Citation Nr: 18149789 Decision Date: 11/13/18 Archive Date: 11/13/18 DOCKET NO. 16-10 865 DATE: November 13, 2018 ORDER Entitlement to a rating in excess of 30 percent prior to June 8, 2016, and in excess of 50 percent thereafter, for service-connected posttraumatic stress disorder (PTSD) is denied. New and material evidence has been received to reopen the claim of entitlement to service connection for rheumatoid arthritis (RA), to include as secondary to herbicide exposure or service-connected PTSD. REMANDED Entitlement to service connection for RA, to include as secondary to herbicide exposure or service-connected PTSD, is remanded. FINDINGS OF FACT 1. Prior to June 8, 2016, the Veteran’s PTSD was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 2. From June 8, 2016, the Veteran’s PTSD results in occupational and social impairment with reduced reliability and productivity, but without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 3. In a final decision issued in December 2011, the Board denied the Veteran’s claim of entitlement to service connection for RA. 4. The evidence associated with the file since the December 2011 Board decision includes evidence that relates to an unestablished fact necessary to substantiate the claim, is neither cumulative nor redundant of evidence already of record and raises a reasonable possibility of substantiating the claim of entitlement to service connection for RA, to include as secondary to herbicide exposure or service-connected PTSD. CONCLUSIONS OF LAW 1. Prior to June 8, 2016, the criteria for a disability rating in excess of 30 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code (DC) 9411. 2. From June 8, 2016, the criteria for a disability rating in excess of 50 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.130, DC 9411. 3. The December 2011 Board decision denying service connection for RA, claimed as being secondary to herbicide exposure, is final. 38 U.S.C. § 7104; 38 C.F.R. §§ 3.104, 3.156, 20.200, 20.201, 20.302, 20.1104. 4. The evidence received after the December 2011 Board decision is new and material as to the claim for service connection for RA, to include as secondary to herbicide exposure or service-connected PTSD, and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1965 through April 1969. The December 2015 statement of the case also addressed the issue of entitlement to an earlier effective date for the grant of a 30 percent evaluation for service-connected PTSD. However, in his substantive appeal, the Veteran checked the box that he wished to limit his appeal and stated that he only wished to appeal the issues of entitlement to an increased evaluation for PTSD and the claim to reopen service connection for RA. Accordingly, there is no appeal as to that issue and it is not addressed herein. 1. Entitlement to a rating in excess of 30 percent prior to June 8, 2016 and in excess of 50 percent thereafter for PTSD. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2017). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. The Veteran has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Under this code, a 30 percent evaluation contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, due to such symptoms as: suicidal ideations; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and the inability to establish and maintain effective relationships. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. However, the symptoms recited in the criteria in the rating schedule for evaluating mental disorders 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 (2002). “[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 (Fed. Cir. 2013). The symptoms shall have caused occupational and social impairment in most of the referenced areas. Vazquez-Claudio, 713 F.3d 112. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126. In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126. Factual History The Veteran filed his current claim for an increased rating on April 3, 2012. From April 2011 until May 2012, VA clinical records show that the Veteran reported anger issues related to a co-worker and poor frustration tolerance; mental status evaluations throughout this time were normal. See April 2011, July 2011, October 2011, and May 2012 VA treatment records. However, beginning in May 2012, the Veteran reported sleep disturbances due to flashback and nightmares occurring at least once a month. See May 2012 VA treatment record. On mental status evaluation the Veteran exhibited no abnormal behavior, an appropriate affect and mood, a coherent and goal driven thought process, no hallucinations or delusions, and appropriate thought content. In February 2013, the Veteran underwent a VA examination for PTSD. See February 2013 VA examination and report. At this time, the Veteran described his marriage as generally stable, although he felt his wife had to deal with his increased irritability due to job stress over the last two years. The Veteran reported that he had a good relationship with his two children and his grandchildren. He told the examiner that he socialized with acquaintances and sometimes traveled to visit his mother. However, the Veteran admitted having issues with a co-worker over the past 6 months and that he had eventually lost his temper, publicly and loudly, for which campus police were called. The Veteran reported no prior issues. The examiner wrote that the Veteran’s problem with his co-worker appeared to be due to the co-worker’s competitiveness, rather than the Veteran’s PTSD symptoms. In the examiner’s report, he assessed the Veteran’s PTSD as causing occupational and social impairment due to mild or transient symptoms which decrease work efficacy and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. From May 2013 through October 2015, the Veteran’s psychiatric treatment records documented no abnormal mental status evaluations or increases in PTSD symptoms. See May 2013 VA treatment record (Veteran planning trip to France, stress under control; neutral mood); October 2014 VA treatment record (Veteran reported working around the house and renovating furniture; neutral mood, negative depression screening); January 2015 VA treatment record (Veteran reported traveling to Cancun and Florida, continued to work around the house; neutral mood and normal appetite); April 2015 VA treatment record (Veteran reported continued travel; neutral mood); July 2015 VA treatment record (Veteran reported working in the garden; sleep and appetite normal, neutral mood); and October 2015 VA treatment record (Veteran reported being in Hawaii and Florida, enjoying travel, working around house; neutral mood, normal appetite and sleep). In February 2016, the Veteran did report dreams and nightmares that were causing sleep disturbances, but nevertheless the clinician documented that sleep and appetite were within normal limits. By May 2016, the Veteran was being prescribed medications for sleep, but his appetite and sleep were still reported as being within normal limits. See May 2016 VA treatment record. On June 8, 2016, the Veteran underwent a VA examination for PTSD. See June 2016 VA examination and report. The Veteran described his marriage as a little rocky due to his PTSD. The Veteran reported having flashbacks and panic attacks 3 times a week. The Veteran reported that he did not speak to his son due anger issues. The Veteran reported that his relationship with his daughter was strained due to prior alcohol use. Further, the Veteran reported that it was hard to hang out with people because of his mood and argumentative nature. In addition, the Veteran reported that he had no hobbies due to a loss of interest, a lack of concentration, and feelings of sullenness. The Veteran stated that he had retired due to difficulties with a co-worker, which he related to his PTSD. The examiner noted symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, and inability to establish and maintain effective relationships. The examiner also noted that the Veteran’s PTSD symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. However, the examiner assessed the Veteran’s symptoms as causing occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The examiner’s assessment included a review of the Veteran’s VA treatment records. The examiner noted that although the Veteran endorsed flashbacks and panic attacks, treatment records only mentioned distressing dreams, sleep disturbances, and anger or irritability. Regarding sleep disturbances, the examiner remarked that the Veteran’s appetite and sleep were considered within normal limits at various times within his treatment records. The examiner also noted that the treatment records did not document a history of panic attacks. Similarly, the examiner explained that although the Veteran reported a diminished capacity to concentrate, his mental status evaluations showed intact memory. The Veteran’s last psychiatric treatment note was September 2016, at which time the Veteran endorsed panic attacks and thinking of past events, as well as nightmares with sleep disturbances and a normal appetite. At the conclusion of this treatment, the Veteran’s medication for his sleep disturbances was changed. Analysis The Board finds that a rating in excess of 30 percent prior to June 8, 2016, and in excess of 50 percent thereafter is not warranted. Initially, the Board finds that the preponderance of the evidence is against a finding of occupational and social impairment with reduced reliability and productivity to warrant a 50 percent rating or higher prior to June 8, 2016. In this regard, although, the Veteran reported anger issues related to a co-worker and poor frustration tolerance, the Veteran’s mental status evaluations from April 2011 until May 2012 consistently documented a neutral mood. Moreover, in February 2013 the Veteran reported having a good relationship with his family, an ability to socialize, and sometimes travel. Indeed, from May 2013 through October 2015, the Veteran was able travel domestically and aboard to visit family, work around the house, and renovate furniture. Although he reported sleep disturbances from nightmares or flashbacks, these complaints were occasional and intermittent prior to June 8, 2016. Importantly, the Veteran did not exhibit symptoms such as flattened affect, circumstantial, circumlocutory, or stereotyped speech; more than once a week panic attacks; difficulty in understanding complex commands; impairment of short and long-term memory; impaired judgment; or impaired abstract thinking. Further, the February 2013 VA examiner assessed the Veteran’s PTSD as causing occupational and social impairment due to mild or transient symptoms which decrease work efficacy and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication, which is the criteria for a lesser 10 percent rating. See 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. Moreover, the Veteran was alert and oriented and cleanly dressed, with no loosening of associations, delusional thinking or loss of reality testing. The Board recognizes that the Court in Mauerhan v. Principi, 16 Vet. App. 436 (2002), stated that the symptoms listed in VA’s general rating formula for mental disorders is 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. However, the Court further indicated that without those examples, differentiating a 30 percent evaluation from a 50 percent evaluation would be extremely ambiguous. Id at 442. In light of the Mauerhan case, the Board observes that the Veteran had been in a long-term relationship with his wife and had a good relationship with his children exhibiting his ability to maintain long term social relationships. Further, although the Veteran reported an incident of losing his temper, the February 2013 VA examiner specifically noted that the Veteran’s anger issues were due to the co-worker’s competitiveness rather than PTSD. Moreover, the Veteran was able to perform his activities of daily living during this period. In other words, the overall PTSD symptomatology during this period did not cause occupational and social impairment with reduced reliability and productivity. Therefore, the Board must conclude that the Veteran’s impairment during this time period warranted a 30 percent rating for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The demonstrated PTSD symptomatology did not more nearly approximate the criteria for a higher rating. Importantly, the first medical evidence of demonstrating increased symptoms is the June 8, 2016 VA examination. From June 8, 2016, the Board finds that a rating in excess of 50 percent is not warranted. During the June 2016 VA examination, the Veteran endorsed a rocky marriage, panic attacks 3 times a week, poor familial relationships, a lack of interest in hobbies, and difficulty establishing social relationships. The examiner noted symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, and inability to establish and maintain effective relationships. In addition, the examiner indicated that the Veteran’s PTSD caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. Nevertheless, the examiner’s assessment was that the Veteran’s PTSD caused occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. Moreover, although the Veteran reported panic attacks, nightmares, flashbacks, poor familial and social relationships, and a loss of interest in hobbies, he has not been consistent in this regard, as he has also told his treating providers that he enjoyed traveling, and only intermittently reported nightmares, flashbacks, or panic attacks. Similarly, the Veteran’s mental status evaluations have documented normal grooming, normal hygiene, unremarkable motor activity, neutral mood, appropriate affect, normal attention, normal concentration, normal recent and remote memory, unremarkable thought content, no suicidal or homicidal ideation, no hallucinations, no insomnia, and a normal appetite; no hopelessness, helplessness, or anhedonia; as well as fair judgment, insight, and impulse control. See September 2016 VA treatment record. In view of the aforementioned evidence, the Board finds that the Veteran’s PTSD is primarily characterized by the following signs or symptoms: depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood. Essentially, the Board finds that the Veteran’s symptoms are similar to many of those contemplated by the currently assigned 50 percent rating. In particular, the General Rating Formula lists, inter alia, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, disturbances of mood and motivation, and impaired judgment, among the types of symptoms associated with a 50 percent rating. 38 C.F.R. § 4.130. These are not unlike those the Board finds to be associated with this Veteran’s PTSD. Id. Further, given the frequency, nature, and duration of those symptoms, as reflected in the medical evidence, the Board finds that they result in no more than occupational and social impairment with reduced reliability and productivity. They do not more closely approximate the types of symptoms contemplated by a 70 percent rating, and therefore, a 70 percent rating is not warranted. See Vazquez-Claudio, 713 F.3d at 114 (holding 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”). Significantly, the evidence shows that the Veteran has been able to perform his activities of daily living, maintain relationships and engage in social activities. The Board notes that although the 70 percent rating criteria contemplate deficiencies in “most areas,” including work, school, family relations, judgment, thinking, or mood, such deficiencies must be “due to” the symptoms listed for that rating level, “or others or others of similar severity, frequency, and duration.” Vazquez–Claudio, supra. That is, simply because this Veteran has depressed mood, and because the 70 percent level contemplates a deficiency these symptoms among other areas, does not mean his PTSD rises to the 70 percent level. Indeed, the 50 percent criteria contemplate some form of mood impairment. Furthermore, at no point during the course of the appeal has the Veteran exhibited symptoms such as near continuous panic, obsessional rituals or neglect of personal hygiene, impaired impulse control or suicidal/homicidal ideation. Also, his anxiety or depression did not affect his ability to function independently, and the Veteran’s speech was never illogical, obscure or irrelevant. Rather, his speech was normal rate, rhythm and amount. He was consistently alert and oriented to place and person. There was no impairment of thought processes or communication. Importantly, as noted above, he has been able to perform his activities of daily living. Moreover, the Board finds that the criteria for a 100 percent rating under the General Rating Formula are not met. In this regard, the evidence does not show that the Veteran has 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. In sum, the Veteran’s symptoms do not more nearly approximate the criteria for a 70 or 100 percent disability rating. The criteria for a 50 percent rating appear to more accurately describe the Veteran’s level of social and occupational impairment, including disturbances in motivation and mood and difficulty in establishing social relationships. The Board finds that his PTSD impairment from June 8, 2016 is adequately contemplated by the 50 percent rating. In determining that the criteria for a rating in excess of 50 percent for the Veteran’s service-connected PTSD are not met, the Board has considered the applicable rating criteria not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for the psychiatric disability in question. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board has carefully reviewed and considered the Veteran’s statements regarding the severity of his PTSD. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran’s descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The Board has considered whether further staged ratings are appropriate for the Veteran’s service-connected PTSD. See Hart, supra. However, the Board find that his symptomatology has been stable both before and after June 8, 2016; therefore, assigning further staged ratings for such disability is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 30 percent prior to June 8, 2016, and in excess of 50 percent thereafter. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. New and material evidence to reopen the claim of entitlement to service connection for RA, to include as secondary to herbicide exposure or service-connected PTSD. The Veteran asserts that new and material evidence has been submitted, which warrants entitlement to service connection for RA, to include as secondary to herbicide exposure or service-connected PTSD. In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.1100, 20.1103. A finally disallowed claim, however, may be reopened when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108. Regardless of the action taken by the RO, the Board must determine whether new and material evidence has been received subsequent to an unappealed RO denial. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). As part of this review, the Board considers evidence of record at the time of the previous final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim, and evidence submitted since a prior final disallowance. Evans v. Brown, 9 Vet. App. 273, 285-86 (1996). 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. For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary’s duty to assist or consideration of a new theory of entitlement. Shade, 24 Vet. App. at 117-18. Additionally, new and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Furthermore, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed but were not associated with the claims file when VA first decided the claim, VA will reconsider the claim, rather than requiring new and material evidence. 38 C.F.R. § 3.156(c)(1). A claim is not reconsidered, however, where VA could not have obtained the records when it initially decided the claim because the records did not exist at that time, or because the claimant failed to provide sufficient information to identify and obtain the records from the respective service department, the Joint Services Records Research Center, or any other official source. 38 C.F.R. § 3.156(c)(2). In a December 2011 decision, the Board denied service connection for RA, claimed as secondary to herbicide exposure, finding that the Veteran’s RA was not shown in service or within the first post-service year, and had not been shown to have been caused by his presumed in-service exposure to herbicides or to have been caused or aggravated by any other in-service injury or illness. As the Chairman did not order reconsideration of the Board’s decision, and no other exception to finality is applicable, the Board’s December 2011 decision is final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C. § 7104; 38 C.F.R. § 20.1100. Evidence of record at the time of the December 2011 decision included the Veteran’s service treatment records, VA treatment records, private medical records, and the Veteran’s statements. Service treatment records did not show a diagnosis of RA during active duty. Private medical records through 2007 reflected that the Veteran was diagnosed with RA; however, there was no opinion connecting the Veteran’s RA to his military service or any other in-service injury or illness. In addition, the Veteran provided statements that his RA was related to his active duty service, particularly his exposure to herbicides, but these statements did not address whether the Veteran’s RA was specifically linked to his exposure to herbicides. Evidence submitted after the December 2011 Board decision includes VA treatment records from February 2011 through September 2016, a March 2013 VA examination and report related to the Veteran’s RA, the Veteran’s statements relating his RA to his service-connected PTSD, and articles discussing the etiological link between PTSD and RA. In the March 2013 VA examination and report, the examiner opined that it was less likely than not that the Veteran’s RA was caused by his service-connected PTSD. The examiner’s rationale was that few studies have suggested an association between PTSD and RA, but it was “possible that the Veteran’s PTSD may have put him at an increased risk for developing RA, however, [RA] may have also [sic] his exposure to [herbicides] during his time serving in Vietnam, the research is just too limited to make a definitive answer in this case.” See March 2013 VA examination and report. The Board finds that new and material evidence has been presented. The examiner’s report is new, because it was not previously considered. The evidence is material because it relates to unestablished facts necessary to establish the claim – whether the Veteran’s RA is etiologically linked to an in-service injury or illness, specifically his exposure to herbicides or service-connected PTSD. See 38 C.F.R. § 3.303(a); Shedden, 381 F.3d at 1167. Additionally, the evidence is neither cumulative nor redundant as that evidence was not of record at the time of the prior denial. See 38 C.F.R. § 3.156(a). Further, new evidence is to be presumed credible for purposes of deciding whether a previously denied claim may be reopened. Justus, 3 Vet. App. at 513. Moreover, when considering the new evidence in conjunction with the evidence already of record, combined with VA assistance including an examination, it raises a reasonable possibility of substantiating the claim. Shade, 24 Vet. App. at 117. Accordingly, for all of the above reasons, the Veteran’s previously denied claim of entitlement to service connection for RA, to include as secondary to herbicide exposure or service-connected PTSD is reopened. REASONS FOR REMAND Entitlement to service connection for RA, to include as secondary to herbicide exposure or service-connected PTSD. Remand is required for a new VA opinion. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In addition, a medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). Here, the Veteran submitted articles that document the relationship between PTSD and autoimmune-related disorders, including RA. See April 2014 private medical records and March 2016 correspondence. In addition, the Veteran served in the Republic of Vietnam, where he engaged the enemy in combat and was decorated with a Vietnam Service Medal and the Air Medal, and has maintained that his RA is secondary to herbicide exposure. See December 2011 Board decision. The Veteran did undergo a VA examination March 2013 related to his claim for RA secondary to his service-connected PTSD. However, in rendering an opinion that the Veteran’s RA was less likely than not proximately due to or the result of the Veteran’s service-connected PTSD, the examiner only mentioned that few studies had suggested an association between PTSD and RA; that it was possible the Veteran’s PTSD may have put him at an increased risk for developing RA; and that the research was just too limited to make a definitive answer in this case. See March 2013 VA examination and report. Moreover, the examiner did not provide an opinion as to whether the Veteran’s RA was related to herbicide exposure, or whether the Veteran’s RA was at least as likely as not aggravated beyond its natural progression by service-connected PTSD. Thus, the VA examination and report currently of record does not contain a clear conclusion with supporting data. See Nieves-Rodriguez, 22 Vet. App. at 301. In sum, the examiner did not provide an opinion on the appropriate theories of entitlement. See Stefl, 21 Vet. App. at 123-24. Therefore, remand for a new VA opinion is required. The matters are REMANDED for the following action: 1. Obtain additional VA clinical records dated form September 2016 to the present. 2. Obtain an addendum opinion regarding the etiology of the Veteran’s RA from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. Any supporting data used to reach a conclusion must be specifically referenced. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s RA had onset in, or is otherwise related to, active military service, to include herbicide exposure. (b.) The examiner must provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s RA was proximately due to or aggravated beyond its natural progression by his service-connected PTSD.   The examiner must specifically discuss the articles provided by the Veteran as well as the March 2013 VA examination and report. J.N. MOATS Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Martinez, Associate Counsel