Citation Nr: 18152154 Decision Date: 11/21/18 Archive Date: 11/21/18 DOCKET NO. 17-06 910 DATE: November 21, 2018 ORDER Entitlement to an initial 10 percent disability rating for restrictive ventilatory defect is granted. Entitlement to an initial rating of 50 percent, but no higher, for posttraumatic stress disorder (PTSD), prior to September 20, 2016, is granted. Entitlement to an increased rating in excess of 50 percent for PTSD, from September 20, 2016, is denied. Entitlement to service connection for lipoma of the scalp is denied. Entitlement to service connection for plantar warts is denied. REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to a compensable rating for bilateral hearing loss is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Since January 2014, the Veteran’s pulmonary function test (PFT) results have manifested by a ratio of Forced Expiratory Volume over the first second (FEV-1) to Forced Vital Capacity (FVC) of 71 to 80 percent predicted. 2. Throughout the appellate period, the Veteran’s PTSD was manifested by symptoms which most closely approximate occupational and social impairment with reduced reliability and productivity. 3. The other than honorable character of the Veteran’s discharge from the period of active duty from June 1979 to February 1988 constitutes a bar to VA benefits. 4. The evidence of record shows the Veteran’s lipoma did not have its onset in a period of honorable service. 5. The evidence of records shows the Veteran’s plantar warts did not have its onset in a period of honorable service. CONCLUSIONS OF LAW 1. The criteria for an initial 10 percent disability rating for restrictive ventilatory defect, and no higher, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1 – 4.7, 4.21, 4.96, 4.97, Diagnostic Code 6845 (2018). 2. The criteria for an initial rating of 50 percent, but no higher, for PTSD prior to September 20, 2016, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1 – 4.7, 4.21, 4.130, Diagnostic Code 9411 (2018). 3. The criteria for an increased evaluation in excess of 50 percent for PTSD from September 20, 2016 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1 – 4.7, 4.21, 4.130, Diagnostic Code 9411 (2018). 4. The criteria for service connection for lipoma of the scalp have not been met. 38 U.S.C. §§ 1110, 1131, 5303 (2012); 38 C.F.R. §§ 3.1, 3.12, 3.303 (2018). 5. The criteria for service connection for plantar warts have not been met. 38 U.S.C. §§ 1110, 1131, 5303 (2012); 38 C.F.R. §§ 3.1, 3.12, 3.303 (2018). 6. The Veteran’s other than honorable discharge from the period of active duty from June 1979 to February 1988 is a bar to the payment of VA benefits. 38 U.S.C. §§ 101, 5303 (2012); 38 C.F.R. § 3.1, 3.12 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from April 1971 to June 1979, and from June 1979 to February 1988. The Veteran’s character of service was other than honorable for the period from June 1979 to February 1988. In an April 1989 administrative decision, VA determined that the Veteran’s discharge for the period of service from June 1979 to February 1988 was considered a bar to VA benefits. The decision noted that basic eligibility existed on the period of service from April 1971 to June 1979. These matters come before the Board of Veterans’ Appeals (Board) on appeal from September 2013 and August 2014 rating decisions by the St. Petersburg, Florida, Regional Office (RO) of the United States Department of Veterans Affairs. These issues were previously before the Board in November 2017 at which time they were remanded for additional development. The issue of entitlement to TDIU has been raised by the Veteran and has been added to the title page to reflect the Board’s jurisdiction over this matter. Rice v. Shinseki, 22 Vet. App. 447 (2009). Further development is needed to properly adjudicate the claim. On August 16, 2018, the Federal Circuit ordered the appeal of Procopio v. Wilkie, No. 17-1821 (U.S. Fed. Cir.). The order stated that the questions before the Federal Circuit include the following: “Does the phrase ‘served in the Republic of Vietnam’ in 38 U.S.C. § 1116 unambiguously include service in offshore waters within the legally recognized territorial limits of the Republic of Vietnam, regardless of whether such service included presence on or within the landmass of the Republic of Vietnam?” As of the date of this decision, Procopio is pending. As this appeal contains at least one issue that may be affected by the resolution of Procopio, the Board will “stay” or postpone action on the following issues: entitlement to service connection for diabetes mellitus, type II; for peripheral neuropathy of the bilateral upper and lower extremities, secondary to diabetes mellitus type II; and for a bilateral eye condition, to include diabetic retinopathy, secondary to diabetes mellitus, type II. Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found, however. This practice is known as “staged” ratings.” Fenderson v. West, 12 Vet. App. 119, 126 127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107 (West 2002); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Initial compensable evaluation for restrictive ventilatory defect The Veteran is seeking an initial compensable rating for his restrictive ventilatory defect. The Veteran’s condition has been evaluated pursuant to 38 C.F.R. § 4.97, Diagnostic Code (DC) 6899-6845. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. In other words, the second Code identifies the criteria being applied. DC 6845, for chronic pleural effusion or fibrosis, is evaluated under the General Rating Formula for Restrictive Lung Disease. A 10 percent rating is assigned if PFT results show the FEV-1 is 71 to 80 percent of predicted, or; FEV-1/FVC is 71 to 80 percent, or; the diffusing capacity of the lung for carbon monoxide in a single breath (DLCO (SB)) is 66 to 80 percent of predicted. A 30 percent rating is warranted where FEV-1 is 56 to 70 percent of predicted, or; the ratio of FEV-1/FVC is 56 to 70 percent, or; DLCO (SB) is 56 to 65 percent of predicted. A 60 percent rating is warranted where FEV-1 is 40 to 55 percent of predicted value, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent (total) rating is warranted if FEV-1 is less than 40 percent of predicted value, or; with FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40 percent predicted, or; with maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; with cor pulmonale (right heart failure), or; with right ventricular hypertrophy, or; with pulmonary hypertension (shown by Echo or cardiac catheterization), or; with episode(s) of acute respiratory failure, or if the Veteran requires outpatient oxygen therapy. Applicable to DC 6845 in this instance, post-bronchodilator studies are required when PFTs are done for disability evaluation purposes except when the results of pre-bronchodilator PFTs are normal or when the examiner determines that post-bronchodilator tests should not be done and states why. 38 C.F.R. § 4.96(d)(4). When there is a disparity between the results of different PFTs (FEV-1, FVC, etc.), so that the level of evaluation would differ depending on which test result is used, use the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96(d)(6). The Veteran underwent a VA respiratory examination in July 2014. PFT pre-bronchodilator results revealed FEV-1 was 46 percent predicted and FVC was 46 percent predicted. FEV-1/FVC was 77 percent predicted. The VA examiner stated that the FEV-1/FVC result most accurately reflected the Veteran’s level of disability and that post-bronchodilator testing was not completed because it was not indicated due to the absence of pre-bronchodilator airway obstruction. The examiner noted that the forced expiration demonstrated only a reduction in vital capacity that suggested the presence of a restrictive defect. PFT testing conducted by VA in April 2016 showed that the FEV-1/FVC was 81 percent predicted. The Board finds that the evidence of record supports an initial disability rating of 10 percent, and no higher, for the Veteran’s restrictive ventilatory defect. The medical evidence of record shows the Veteran’s respiratory symptoms have met the criteria for a 10 percent disability rating throughout the period on appeal, based on the measure identified by doctors as the best evaluator of her degree of disability, the pre-bronchodilator FEV-1/FVC ratio. While some results meet the criteria for higher or lower ratings, the most probative and competent evidence of record, as identified by the medical professionals, requires assignment of a 10 percent rating, and no higher. See 38 C.F.R. § 4.97. Increased ratings for PTSD The Veteran’s service-connected PTSD was assigned a 30 percent disability evaluation prior to September 20, 2016, and a 50 percent disability evaluation thereafter under 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran contends that a higher disability evaluation is warranted for his PTSD. When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant’s capacity for adjustment during periods of remission. VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Pursuant to 38 C.F.R. § 4.130, psychiatric impairment is rated under the General Rating Formula for Mental Disorders (“General Rating Formula”). A 30 percent evaluation is warranted where there is 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 where 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 evaluation is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; 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); inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation or name. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is the Veteran’s symptoms, but it must also make findings as to how those symptoms impact the Veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 426, 442 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the General Rating Formula are also associated with objectively observable symptomatology, and the plain language of the regulation makes it clear that a Veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency and duration. Vazquez-Claudio, 713 F.3d at 118. Having carefully considered all the evidence of record, the Board finds that based on the overall disability, an initial rating in excess of 30 percent prior to September 20, 2016 and a rating in excess of 50 percent thereafter, are not warranted. Prior to September 20, 2016 The Veteran’s VA treatment records show that in December 2011 he was seen for a psychiatry consultation. The Veteran complained of experiencing depression and irritability since he stopped working in October 2010. The examiner noted that mental status examination revealed the Veteran to be casually dressed and cooperative. He maintained fair eye contact. His mood was noted as depressed; his thought process was organized and there was no evidence of delusions. The Veteran’ insight and judgement were noted as fair and he reported no suicidal or homicidal ideation. The Veteran underwent a VA initial PTSD examination in August 2013. The examiner summarized the level of the Veteran’s impairment as 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. The Veteran reported that he was currently married to his second wife and had been for 26 years. The Veteran stated that he and his wife have experienced periods of conflict and separation due to his irritability. His first marriage ended after 6 years due to his wife’s infidelity. The Veteran has eight children from his two marriages, and had good relationships with them. He reported that he does not have close friends, but does have “a few friendly associates.” He spends his time doing chores around the house and watching TV. The examiner noted that the Veteran had difficulty in establishing and maintaining effective work and social relationships and in adapting to stressful circumstances. The Veteran reported that he avoids crowds and experiences irritability and hypervigilance. VA treatment records show that in November 2015, the Veteran reported at primary care visit that he had PTSD and have never been treated for it. The Veteran reported for a psychiatry consultation in December 2015. The Veteran reported that he felt anxious and that someone is following him. The Veteran did not endorse visual, auditory, tactile or olfactory hallucinations. He stated that he sometimes has nightmares but was able to cope with them. He reported that he still gets angry, but felt that it had decreased. He endorsed no depressed, euphoric, irritable or anxious mood, feelings of hopelessness, worthlessness or helplessness, death wishes, and suicidal or homicidal ideation. The Veteran was not taking any medication for PTSD. A February 2016 treatment note indicated the Veteran was cooperative and oriented to person, place, and time. He exhibited a euthymic mood, with a restricted to blunted affect. The Veteran’s thought process was noted to be organized and goal directed. The clinician noted that while persecutory delusions were present, the Veteran exhibited no feelings of hopelessness, worthlessness, helplessness, death wishes, and/or suicidal or homicidal ideation. His insight was superficial and judgment was adequate. The Veteran was attentive and his concentration was intact. His memory was noted to be good. A treatment note dated May 2016 documented similar findings. The Veteran submitted lay statements from his wife and mother dated July 2016 and August 2016, respectively, which were received in February 2017. The Veteran’s mother, J.R., stated that the Veteran is angry all the time and lashes out. J.R. stated that he had a hard time understanding her when they talk which causes him to be angry. She stated that he seemed to “stressed out, has panic attacks, and even forgets where he is at times.” J.R. stated that she thought he could be a danger to others when he is mad. The Veteran’s wife, A.G., stated that the Veteran has a hard time understanding people in conversation because he gets confused. She stated his “PTSD is worse when he’s driving and causes him to have panic attacks.” A.G. reported that the Veteran loses things, such as his keys and his wallet. She stated that he slept with a knife under his pillow. A.G. stated that the Veteran has a hard time staying focused and tends to stray from the topic at hand. Prior September 20, 2016, the Veteran’s symptoms more closely approximate the criteria for an increased 50 percent evaluation, and no higher. The August 2013 examiner noted that the Veteran had difficulty in establishing and maintaining effective work and social relationships and in adapting to stressful circumstances at the time of the examination. His wife and mother, those in the best position to observe and report on his interactions with others, corroborate his reports, and additionally indicate that the Veteran is having difficulty with basic communication and understanding. The Board finds that the symptoms the Veteran exhibited for the period on appeal from August 22, 2011 to September 20, 2016, most closely approximate occupational and social impairment with reduced reliability and productivity, the criteria associated with a 50 percent disability evaluation. Since September 20, 2016 The Veteran submitted the report of a private PTSD review examination, conducted by Dr. H.H.G. on September 20, 2016. The Veteran reported that he was married to his second wife for 26 years and had nine children. He tried to keep his struggles to himself, not wanting to burden others and felt isolated and withdrawn. He endorsed, using a checklist, depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression affecting the ability to function independently appropriately and effectively, chronic sleep impairment, flattened affect, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a work-like setting, inability to establish and maintain effective relationships, persistent delusions or hallucinations. The Veteran detailed great ongoing difficulty with his symptom pattern; he remarked that he can no longer enjoy the simplest of activities. The Veteran’s attention was normal and his concentration appeared variable. The Veteran complained of increased trouble with short and long-term memory. He struggled to remember basic information. The Veteran’s speech flow was noted to be normal, and thought content was appropriate, and goal-directed. The examiner noted that the Veteran’s judgment was below average. His mood was observed to be anxious and nervous, with restricted affect. He reported feeling anxious and depressed, was vague with responses, suspicious, and seemed vigilant when speaking with the examiner. The Veteran’s VA treatment records include an October 2017 outpatient treatment note. The Veteran reported that he continues to feel he is being followed. He denied a daily depressed mood, suicidal/homicidal idea, intent or plan. He reported that he sleeps well at night and had a good appetite. The Veteran reported experiencing intrusive memories about Vietnam. He denied auditory hallucinations. He reported experiencing short-term memory difficulties. He stated that he had not been taking his medication consistently and that his medication was expired. The clinician noted the Veteran to be cooperative, maintaining good eye contacted, and to be casually dressed. He was alert and his speech was clear and coherent, at normal rate, tone and volume. His mood was good and his affect was euthymic. His thought process was noted to be organized and goal directed. His insight and judgment were fair and there was no evidence of suicidal/homicidal ideation. A December 2017 outpatient treatment note indicated the Veteran was seen for a follow-up visit and reported his mood as “so-so.” He stated that he gets irritable with his family, but denied physical aggression. He stated he may feel depressed at times but that it is fleeting. A treatment record dated June 2018 indicates the Veteran was seen for a psychiatric consultation. The Veteran reported that he was referred for an evaluation after he had issues with the psychiatrist at the VA Homestead clinic which resulted in her calling the police. The Veteran denied depressive or manic symptoms. He had good energy, motivation, and concentration. He denied visual and auditory hallucinations, but endorsed paranoid delusions that the government is following him. He denied experiencing nightmares, but admitted to occasional intrusive thoughts which he is able to cope with. His hobbies include watching TV and lawnmowing; he is also a deacon at this church and attends church three times per week. The clinician noted that the Veteran is in contact with reality and had no suicidal or homicidal ideas, plan or intentions. The clinician noted that the Veteran was cooperative and maintained good eye contact. He was alert and oriented to person, place, time and situation. The Veteran’s speech was coherent and clear, at normal rate and volume. The Veteran’s mood was “ok” and his affect was restricted. His thought processes were goal directed and organized. The Veteran’s recent and remote memory were good and his judgment was fair. The Veteran was noted to have a strong support system, good insight, judgement and effective coping skills. The Veteran declined treatment at that time. The Board finds that the evidence since September 20, 2016, is reflective of, at most, the 50 percent disability rating that has been assigned. The Veteran continues to be irritable and suspicious, with communication difficulties. He has some panic attacks, and is largely isolated, though he continues to interact with his extended family and a few friends. The Board notes that treatment records and notations made by the private examiner are often at odds, with the Veteran describing a lesser level of impairment when questioned than the checklist format used in examination allowed. His reports in treatment are therefore given greater weight, and the examiner’s opinion that an increased rating was warranted is not attributed much probative value. Her narrative descriptions, however, are consistent with the treatment records and the overall disability picture meeting the 50 percent criteria. In sum, there is no impaired reality testing or near continuous panic or depression that so impairs the Veteran as to interfere with his independent functioning. He has no suicidal ideation or obsessional rituals, and only a single, remote instance of violence has been noted. Even that has not been clearly reported as related to PTSD. No increased evaluation is warranted, The Board has considered the applicability of the benefit of the doubt doctrine in reaching this conclusion. However, the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107 (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection on a direct basis, the record requires competent evidence showing: (1) the existence of a present disability; (2) in service incurrence or aggravation of an injury or disease; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection for lipoma of the scalp and plantar warts The Veteran is seeking service connection for lipoma of the scalp and for plantar warts. The Veteran had active duty from April 1971 to June 1979 and from June 1979 to February 1988. However, the service department has characterized the Veteran’s service from June 1979 to February 1988 as other than honorable, and VA determined in an April 1989 administrative decision that the Veteran’s discharge for this period of service is a bar to benefits under the provisions of 38 U.S.C. § 5303 and 38 C.F.R. § 3.12(c). The Veteran’s service treatment records show he was diagnosed with and treated for plantar warts in August 1982 and that in September 1982 he underwent an excision of a lipoma on his scalp. These are the sole entries regarding these disabilities; the “good” period of service is silent for any mention of plantar warts or lipomas. The Veteran has made no other allegation regarding these conditions, and offered no other theory of entitlement. As the claims are grounded solely in the other than honorable period of service, and the unchallenged bar to VA benefits under 38 U.S.C. § 5303 and 38 C.F.R. § 3.12 applies, service connection must be denied as a matter of law. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD is remanded The Veteran has submitted evidence to refute the rationale offered in support of the negative August 2018 VA opinion. Remand is necessary for proper consideration of such. Colvin v. Derwinski, 1 Vet. App. 171 (1991). 2. Entitlement to a compensable rating for bilateral hearing loss is remanded The Veteran’s VA treatment records show that he was seen for an audiology evaluation in October 2017. The audiometric results have not been associated with the electronic file. A remand is required to obtain these audiometric testing results. 3. TDIU The Veteran asserts that his service-connected disabilities cause him to be unemployable, and a claim for TDIU is inferred as part and parcel of his claims for increased rating. In order to properly consider such, development is necessary to ensure a complete record on the involved factors. Additionally, the claim for TDIU is inextricably intertwined with pending appeals for increased rating. The matters are REMANDED for the following action: 1. Associate with the claims file updated VA treatment records from the medical center in Miami and all associated clinics, including Homestead. VA audiological treatment records, to include complete audiograms, performed in October 2017 must be specifically requested. 2. Contact the appellant and provide him fully compliant notice as required under applicable laws, regulations, and legal precedents. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159; Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); and Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice must include information on TDIU and a request to complete a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. 3. Return the file to the VA examiner who provided the October 2017 sleep apnea opinion. The claims file must be reviewed in conjunction with the examination. If the examiner is not available, another appropriate medical professional may be consulted. If the examiner determines another VA examination is necessary, one should be scheduled. The examiner must opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s obstructive sleep apnea is related to service, to include service-connected PTSD. The examiner must comment on the medical treatises submitted by the Veteran in support of his claim; specifically, Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort. A full and complete rationale for all opinions expressed is required. 4. Upon completion of the above, review the records, conduct any additional development deemed necessary (including VA examinations if warranted), and readjudicate the remanded issues. If the benefits sought remain denied, the Veteran should be provided with a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. M. Lunger, Associate Counsel