Citation Nr: 18150890 Decision Date: 11/16/18 Archive Date: 11/15/18 DOCKET NO. 16-10 713 DATE: November 16, 2018 ORDER Entitlement to service connection for headaches is granted. Entitlement to service connection for vitamin D deficiency is denied. Entitlement to service connection for peripheral neuropathy is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for a lumbar spine disorder is denied. Entitlement to service connection for carpal tunnel syndrome of the left wrist is denied. Entitlement to service connection for carpal tunnel syndrome of the right wrist is denied. Entitlement to an initial rating in excess of 10 percent for coronary artery disease is denied. Entitlement to an initial rating in excess of 10 percent for diabetes mellitus is denied. Entitlement to an initial 70 percent rating, but no higher, for posttraumatic stress disorder (PTSD) is granted. Entitlement to an effective date earlier than March 13, 2015, for the grant of service connection for PTSD is denied. Entitlement to an effective date earlier than December 14, 2010, for the grant of service connection for coronary artery disease is denied. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a kidney disorder is remanded. Entitlement to service connection for aortic aneurysm is remanded. Entitlement to service connection for peripheral vascular disease is remanded. Entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s headaches are at least as likely as not related to his service-connected PTSD and tinnitus. 2. Vitamin D deficiency is a laboratory finding and not a disability under VA law and regulations. 3. The preponderance of the evidence indicates that the Veteran did not have peripheral neuropathy during the pendency of the appeal. 4. The preponderance of the evidence indicates that sleep apnea was not manifested during service and is not causally related to an in-service event, injury or disease. 5. The preponderance of the evidence indicates that a lumbar spine disorder was not manifest during service or within one year of separation, and is not causally related to an in-service event, injury or disease. 6. The preponderance of the evidence indicates that carpal tunnel syndrome of the left wrist was not manifest during service or within one year of separation, and is not causally related to an in-service event, injury or disease. 7. The preponderance of the evidence indicates that carpal tunnel syndrome of the right wrist was not manifest during service or within one year of separation, and is not causally related to an in-service event, injury or disease. 8. For the entire appeal period, the Veteran’s coronary artery disease was productive of a workload of greater than 7 metabolic equivalents (METs), and did not result in dyspnea, fatigue, angina, dizziness, or syncope, or evidence cardiac hypertrophy or dilatation in electrocardiogram, echocardiogram or X-ray. 9. For the entire appeal period, the Veteran’s diabetes mellitus was managed by a restricted diet only. 10. For the entire appeal period, the Veteran’s PTSD was manifested by symptoms productive of functional impairment most comparable to occupational and social impairment with deficiencies in most areas. 11. The Veteran filed an original service connection claim for PTSD that was received by the VA on March 13, 2015; a claim for service connection for PTSD was not received prior to March 13, 2015. 12. Ischemic heart disease, including coronary artery disease, was added to the list of diseases presumed to be related to herbicide exposure effective August 31, 2010; a claim for service connection for coronary artery disease was not received prior to December 14, 2011. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for headaches have been met. U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to service connection for Vitamin D deficiency have not been met. 38 U.S.C. § 5107; 38 C.F. R. § 3.303. 3. The criteria for entitlement to service connection for peripheral neuropathy have not been met. 38 U.S.C. § 5107; 38 C.F. R. § 3.303. 4. The criteria for entitlement to service connection for sleep apnea have not been met. 38 U.S.C. § 5107; 38 C.F. R. § 3.303. 5. The criteria for entitlement to service connection for a lumbar spine disorder have not been met. 38 U.S.C. § 5107; 38 C.F. R. §§ 3.303, 3.307, 3.309. 6. The criteria for entitlement to service connection for carpal tunnel syndrome of the left wrist have not been met. 38 U.S.C. § 5107; 38 C.F. R. § 3.303. 7. The criteria for entitlement to service connection for carpal tunnel syndrome of the right wrist have not been met. 38 U.S.C. § 5107; 38 C.F. R. § 3.303. 8. The criteria for an initial rating in excess of 10 percent for coronary artery disease have not been met. 38 U.S.C. § 5107; 38 C.F.R. § 4.104, Diagnostic Code 7005. 9. The criteria for an initial rating in excess of 10 percent for diabetes mellitus have not been met. 38 U.S.C. § 5107; 38 C.F.R. § 4.119, Diagnostic Code 7913. 10. The criteria for a 70 percent initial rating, but no higher, for PTSD have been met. 38 U.S.C. § 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 11. The criteria for entitlement to an effective date earlier than March 13, 2015, for the grant of service connection for PTSD have not been met. 38 U.S.C. 5110; 38 C.F.R. 3.400. 12. The criteria for an effective date earlier than December 14, 2010, for service connection for coronary artery disease are not met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.400, 3.816 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the United States Army from May 1967 to May 1969. He died in February 2018. The Appellant is his surviving spouse and has been properly substituted as the appellant for the purposes of claims pending before VA at the time of the Veteran’s death. In correspondence received in October 2018, the Appellant, through her attorney, raised the issue of entitlement to a TDIU. As such, the Board must consider whether a TDIU is warranted. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a TDIU claim is part of an increased disability rating claim when such claim is raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Also, in October 2018, the Appellant’s attorney submitted additional evidence along with a waiver of initial RO review of the evidence. Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. § 1131 (2012); 38 C.F.R. § 3.303(a) (2018). Certain chronic diseases, including hypertension, arthritis, cardiovascular- renal disease, and organic diseases of the nervous system such as carpal tunnel syndrome, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2018). A disability may also be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated beyond its natural progress by a service-connected disease or injury. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.310(a), (b) (2018). In the absence of proof of present disability, there can be no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 1. Entitlement to service connection for headaches The Veteran was diagnosed with headaches and was service-connected for PTSD and tinnitus. The record contains a February 2017 private opinion from Dr. H. S. after a review of the Veteran’s treatment records, an interview with the Veteran, and review of supporting treatise evidence, he opined that it was “as likely as not the veteran’s headaches are caused and permanently aggravated by PTSD and tinnitus.” Dr. H. S. stated that it was well documented within the medical community that psychiatric impairments, stress, and persistent tinnitus contribute materially and substantially to the development and permanent aggravation of headaches. There is no medical evidence to the contrary. Accordingly, service connection for headaches is granted. 2. Entitlement to service connection for vitamin D deficiency Vitamin D deficiency is not a deficiency within the meaning of the applicable legislation. The term “disability” means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1 (2018). Furthermore, a vitamin D deficiency is simply a laboratory test finding. In this case, a vitamin D deficiency, without a diagnosed or identifiable underlying malady or condition, does not constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). In this case, VA treatment records show that the Veteran had a vitamin D deficiency. However, there is no indication of a particular disorder attributable to his vitamin D deficiency. Accordingly, the claim is denied. 3. Entitlement to service connection for peripheral neuropathy The service treatment records do not show any treatment or complaints pertaining to peripheral neuropathy. Additionally, his May 1969 report of medical examination at separation indicated that neurologic examination was within normal limits. A June 2013 VA diabetes mellitus examination report was silent for any evidence of peripheral neuropathy. On VA examination of the peripheral nerves in July 2013 VA, the examiner determined that the Veteran did not have a peripheral nerve condition or peripheral neuropathy. Likewise, a July 2015 peripheral neuropathy review indicated that the Veteran was not diagnosed with peripheral neuropathy. As there is no competent evidence of a current diagnosis of sleep apnea or peripheral neuropathy, there is no basis on which the claims for service connection for either of these disorders may be granted. See Brammer, 3 Vet. App. at 225. It is therefore unnecessary to address any other element of service connection. Accordingly, the appeal on these issues are denied. 4. Entitlement to service connection for sleep apnea, a lumbar spine disorder, and carpal tunnel syndrome of the left and right wrists The Veteran’s service treatment records do not show any treatment or complaints for sleep apnea, lumbar spine disorder, or for carpal tunnel syndrome of either wrist. His May 1969 report of medical examination at separation indicates that clinical evaluation of the Veteran’s spine, upper extremities, and neurologic system was within normal limits. Moreover, on his corresponding report of medical history, the Veteran expressly denied currently having or every having shortness of breath; bone, joint, or other deformity; arthritis or rheumatism; back trouble; neuritis; or frequent trouble sleeping. Post-service, VA treatment records note that sleep apnea was suspected. Nevertheless, the Veteran declined to undergo a sleep study so a conclusive diagnosis was never made. A December 2012 MRI report of the lumbar spine shows that the Veteran was diagnosed as having multilevel degenerative disc disease. A January 2013 VA treatment record shows that the Veteran was diagnosed as having bilateral carpal tunnel syndrome. Upon review, the record does not contain any indication of a nexus between the Veteran’s suspected sleep apnea, current lumbar spine disorder, and current bilateral carpal tunnel syndrome and his active duty service. Sleep apnea was not indicated or otherwise suspected until many years after service. Likewise, the Veteran was not diagnosed with degenerative disc disease of the lumbar spine or carpal tunnel syndrome of the left and right wrists until many years after his period of service and aside from the Veteran’s own claim, there is no evidence suggesting a link between his current disabilities and his active duty service. Additionally, the Board notes that there is no evidence that osteoarthritis of the lumbar spine or carpal tunnel syndrome was manifested to a compensable degree within one year of the Veteran’s separation from military service. Accordingly, service connection for sleep apnea, a lumbar spine disorder, and for carpal tunnel syndrome of the left and right wrists is denied. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating 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. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). 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. 38 C.F.R. § 4.7 (2018). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). 5. Entitlement to an initial rating in excess of 10 percent for coronary artery disease The Veteran’s coronary artery disease is rated under Diagnostic Code 7005. See 38 C.F.R. § 4.104 (2018). Diagnostic Code 7005 provides that a 10 percent rating is warranted for a workload of greater than 7 METs but not greater than 10 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication is required. A 30 percent rating is warranted for a workload of greater than 5 METs but not greater than 7 METs that results in in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram or X-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent maximum rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2) (2018). On VA heart examination in July 2013, it was noted that the Veteran had undergone a percutaneous coronary intervention and coronary artery bypass surgery in March 2000 at a private hospital. He did not have a history of myocardial infarction, heart transplant, implanted cardiac pacemaker or defibrillator. He did not have congestive heart failure. He did take continuous medication for his coronary artery disease. Stress test results revealed an estimated MET of 8. Left ventricular ejection fraction was at 66%. There was no evidence of cardiac hypertrophy or dilatation. The Veteran reported a lack of stamina related to the coronary artery disease. The examiner noted that the Veteran did not have any other complications related to the ischemic heart disease. In his notice of disagreement in July 2014, the Veteran stated that his METs had been incorrectly estimated and had been based on old tests. The Veteran’s medical records were reviewed by a VA physician in February 2016. The physician opined that no further testing was required. The physician stated that the left ventricular ejection fraction of 65% noted on the nuclear test of August 2015 was most representative of his heart condition. It was noted that a January 2016 cardiology record indicated that the Veteran endorsed shortness of breath with exertion such as climbing one flight of stairs, but denied chest pain with similar activity. The cardiology record noted that the Veteran’s limitations were, at least in part, due to his peripheral vascular disease. The VA physician noted that his shortness of breath had many causes, including the Veteran’s age, morbid obesity, former smoking status, moderate chronic obstructive pulmonary disease, and peripheral vascular disease. Upon a review of the record, the Board finds that an initial rating in excess of 10 percent for the Veteran’s coronary artery disease is not warranted. The Board notes that a workload of 5 METs but not greater than 7 METs which results in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram or X-ray is required for a higher 30 percent rating under Diagnostic Code 7005. There is no evidence that the Veteran’s coronary artery disease meets the criteria for a higher rating. On VA examination in July 2013, stress test results revealed an estimated MET of 8. Likewise, stress testing in August 2015, September 2016, consistently indicated that the Veteran had an ejection fraction greater than 55%. Additionally, there is no evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram or X-ray. The Board has not overlooked the evidence of record indicating that the Veteran experienced shortness of breath with exertions, including climbing one flight of stairs, which would correspond to a METs level of greater than 5 but less than 7. See Heart Conditions Disability Benefits Questionnaire (DBQ). Nevertheless, the medical evidence indicates that level of limitation is not solely due to the Veteran’s service-connected coronary artery disease. Rather, the January 2016 cardiology record indicated that the Veteran’s shortness of breath was, at least in part, due to his peripheral vascular disease. Likewise, the February 2016 VA opinion also indicated that the Veteran’s shortness of breath was not solely due to his coronary artery disease and that it had many causes, including the Veteran’s age, morbid obesity, former smoking status, moderate chronic obstructive pulmonary disease, and peripheral vascular disease. Accordingly, the weight of the evidence indicates that the Veteran’s METs level restriction, solely due to his coronary artery disease, does not met or more nearly approximate the criteria for a rating in excess of 10 percent. As such, the Board finds that an increased rating is not warranted for the Veteran’s service-connected coronary artery disease. 6. Entitlement to an initial rating in excess of 10 percent for diabetes mellitus The Veteran’s diabetes mellitus is rated under the provisions of Diagnostic Code 7913. Pursuant to Diagnostic Code 7913, a rating of 10 percent is assigned for diabetes that is manageable by restricted diet only. A rating of 20 percent is assigned for diabetes requiring insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. A 40 percent rating is warranted when the diabetes requires insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted when the diabetes requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when the diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119. Because of the successive nature of the rating criteria, such that the evaluation for each higher disability rating includes the criteria of each lower disability rating, each of the three criteria listed in the next higher rating must be met to warrant such a rating. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). In addition, a 40 percent rating under Diagnostic Code 7913 requires medical evidence that occupational and recreational activities have been restricted by diabetes. Camacho v. Nicholson, 21 Vet. App. 360, 363-65 (2007). Note 1 to Diagnostic Code 7913 provides that compensable complications of diabetes are to be separately evaluated unless they are part of the criteria used to support a 100 percent rating, and that noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. On VA diabetes mellitus examination in July 2013, the examiner noted that the Veteran’s diabetes was managed by restricted diet only. There was no regulation of activities as part of medical management of diabetes mellitus. The Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times a month. The Veteran had not been hospitalized for his diabetes mellitus and had no episodes of hypoglycemia. He did not have loss of strength or weight attributable to diabetes mellitus. He did not have any complications as result of his diabetes mellitus. A VA optometry record from July 28, 2015 also indicated that the Veteran diabetes mellitus was controlled with diet and exercise. It further noted that no medication had been required. The medical evidence of record demonstrates that the Veteran’s diabetes mellitus was managed by a restricted diet only. There is no evidence indicating that the Veteran’s diabetes mellitus required oral hypoglycemic agents or insulin. Additionally, there is no evidence of any complications related the Veteran’s service-connected diabetes mellitus. Accordingly, here is no basis upon which to assign a higher initial rating for diabetes mellitus. 7. Entitlement to an initial 70 percent rating for PTSD The Veteran’s PTSD is rated under 38 C.F.R. 4.130, Diagnostic Code 9411 (2018). All psychiatric disabilities are evaluated under a general rating formula for mental disorders. In pertinent part, a 50 percent rating is warranted for 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 effective work and social relationships. Id. A 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such an unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. Id. A total schedular rating of 100 percent is warranted when the disorder results in 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 mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. On VA PTSD examination in December 2015, the examiner noted the following symptoms that applied to the Veteran’s PTSD diagnosis: depressed mood, anxiety, chronic sleep impairment and disturbances of motivation and mood. He was also noted to have markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; irritable behavior and angry outbursts; hypervigilance; problems with concentration; and sleep disturbance. On mental status examination, the Veteran was noted to be mildly depressed and his affect was congruent to mood. He did not report any current suicidal ideation or homicidal ideation. His behavior was cooperative and appropriate to the interview setting. Although the Veteran and his wife were still legally married, they have spent a significant amount of years being separated. He reported that they hadn’t lived together in 30 years and that he was living in a basement apartment in one of his son’s homes. He reported that he avoided people and crowds and stayed to himself much of the time. The examiner noted that the Veteran’s psychiatric condition was best described as occupational and social impairment with reduced reliability and productivity. VA mental health treatment records from September 2013 to January 2016 note that the Veteran had difficulty holding down a job, had no friends, was isolated, and had persistent negative beliefs, suicidal thoughts, and continuous depression. Statements received from the Veteran’s wife and son in October 2017 indicate that the Veteran was paranoid, easily agitated, isolated, and neglected personal hygiene. A January 2017 PTSD DBQ report, which was completed by a private psychologist reflects the following symptoms: depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work and a work like setting, inability to establish and maintain effective relationships, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The private psychologist opined that the Veteran’s PTSD resulted occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The evidence shows that throughout the rating period, the Veteran’s symptomatology was more reflective of a 70 percent disability. The psychiatric examinations of record indicate that overall, the Veteran has occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and / or mood. He had demonstrated suspiciousness, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, impairment of short and long term memory, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, and obsessional rituals which interfere with routine activities and persistent delusions or hallucinations. For these reasons, the Board finds that the Veteran’s PTSD symptoms more nearly approximate the criteria under Diagnostic Code 9411 for a 70 percent rating throughout the period on appeal. The criteria for a disability rating of 100 percent have not been met or more nearly approximated for any period on appeal. The evidence shows no symptoms of persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, or memory loss for names of close relatives, own occupation, or own name. The Board has not overlooked the evidence of record indicating that the Veteran sometimes neglected his personal appearance and hygiene. Nevertheless, the presence or absence of specific symptoms, which correspond to a particular rating, is not dispositive. 38 C.F.R. § 4.130 (2018); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In present case, even considering that symptom, the preponderance of the evidence, including two medical opinions, is against finding that the Veteran’s PTSD symptoms have resulted in or more nearly approximated total occupational and social impairment. For these reasons, the Board finds that a preponderance of the evidence is against an initial rating of 100 percent for PTSD throughout the period on appeal. Effective Date An award of direct service connection will be effective on the day following separation from active military service or the date on which entitlement arose if the claim is received within one year of separation from service. Otherwise, except as specifically provided, the effective date of an evaluation and award for pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after a final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. A “claim” is defined as a formal or informal communication, in writing, requesting a determination of entitlement, or evidencing a belief in entitlement to a benefit and VA is required to identify and act on informal claims for benefits. 38 C.F.R. §§ 3.1(p), 3.155(a); see also Servello v. Derwinski, 3 Vet. App. 196, 198-200 (1992). Pursuant to 38 C.F.R. § 3.155, any communication or action indicating intent to apply for one or more VA benefits, including statements from a veteran’s duly authorized representative, may be considered an informal claim. Such an informal claim must identify the benefit sought. 38 C.F.R. § 3.1(p) defines application as a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. See Rodriguez v. West, 189 F.3d. 1351 (Fed. Cir. 1999). The date of receipt of a claim is the date on which a claim, information, or evidence is received by VA. 38 C.F.R. § 3.1(r). 8. Entitlement to an effective date earlier than March 13, 2015, for the grant of service connection for PTSD The record shows that the Veteran’s claim for service connection PTSD (mental condition) was received by VA on March 13, 2015. There are no additional documents of record that could be construed as a claim for service connection for PTSD received prior to March 13, 2015. Thus, the first document asserting a claim for service connection for PTSD was received by VA on March 13, 2015, which is more than one year following the Veteran’s separation from active service. In light of the facts presented above, the Board finds that the appropriate effective date for the award of service connection for PTSD is March 13, 2015, the date the claim was received by VA. Accordingly, an earlier effective date is not authorized by law and the Veteran’s claim must be denied. 9. Entitlement to an effective date earlier than December 14, 2010, for the grant of service connection for coronary artery disease With respect to earlier effective date claims involving service connection for diseases presumed to be caused by herbicide or Agent Orange exposure, VA has issued special regulations to implement orders of a United States district court in the class action of Nehmer v. United States Dep’t of Veterans’ Affairs. 38 C.F.R. § 3.816 (2017). See Nehmer v. United States Veterans Admin., 32 F. Supp. 1404 (N.D. Cal. 1989) (Nehmer I); Nehmer v. United States Veterans Admin., 32 F. Supp. 2d 1175 (N.D. Cal 1999) (Nehmer II); Nehmer v. Veterans Admin. of the Gov’t of the United States, 284 F.3d 1158 (9th Cir. 2002) (Nehmer III). Specifically, a Nehmer class member is defined as a Vietnam veteran who has a covered herbicide disease; or a surviving spouse, child, or parent of a deceased Vietnam Veteran who died from a covered herbicide disease. 38 C.F.R. § 3.816 (b)(1)(i) & (ii) (2018). The term “covered herbicide disease” includes coronary artery disease. 38 C.F.R. §§ 3.816(b)(2); 3.309(e) (2018). This regulation applies to claims for disability compensation for the covered herbicide disease that were either pending before VA on May 3, 1989, or were received by VA between that date and the effective date of the statute or regulation establishing a presumption of service connection for the covered disease. 38 C.F.R. § 3.816(c) (2018). If a Nehmer class member’s claim for disability compensation for the covered herbicide disease was either pending before VA on May 3, 1989, or was received by VA between that date and the effective date of the statute or regulation establishing a presumption of service connection for the covered disease, the effective date of the award will be the latter of the dates (1) such claim was received by VA, or (2) the date the disability arose. 38 C.F.R. § 3.816(c)(2). A claim will be considered a claim for compensation for a particular covered herbicide disease if the application and other supporting statements and submissions may reasonably be viewed, under the standards ordinarily governing compensation claims, as indicating intent to apply for compensation for the covered herbicide disability. 38 C.F.R. § 3.816(c)(2)(i) (2018). In this case, the Veteran’s claim for coronary artery disease was granted on the basis of presumption of exposure to herbicide agents during service. See July 2013 rating decision. Ischemic heart disease, including coronary artery disease, was added to the list of diseases presumed to be related to herbicide exposure under 38 C.F.R. § 3.309(e) effective August 31, 2010. See 75 Fed. Reg. 53,202 (August 31, 2010). The Veteran’s original claim for coronary artery disease was received by VA on December 14, 2011. In a July 2013 rating decision, the RO initially assigned an effective date of December 14, 2011 for the grant of service connection for coronary artery disease. However, in a February 2016 rating decision, the RO assigned an earlier effective date of December 14, 2010 for grant of service connection for coronary artery disease. Because treatment records showed that the Veteran had coronary artery disease at the time of the liberalizing regulation, the RO assigned the earliest possible effective date under the law (December 14, 2010), which is one year prior to the date of receipt of the Veteran’s claim (December 14, 2011), because the claim was received more than one year after the effective date (August 31, 2010) that ischemic heart disease was added to the list of diseases under 38 C.F.R. § 3.309(e) that are presumed to be related to herbicide agent exposure. Accordingly, the claim for an effective date earlier than December 14, 2010, must be denied. REASONS FOR REMAND 1. Entitlement to service connection for hypertension and for a kidney disorder are remanded. Following VA hypertension and kidney conditions examinations in January 2016, a VA examiner opined that the Veteran’s hypertension and chronic renal disease were less likely than not proximately due to or the result of his service-connected condition (diabetes mellitus). The Board notes that the examiner’s opinion did not address the aggravation prong of secondary service-connection. See Allen v. Brown, 7 Vet. App. 439, 449 (1995) (stating that “caused by” and “related to” do not address the aggravation aspect of secondary service connection). In light of the above, an addendum opinion is warranted. 2. The claims of entitlement to service connection for aortic aneurysm and for peripheral vascular disease are remanded. A July 2013 VA artery and veins examination report shows that the Veteran under a coronary artery bypass graft in 2000 and that following the procedure he reported claudication of the bilateral lower extremities. He was diagnosed with peripheral arterial disease in 2010 and underwent right iliac artery stenting by a private physician at St. Francis Hospital in July 2010. The statement by the VA examiner has raised consideration of the Veteran’s service-connected coronary artery disease as either causing or aggravating the Veteran’s aortic aneurysm and peripheral vascular disease. Thus, the Board finds that further opinion is warranted. The claims folder reflects that that the Veteran’s coronary artery bypass graft was performed in March 2000 at the New York Presbyterian Hospital. Treatment records for both procedures conducted at the New York Presbyterian Hospital and from St. Francis Hospital are not of record. Prior to obtaining an opinion, the RO should contact the appellant and obtain authorization to obtain the Veteran’s complete treatment records from both hospitals. 3. Entitlement to a TDIU is remanded. As noted above, the issue of TDIU has been raised. Specifically, the representative expressly raised the issue of entitlement to a TDIU. Thus, the Board finds that the issue of entitlement to a TDIU is part and parcel of the Veteran's increased rating claims. To date, this issue has not yet been fully developed or adjudicated by the AOJ. Accordingly, it is remanded for initial development and adjudication. The matters are REMANDED for the following actions: 1. Ask the Appellant to provide the names and addresses of all medical care providers who treated the Veteran for his claimed disabilities prior to his death. After securing any necessary releases, the AOJ should request any relevant records identified. If any requested records are unavailable, the Appellant should be notified of such. 2. Provide the Appellant and her representative notice pursuant to the Veterans Claims Assistance Act (VCAA) as to the issue of entitlement to a TDIU. Additionally, ask her to fully complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, to include any part time or occasional employment. 3. After the above is completed to the extent possible, forward the claims file to a VA clinician to obtain addendum opinions regarding the Veteran's hypertension, kidney disorder, aortic aneurysm, and peripheral vascular disease claims. Following review of the claims file, the clinician should opine: (a.) Whether it is at least as likely as not (50 percent probability or greater) that Veteran’s hypertension, kidney disorder, aortic aneurysm, or peripheral vascular disease had its onset during service or is otherwise related to service. (b.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension, kidney disorder, aortic aneurysm, or peripheral vascular disease was caused by his service-connected diabetes mellitus or coronary artery disease? (c.) If not caused by the service-connected diabetes mellitus or coronary artery disease, is it at least as likely as not that the Veteran's hypertension, kidney disorder, aortic aneurysm, or peripheral vascular disease was worsened beyond natural progression (aggravated) by his service-connected diabetes mellitus or coronary artery disease? If the clinician finds that the Veteran's hypertension, kidney disorder, aortic aneurysm, or peripheral vascular disease was aggravated by his service-connected disabilities, the clinician should attempt to quantify the level of aggravation beyond the baseline level of the hypertension, kidney disorder, aortic aneurysm, or peripheral vascular disease. A complete rationale should be provided for all opinions and conclusions expressed. 4. After completing the above, the claims, including entitlement to a TDIU, should be readjudicated based on the entirety of the evidence. If any claim remains denied, the Appellant and her representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. J. A. Anderson Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Henriquez, Counsel