Citation Nr: 18150238 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 16-07 655 DATE: November 14, 2018 ORDER New and material evidence having been received, the claim of entitlement to service connection for an acquired psychiatric disorder is reopened. New and material evidence having not been received, the claim to reopen the claim of entitlement to service connection for hypertension is denied. Entitlement to service connection for an acquired psychiatric disorder characterized as an anxiety disorder to include as secondary to service-connected migraines, is granted. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected anxiety disorder is granted. Entitlement to service connection for Bell’s Palsy is denied. Entitlement to service connection for dementia is denied. Entitlement to a 30 percent disability rating for migraines is granted prior to June 18, 2015; and a 50 percent rating is granted thereafter, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to service connection for arthritis is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. In an unappealed January 2010 rating decision, the RO denied the Veteran’s claims of entitlement to service connection for an acquired psychiatric disorder and entitlement to service connection for hypertension. 2. Additional evidence has been received since the January 2010 rating decision that relates to an unestablished fact necessary to substantiate the previously denied claim of entitlement to service connection for an acquired psychiatric disorder. 3. The evidence added to the record since the January 2010 rating decision is cumulative or redundant of the evidence at the time of such decision and does not raise a reasonable possibility of substantiating the Veteran’s claim for service connection for hypertension. 4. The Veteran’s anxiety disorder is aggravated by his service-connected migraines. 5. The Veteran’s obstructive sleep apnea is aggravated by his service-connected anxiety disorder. 6. The Veteran’s Bell’s Palsy was not incurred in, or caused by, his military service. 7. The Veteran does not have a current diagnosis of dementia. 8. Prior to June 18, 2015, the Veteran’s migraines were manifest in characteristic prostrating attacks occurring on average once per month. 9. From June 18, 2015, the Veteran’s migraines have been manifest in frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The January 2010 rating decision that denied entitlement to service connection for a mental health condition and hypertension is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.302. 2. As new and material evidence has been received, the criteria for reopening the claim for service connection for an acquired psychiatric disorder have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. As new and material evidence has not been received, the criteria for reopening the claim for service connection for hypertension have not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. The criteria for entitlement to service connection for unspecified anxiety disorder as secondary to service-connected migraines have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for entitlement to service connection for obstructive sleep apnea as secondary to service-connected anxiety disorder have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for entitlement to service connection for residuals of Bell's Palsy have not been met. 38 U.S.C. §§ 1101, 5107; 38 C.F.R. § 3.303. 7. The criteria for service connection for dementia have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 8. The criteria for a 30 percent disability rating, but no higher, for migraines have been met prior to June 18, 2015. 38 U.S.C. §§ 1155; 5107; 38 C.F.R. §§ 3.102, 4.118, Diagnostic Code 7804. 9. The criteria for a 50 percent disability rating, but no higher, for migraines has been from June 18, 2015. 38 U.S.C. §§ 1155; 5107; 38 C.F.R. §§ 3.102, 4.118, Diagnostic Code 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1996 to May 2000 and from February 2009 to March 2009, and has a verified period of active duty for training from February 1995 to June 1995 with additional periods of reserve service. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. Concerning the Veteran’s claim for service connection for a mental health condition, the Board notes that the record reflects various diagnostic impressions, including anxiety disorder and attention deficit disorder. Because the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim and reported syndromes and all other information of record, the Board finds that it is more appropriate to characterize his mental health claims broadly, as a single claim of entitlement to service connection for an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The issue of entitlement to a TDIU has been raised by the record and has been added to the appeal. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009) (holding that a request for a TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate “claim” for benefits, but rather, can be part of a claim for increased compensation); see also Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001) (holding that a separate, formal claim is not required in cases where an informal claim for TDIU has been reasonably raised). The Veteran’s present claims of entitlement to service connection for an acquired psychiatric disorder and obstructive sleep apnea and claim for an increased rating for migraines have given rise to a new claim for entitlement to a TDIU. The Board has considered the Veteran’s claims and decided entitlement based on the evidence. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). New and Material Evidence Initially, the Board notes that whenever a claim to reopen is filed, regardless of how it was characterized by the agency of original jurisdiction, the Board must make a de novo determination as to whether new and material evidence has been received. Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). In general, VA rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.302. A finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108. New evidence is defined as evidence not previously submitted to agency decisionmakers. 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). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. Smith v. West, 12 Vet. App. 312 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. When determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). VA must evaluate submissions received during the year following notice of a rating decision to determine whether they contain new and material evidence, even if the new submission may support a new claim. 38 C.F.R. § 3.156(b); Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011); Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). 1. Mental Health Condition A January 2010 rating decision denied service connection for a mental health condition because there was no evidence the Veteran’s disorder was related to his active duty service. The relevant evidence of record at that time included the Veteran’s claim, service treatment records, and post-service treatment records. See January 2010 Rating Decision. The Veteran was notified of the January 2010 rating decision and of his appellate rights by letter dated January 27, 2010. The Veteran did not file a timely appeal to the January 2010 rating decision. As such, the January 2010 rating decision is final in regards to the Veteran’s claim of entitlement to service connection for a mental health condition. In August 2012, the Veteran filed a new claim of entitlement to service connection for a mental health condition. Since the time of the January 2010 rating decision, additional relevant evidence, to include a private psychological evaluation, has been added to the claims file. This evidence, not previously submitted to decision makers and relating to an unestablished fact necessary to substantiate the claim, raises a reasonable possibility of substantiating the claim and is thus new and material. 38 C.F.R. § 3.156(a). Therefore, the claim for service connection for an acquired psychiatric disorder is reopened. 2. Hypertension A January 2010 rating decision denied service connection for hypertension because there was no evidence the Veteran’s disorder was related to his active duty service. The relevant evidence of record at that time included the Veteran’s claim, service treatment records, and post-service treatment records. See January 2010 Rating Decision. The Veteran was notified of the January 2010 rating decision and of his appellate rights by letter dated January 27, 2010. The Veteran did not appeal the January 2010 rating decision. As such, the January 2010 rating decision is final in regards to the Veteran’s claim of entitlement to service connection for hypertension. The evidence of record received subsequent to the January 2010 rating decision consists of post-service medical records. The Board concludes that the evidence is new, because it was not before the RO when it denied the claim of service connection for high blood pressure. Although the evidence is new, the Board finds that it is not material because it contains no indication that the Veteran’s hypertension is related to service. The evidence does not relate to an unestablished fact necessary to substantiate the claim or raise a reasonable possibility of substantiating the claim. See Cornele v. Brown, 6 Vet. App. 59, 62 (1993) (medical evidence which merely documents continued diagnosis and treatment of a disease, without addressing the crucial matter of a medical nexus, does not constitute new and material evidence). The additional medical evidence is therefore not so significant that it must be considered in order to fairly decide the merits of the claim. In light of the above, the Board finds that the evidence submitted since the last final denial of the claim does not meet the new and material evidence standard, and thus the claim cannot be reopened. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent medical or lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted on a secondary basis for a disability which is proximately due to, or the result of, a service connected disability. 38 C.F.R. § 3.310. 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) proximately caused by; or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C. § 1110; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (holding that in the absence of proof of a present disability there can be no valid claim). 1. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to service-connected migraines The Veteran asserts that his acquired psychiatric disorder is aggravated by his service-connected migraines. For the following reasons and bases, the Board finds that entitlement to service connection for an acquired psychiatric disorder characterized as an anxiety disorder have been met on a secondary basis. The Veteran has been diagnosed with an unspecified anxiety disorder. See November 2015 Mental Health Note. Accordingly, the Veteran has a current disability. Davidson, 581 F.3d 1313. In support of his claim, the Veteran submitted a Mental Disorders (Other than PTSD and Eating Disorders) Disability Benefits Questionnaire (DBQ) completed by a private psychologist. Following an in-person examination of the Veteran, the psychologist opined that the Veteran’s anxiety disorder was more likely than not aggravated by his service-connected migraines. The psychologist rationalized that the Veteran’s frequent migraines interfere with his interpersonal relationships, work, and general life, thereby exacerbating his anxiety disorder. See May 2015 Mental Disorder DBQ; May 2015 Psychological Evaluation. In light of the medical evidence linking the Veteran’s anxiety disorder with his service-connected migraines, and no evidence to the contrary, service connection is warranted for the Veteran’s anxiety disorder. 2. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected disabilities The Veteran asserts that his obstructive sleep apnea is caused, or aggravated, by his anxiety disorder. As stated above, the Veteran is now service-connected for an acquired psychiatric disorder. Here, the evidence reflects that the Veteran has a current disability of obstructive sleep apnea. See November 2016 Sleep Apnea DBQ. Further, the Veteran submitted a positive nexus between the Veteran’s anxiety disorder, and the medications used to treat his anxiety disorder, and his obstructive sleep apnea. See id. (stating the Veteran’s anxiety disorder and antidepressant more likely than not aided in the development of, and permanently aggravates his sleep apnea). The examiner also stated that research shows anxiety and the antidepressant Sertraline are known to cause sleep difficulties and disturbances. Id. The Board notes that a December 2002 examination noted the Veteran’s obstructive sleep apnea was due to a genetic condition. See December 2002 Special Chronic Fatigue Examination. As that examination was limited to the etiology of his sleep apnea, and did not address the impact the Veteran’s anxiety disorder had on his sleep apnea, the Board finds it inadequate. In light of the medical evidence linking the Veteran’s obstructive sleep apnea with his service-connected anxiety disorder service connection is warranted for the Veteran’s obstructive sleep apnea. 3. Entitlement to service connection for residuals of Bell's Palsy The Veteran asserts that his Bell’s Palsy is related to his active duty service. He has not provided more specific contentions. For the following reasons and bases, the Board finds that service connection for Bell’s Palsy is not warranted. The Veteran was diagnosed with Bell’s Palsy affecting the left side of his face in January 2013. See January 2013 Mental Health Note. Accordingly, the Board finds that the Veteran has a current disability. See Davidson, 581 F.3d 1313. The Veteran has not contended, and the evidence does not otherwise show, any injury, event, or disease occurred during service which resulted in his current Bell’s Palsy. Accordingly, entitlement to service connection for Bell’s Palsy has not been established. Id. The determination in this case is medically complex, since whether the Veteran’s Bell’s Palsy was incurred during his service cannot be perceived through the senses alone. Therefore, competent medical evidence is required. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 470-71 (1994) (holding that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). As the Veteran is a lay person in the field of medicine, his unsupported claim of a relationship between his active duty service and Bell’s Palsy is not competent evidence on this issue, and thus lacks probative value. See Layno, 6 Vet. App. at 470-71. In sum, the preponderance of the evidence weighs against the Veteran’s claim. As such, the benefit-of-the-doubt rule does not apply and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for dementia The Veteran claims entitlement to service connection for dementia. He has not provided more specific contentions. For the following reasons and bases, the Board finds that entitlement to service connection for dementia is not warranted. The Board notes that the Veteran has never been diagnosed with dementia. The competent and credible medical evidence does not show any current diagnoses of dementia at any time. While the Veteran asserts that he has a dementia and memory-related symptomatology, as a layperson he does not have the medical competence to identify or these conditions, as this is a complex determination that cannot be made based on lay observation alone. Jandreau, 492 F.3d at 1377 (observing that a layperson can be competent to identify conditions that are simple, such as a broken leg, but is not competent to identify more complex conditions such as a form of cancer); Barr, 21 Vet. App. at 309 (holding that lay testimony is competent as to matters capable of lay observation, but not with respect to determinations that are “medical in nature”); Layno, 6 Vet. App. at 470-71 (holding that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). Furthermore, VA treatment records reflect that a diagnosis of dementia has been specifically ruled out following cognitive testing. See October 2012 Neuropsychology Consult (finding no evidence of a progressive dementia and that the Veteran’s cognitive abilities are within normal limits). As stated above, service connection may only be granted for a current disability. The Board concludes that the preponderance of the evidence is against a finding that the Veteran has a current diagnosis of dementia. Accordingly, the claim is denied.   Increased Rating VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. The Schedule assigns Diagnostic Codes to individual disabilities. Diagnostic Codes provide rating criteria specific to a particular disability. If two Diagnostic Codes are applicable to the same disability, the Diagnostic Code that allows for the higher disability rating applies. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the claimant. 38 C.F.R. § 4.3. The Schedule recognizes that a single disability may result from more than one distinct injury or disease; however, rating the same disability or its manifestation(s) under different Diagnostic Codes-a practice known as pyramiding-is prohibited. Id.; see 38 C.F.R. § 4.14. Because the level of disability may have varied over the course of the claim, the rating may be “staged” higher or lower for segments of time during the period under review in accordance with such variations, to the extent they are sufficient to warrant changes in the evaluations assignable under the applicable rating criteria. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). For increased-rating claims, where a claimant seeks a higher evaluation for a previously service-connected disability, it is the present level of disability that is of primary concern, and VA considers the level of disability for the period beginning one year prior to the claim for a higher rating. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994); see also 38 C.F.R. § 3.400(o)(2). Entitlement to a rating in excess of 10 percent for migraines The Veteran’s migraines have been assigned a 10 percent rating under Diagnostic Code (DC) 8100. See 38 C.F.R. § 4.124a. Under DC 8100, a 50 percent rating is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability; a 30 percent rating is assigned for migraines with characteristic prostrating attacks occurring on an average of once a month over the last several months; a 10 percent rating is assigned for migraines with characteristic prostrating attacks averaging one in 2 months over the last several months; and a noncompensable rating is assigned for less frequent attacks. Id. The regulation does not define “economic inadaptability.” The U.S. Court of Appeals for Veterans Claims (Court) has held that under DC 8100, a headache disorder need only be “capable of producing” economic inadaptability, and that this standard is different from the “unemployability” standard applicable in the context of determining entitlement to a total disability rating based on individual unemployability (TDIU). Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004); see 38 C.F.R. §§ 3.340, 4.16 (setting forth the requirements for establishing entitlement to TDIU). The Court has recently held that 50 percent criterion of “completely” prostrating attacks necessarily subsumes the 30 percent criterion of “characteristically” prostrating attacks based on the plain meaning of the words, and that the phrase “very frequent,” while inexact, connotes a frequency greater than the 30 percent required once a month. Johnson v. Wilkie, No. 16-3808, 2018 U.S. App. Vet. Claims LEXIS 1253, at *16 (Sept. 19, 2018). Further, the Court noted that the use of the conjunctive “and” before “prolonged” makes clear that the headaches must be both “very frequent,” long in duration, and productive of economic inadaptability. Id. Accordingly, DC 8100 contains successive rating criteria, as each disability level builds on another in terms of duration and frequency and requires that a veteran rated at a higher level satisfy all of the requirements of the lower levels. The Court held further, that “[c]haracteristic” is “a trait, quality, or property or a group of them distinguishing an individual, group, or type”, and that “[p]rostrating” means “lacking in vitality or will: powerless to rise: laid low”, citing Webster’s Third New International Dictionary of the English Language Unabridged 376 (1966) (Webster’s). Id. The Court stated further, that difference between the 50 percent disability rating and the lower disability ratings is that “completely” modifies “prostrating headaches” in the 50 percent rating while “characteristic” modifies “prostrating headaches” in the lower ratings; and “[c]ompletely” is defined as “to complete degree: entirely”, again citing to Webster’s. Id. The Court noted that this change signals that the nature of the headaches for the 50 percent criteria is more severe than that for the lower ratings and that the relevant feature of the 50 percent rating is that the headache attacks must be “completely prostrating.” Id. The Court concluded that “[i]n other words, the headaches must render the veteran entirely powerless”. Id. Finally, the Court noted that the phrase “very frequent” found in the criteria for the 50 percent rating connotes a frequency greater than once a month, which is enumerated in the 30 percent rating level, and once every 2 months, which is enumerated for the 10 percent, and because the 50 percent rating requires “very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability,” the use of the conjunctive “and” makes clear that the headaches must be long in duration. Id. In this regard, the Court observed that Webster’s defines “[p]rolong” as “to lengthen in time: extend duration: draw out: continue, protract.” Id. The Board has utilized these common definitions in evaluating the Veteran’s claim. Finally, the Court has indicated that the Board must consider the provisions of 38 C.F.R. § 4.21 in applying DC 8100, which states that “it is not expected... that all cases will show all the findings specified” in the rating criteria, but that “findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function... will be expected in all instances.” Pierce, 18 Vet. App. at 447. On September 15, 2012, the Veteran was treated for a migraine at an emergency department. At that time, he reported a worsening headache, localized at his scalp with nausea and vomiting. He further reported it “had been quite some time since [his] last migraine.” See September 2012 Emergency Department Note. At an August 2013 emergency room visit, the Veteran reported experiencing a migraine the night before, which he treated at home with naproxen. On November 29, 2013, the Veteran reported experiencing migraines twice a week, noting that naproxen helped. A July 2014 VA examination report noted the Veteran described his migraines as occurring weekly, and being localized to the top of his head, with accompanying nausea, vomiting, and sensitivity to light and sound. He stated he takes one to two Naproxen to treat his migraines when they occur, and lays down for 30 to 45 minutes until they resolve. The Veteran was noted as having characteristic prostrating attacks, but it was not noted how often the prostrating attacks occurred, just that their frequency was less frequent. See July 2014 Headaches DBQ. On December 23, 2014, the Veteran was treated for influenza, and noted he developed a typical migraine-like headache. In March 2015, the Veteran was treated for a migraine headache. He reported his migraines had increased in frequency, occurring three to four times a month. He also described his usual migraine as left sided, throbbing, and lasting up to several hours with nausea and accompanying sensitivity to light and sound. See March 2015 Outpatient Note. In support of his claim, the Veteran submitted a June 2015 Headaches DBQ a private physician had completed. The examination report reflected the Veteran experienced migraines two to three times a week, with each migraine lasting up to three hours. The migraines consisted of a pulsing or throbbing head pain on both sides of the Veteran’s head, with non-headache symptoms of nausea, vomiting, and sensitivity to light and sound. The examiner noted that the Veteran had characteristic prostrating attacks more frequently than once a month, and that the Veteran recently had to quit his job due to his migraines. See June 2015 Headaches DBQ. After having carefully reviewed the probative evidence of record, the Board finds that, from June 18, 2015 forward, the Veteran’s migraines have more closely approximated very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability, and therefore warrants a 50 percent rating. See 38 C.F.R. § 4.7. First, the Board finds that the Veteran’s migraines were very frequent, occurring two to three times each week. Second, the June 2015 examiner noted the Veteran’s migraines were a 10 out of 10 on a pain scale, and required the Veteran to lie down in a dark room until the migraine subsided. Furthermore, the Board finds that the Veteran’s migraines are productive of severe economic inadaptability, particularly when reasonable doubt is resolved in his favor. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Here, the Veteran reported having to miss six to nine hours of work a week due to his migraine headaches, and ultimately had to leave his job due to his migraines. See June 2015 Headaches DBQ. Additionally, the June 2015 physician noted that without the accommodations granted by his previous employer, the Veteran would not have been able to maintain that employment. Id. As previously noted, a complete inability to work need not be shown. Pierce, 18 Vet. App. at 446. Looking at the Veteran’s entire disability picture, his service-connected migraines have more closely approximated symptoms warranting a 50 percent rating from June 18, 2015, forward. Prior to June 18, 2015, the Board finds that the Veteran’s migraines were manifest by characteristic prostrating attacks occurring on average once a month over the last several months. In this regard, the evidence reflects the Veteran had begun to experience more frequent and powerful migraines beginning in September 2012. Although the exact frequency of the Veteran’s prostrating attacks is not documented, the Board finds that, resolving doubt in the Veteran’s favor, his migraines more closely approximated symptoms warranted a 30 percent rating prior to June 18, 2015. REASONS FOR REMAND 1. Entitlement to service connection for arthritis is remanded. The Veteran asserts his arthritis is due to his active duty service. He has not provided more specific contentions. The Board notes that the Veteran has been diagnosed with acute monoarthritis of the left ankle. See April 2013 Nursing Triage Note. Additionally, the Veteran’s service treatment records reflect, in pertinent part, treatment for left ankle pain and left ankle tendonitis. See July 1997 Treatment Note. Given the evidence of left ankle treatment in service, a VA examination is warranted for an opinion addressing whether the Veteran’s left ankle arthritis was incurred in or is otherwise related to his active service. McClendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 2. Entitlement to a TDIU is remanded. As indicated above, the issue of entitlement to a TDIU has been raised by the record and has been added to the appeal. The Veteran, by and through his representative, indicated that he ius unable to work due to his migraines and anxiety disorder. The Board, therefore, finds that an inferred claim of entitlement to a TDIU has been raised by the record. See Rice, 22 Vet. App. 447. However, the Veteran’s claim for TDIU is inextricably intertwined with the pending evaluation of his newly service-connected anxiety disorder and obstructive sleep apnea, in addition to the remanded service connection claim. Accordingly, a decision by the Board on the Veteran’s TDIU claim would be premature. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim.). Finally, as this matter is being remanded, the Veteran’s updated VA treatment records should be obtained. The matter is REMANDED for the following action: 1. Make arrangements to obtain the Veteran’s VA treatment records, dated from December 2015, forward. 2. Thereafter, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his left ankle arthritis. The claims file, to include a copy of this remand, must be made available to the VA examiner, who must note its review. The examiner should use the appropriate Disability Benefits Questionnaire (DBQ). The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s left ankle arthritis had its clinical onset or is related to any incident of service, including the Veteran’s in-service left ankle complaints. (Continued on the next page)   All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. M. Stedman, Associate Counsel