms, including erectile dysfunction. The VA examiner noted that the Veteran had been diagnosed with schizoaffective disorder, bipolar type with posttraumatic stress disorder traits and was being treated with Ariprazole, Divalproex, Trazodone and Ziprasidone. The examiner diagnosed the Veteran with erectile dysfunction and opined that his schizoaffective disorder and the medications for schizoaffective disorder were causing his erectile dysfunction. The Board has herein granted service connection for an acquired psychiatric disability. As such, the Board grants service connection for erectile dysfunction on a secondary basis. 12. Entitlement to service connection for muscle tension headaches. The Veteran contends that his headaches are related to his acquired psychiatric disability, which is now service-connected. On review of the evidence, the Board finds that service connection is warranted. The Veteran underwent a VA examination in July 2010 for his service-connected hypertension and related symptoms, including headaches. The VA examiner diagnosed the Veteran with muscle tension headaches and stated that the headaches were less likely than not caused by or a result of his hypertension but were “most likely caused by stress secondary to Veteran’s mental disorder.” The Board has herein granted service connection for an acquired psychiatric disability. As such, the Board grants service connection for headaches on a secondary basis. 13. Entitlement to service connection for depression. The Veteran contends that service connection is warranted for depression, to include as secondary to his service-connected hypertension. As discussed elsewhere in this decision, the Board has granted service connection for an acquired psychiatric disorder. Having reviewed the relevant evidence, the Board finds no indication that the Veteran has been diagnosed with depression within the appeals period. A June 2014 VA mental disorders examination diagnosed the Veteran with schizoaffective disorder, bipolar type and noted that the diagnosis reflected the Veteran’s history of depressive episodes. A separate diagnosis of depression was not rendered. Moreover, VA treatment records note that the Veteran had a history of depression but do not contain a confirmed diagnosis of depression. In the absence of such evidence, the Board finds that the issue of service connection for depression must be denied. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that in the absence of proof of present disability, there can be no valid claim of service connection). Consequently, the claim of service connection for depression must be denied, as the preponderance of the evidence is unfavorable leaving the benefit-of-the-doubt doctrine inapplicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 14. Entitlement to an increased rating in excess of 10 percent for hypertension. Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned specific diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as “staged” ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. The RO has rated the Veteran’s hypertension as 10 percent disabling under Diagnostic Code 7101. 38 C.F.R. § 4.104, Diagnostic Code 7101. Under Diagnostic Code 7101, a 10 percent disability rating requires diastolic pressure predominantly 100 or more, systolic pressure predominantly 160 or more, or that an individual with a history of diastolic pressure predominantly 100 or more requires continuous medication for control. A 20 percent disability rating requires diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. A 40 percent evaluation is assigned for hypertensive vascular disease with diastolic pressure predominantly 120 or more. Hypertensive vascular disease with diastolic pressure predominantly 130 or more is rated 60 percent disabling. The Veteran was afforded a VA hypertension examination in October 2014. The examiner noted that the Veteran’s treatment plan included taking continuous medication for hypertension and that the Veteran’s blood pressure remained fairly stable with medication. The Veteran also did not have a history of a diastolic blood pressure elevation to predominantly 100 or more. The average blood pressure reading taken from three separate readings between April 2013 and June 2014 was 132/79. In this case, the medical evidence of record does not support a rating in excess of 10 percent. VA treatment records from February 2008 to October 2014 reflect numerous blood pressure readings which consistently found diastolic pressure less than 110 and systolic pressure less than 200. A rating in excess of 10 percent is not warranted because there is no competent evidence demonstrating that the Veteran had diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more at any time during the course of the appeal. Additionally, in making this determination, the Board has reviewed all the evidence of record, both medical and lay evidence, regarding the frequency, duration, and severity of the Veteran’s symptoms and finds there is no distinct period during which a higher/staged rating is warranted. Accordingly, the Board finds that the preponderance of the evidence is against the claim for an increased rating for hypertension, and it must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for tremors as secondary to a service-connected disability is remanded. The Veteran contends that service connection for tremors is warranted, to include as secondary to service-connected hypertension or to newly service-connected acquired psychiatric disorder. In a June 2010 VA examination, the VA examiner diagnosed the Veteran with tremors from possible tardive dyskinesia and noted that the Veteran “appears to have possible tardive dyskinesia based on his history probably related to his psychiatric medications.” June 2010 VA examination at 14. VA treatment records also contain August 2011 and July 2013 indications of a mild symmetric essential tremor in the Veteran’s hands and an August 2014 negative evaluation for symptoms of tardive dyskinesia. As it is unclear whether the Veteran’s reported tremors are the result of an underlying disability or are otherwise attributable to service or to a service-connected disability, a VA examination and opinion is necessary. The matter is REMANDED for the following action: 1. Schedule the Veteran for appropriate VA examinations to assess the nature and etiology of his tremors. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to each examiner for review of pertinent documents, and each examiner should review the Veteran’s medical history. The respective examiners are asked to take a history from the Veteran as to the onset and progression of the Veteran’s claimed symptoms, and to provide responses to each of the following: a. Identify any currently diagnosed disorder manifested by tremors. b. For each diagnosed disability, opine whether it is at least as likely as not (50 percent probability or greater) that any such disability was incurred in or caused by active service. c. If not, opine whether it is at least as likely as not (50 percent probability or greater) that such disability was caused by the Veteran’s service-connected acquired psychiatric disorder. d. If not, opine whether it is at least as likely as not (50 percent probability or greater) that such disability was aggravated (i.e., chronically worsened beyond the natural progress) by the Veteran’s service-connected acquired psychiatric disorder.   A full rationale must be provided for any opinion offered. If an opinion cannot be offered without resort to mere speculation, the examiner must indicate why this is the case and indicate what additional evidence, if any, would allow for a more definitive opinion. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Thompson, Associate Counsel