Citation Nr: 18152703 Decision Date: 11/27/18 Archive Date: 11/23/18 DOCKET NO. 14-33 825 DATE: November 27, 2018 ORDER Entitlement to an initial rating of 70 percent for posttraumatic stress disorder (PTSD) with anxiety disorder not otherwise specified (NOS) from February 27, 1998, to June 3, 2015, is granted, subject to the regulations governing the payment of monetary awards. Entitlement to an initial compensable rating for bilateral hearing loss is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) from June 1, 2004, to June 3, 2015, is granted, subject to the regulations governing the payment of monetary awards. Entitlement to an initial rating higher than 10 percent for residuals of traumatic brain injury (TBI) with post concussive disorder is denied. Entitlement to an initial compensable rating of 10 percent, but no higher, for headaches, as a residual of TBI, is granted, subject to the regulations governing the payment of monetary awards. REMANDED Entitlement to service connection for a skin disability is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for hiatal hernia is remanded. FINDINGS OF FACT 1. From February 27, 1998, to June 3, 2015, the symptoms and overall impairment caused by the Veteran’s PTSD with anxiety disorder NOS more nearly approximated occupational and social impairment with deficiencies in most areas, but they have not more nearly approximated total social and occupational impairment. 2. The Veteran’s bilateral hearing loss is no worse than a level I hearing impairment in right ear and a level II hearing impairment in the left ear. 3. From June 1, 2004, to June 3, 2015, the evidence is at least evenly balanced as to whether the Veteran’s service-connected disabilities precluded him from securing and following substantially gainful employment consistent with his education and occupational experience. 4. Residuals of the Veteran’s TBI, have included loss of mild memory and sensitivity to light and sound with the highest level of impairment of any facet related to cognitive impairment and subjective symptoms being level 1. 5. The Veteran’s headaches are a residual of his TBI. 6. The evidence is approximately evenly balanced as to whether the symptoms of the Veteran’s headaches are characterized as prostrating attacks averaging one in two months over the last several months, but not characteristic prostrating attacks occurring on an average of once a month over the last several months. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial rating of 70 percent, but no higher, for PTSD anxiety disorder NOS, from February 27, 1998, to June 3, 2015, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Codes (DCs) 9413-9411. 2. The criteria for an initial compensable rating for bilateral hearing loss are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.7, 4.10, 4.21, 4.85, 4.86, DC 6100. 3. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to a TDIU from June 1, 2004, to June 3, 2015, are met. 38 U.S.C. § 1155, 5107, 5110; 38 C.F.R. §§ 4.1-4.7, 4.16. 4. The criteria for an initial rating higher than 10 percent for residuals of TBI are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.124a, 4.130, DC 8045. 5. With reasonable doubt resolved in favor of the Veteran, the criteria for a separate, initial rating of 10 percent, but no higher, for headaches are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.124, DC 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1967 to August 1971. He received the Purple Heart Medal with 1 star and Combat Action Ribbon. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from October 2012 and April 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In the October 2012 rating decision, the RO denied service connection for a skin disability and granted service connection for residuals of TBI with post concussive disorder (residuals of TBI ) and assigned a 10 percent disability rating effective December 23, 2010 (the receipt date of the claim). In the April 2013 rating decision, the RO denied the Veteran’s claim for service connection for GERD and hiatal hernia. Also, in that decision, the RO granted service connection for an anxiety disorder and assigned a 30 percent rating, effective from December 16, 2010, and granted service connection for bilateral hearing loss and assigned a noncompensable rating, effective December 23, 2010 (the receipt date of the claim). The Veteran timely disagreed with the initial ratings assigned, in addition to the remaining claims on appeal. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ) in November 2016. In March 2017 and May 2018, the Board, in pertinent part, remanded the claims on appeal to the agency of original jurisdiction (AOJ) for additional development. For the reasons indicated below, the AOJ complied with the Board’s remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). In March 2017, the Board addressed the issue of entitlement to service connection for autoimmune hepatitis. Evidence reflects that further development is still being conducted on this issue. See, e.g., certification for BVA video conference hearing dated June 2018. Hence, this matter will not be addressed at this time. In May 2018, the Board expanded the appeal to include entitlement to a TDIU. (consistent with Rice v. Shinseki, 22 Vet. App. 447 (2009)). Specifically, the Board dismissed the issue of entitlement to a TDIU since June 4, 2015, and remanded the issue of the entitlement to a TDIU prior to June 4, 2015. In an April 2017 rating decision, the Appeals Management Center granted service connection for PTSD and rated that disability in conjunction with the already service-connected anxiety disorder NOS. The disability rating for the service-connected psychiatric disability remained at 30 percent from December 16, 2010, through June 3, 2015, but a total (100 percent) rating was assigned, from June 4, 2015. As the Veteran is granted the full benefit sought for the service-connected PTSD with anxiety disorder NOS since June 4, 2015, his appeal for an initial higher rating for this disability during that period will not be addressed. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In an October 2018 rating decision, the Decision Review Officer (DRO), granted service connection for sleep disorder and anemia, which had previously been on appeal after being denied by the RO’s October 2012 rating decision. As the Veteran has not appealed either the rating or effective date assigned to these disabilities, these matters are not before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Duty to Assist In May 2018, the Board remanded the Veteran’s claims listed on appeal for further development. Specifically, the Board remanded the service-connected claim for residuals of TBI to schedule him a VA examination to determine the current severity of his disability. The Veteran’s service-connected PTSD was remanded, in pertinent part, to obtain a retroactive opinion, VA psychiatric treatment records from 1998, and any identified private psychiatric treatment records. Additionally, the claims were remanded to obtain and associate with the record social Security Administrative (SSA) records. As to the claim for entitlement to a TDIU prior to June 4, 2015, the Board is granting the benefits sought in full and further discussion of the VCAA is unnecessary for that claim. With respect to the initial higher rating for residuals of TBI, in August 2018, the Veteran was afforded an examination as to the severity of his service-connected residuals of TBI. For the reasons indicated in more detail below, the examination report is adequate as it described the Veteran’s disability in sufficient detail to allow the Board to make a fully informed evaluation. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). As to the initial higher rating for the PTSD claim, in August 2018, a retrospective medical opinion was obtained to determine the severity of the Veteran’s PTSD from February 1998 effective date of service connection. The opinion is adequate as it is based upon consideration of the Veteran’s prior medical history and examinations, describes the disability in sufficient detail so that the Board’s evaluation is a fully informed one, and contains a reasoned explanation. In a June 2017 letter, the AOJ requested the Veteran to identify the location and name of any VA or private medical facility where he received treatment for his psychiatric disability, to include the VA facility in New York where he received psychiatric treatment in 1998. Also, the Veteran was requested to complete authorizations for VA to obtain private treatment records for any treatment he received for his psychiatric disability. He did not respond. Thereafter, the AOJ attempted to obtain VA psychiatric treatment records dated from February 1998. However, the AOJ has indicated that the VA treatment records from 1998 are unavailable and no records from that time period do not exist. See VA 27-0820 report of general information dated October 2018. The AOJ has made reasonable efforts to obtain the treatment records from 1998. Any further attempts to obtain the treatment records would be futile and additional action is therefore not required. 38 C.F.R. § 3.159(c)(1) (VA not required to make follow-up request for private treatment records where follow-up request for records would be futile); 38 C.F.R. § 3.159(c)(2) (requiring VA to continue to request Federal records unless it concludes that records sought do not exist or that further efforts to obtain them would be futile) Finally in this regard, the Veteran’s SSA were obtained and associated with the record. The Veteran has not otherwise identified any additional relevant, outstanding records that need to be obtained before deciding these claims. Therefore, the duty to assist has been satisfied, and an additional remand is not warranted. Neither the Veteran nor his representative has raised any issue with the duty to notify or duty to assist with the claims on appeal. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Initial Higher Ratings Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to an initial compensable rating prior to December 16, 2010, and a higher rating than 30 percent from December 16, 2010, to June 3, 2015, for PTSD with anxiety disorder NOS (PTSD). The Veteran’s PTSD is rated under 38 C.F.R. § 4.130, DCs 9413- 9411. All acquired psychiatric disorders, with the exception of eating disorders, are evaluated under the General Rating Formula for Mental Disorders. Under this criteria, a 30 percent rating is assigned when 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, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty establishing effective work and social relationships. A 70 percent rating is assigned when 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 work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned when there is evidence of 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. The use of the term “such as” in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating, in addition to permitting consideration of other symptoms particular to each veteran and disorder, and the effect of those symptoms on his/her social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit stated that “a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” It was further noted that § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. The evidence reflects that sometime on June 1, 2004, the Veteran retired as a correctional officer from the New York Department of Correction. See Social Security Administration (SSA) disability benefits records dated February 2006. He was employed for 32 years as a correctional officer; he is currently retired. See VA treatment record dated January 2011. The Veteran has submitted documentation, dated from 2003, that reflects that he was absent several times from work and that his name was added to the Time Abuse list. See Memorandum of counseling session- time abuse status dated October 2003. The Veteran’s VA treatment records, dated at the earliest from 2010, reflect that the Veteran avoids social engagements, crowds, public experiences, and activities. He reports social withdraw and outburst of anger. See VA treatment records dated January 2011 and May 2011. Furthermore, the Veteran’s VA treatment records show that during a January 2011 treatment visit, he stated that he has experienced psychiatric symptoms (such as depression, chronic sleep impairment, and irritability) since 1970. He reports that he has been married for 39 years. See, e.g., VA treatment records dated January 2011. He has two adult children. Id. He indicated that his behavior has caused difficulty in his relationship with his children. He indicated that he has no friends and has difficulty trusting other or relating to others. He has a GED, and took some college courses. In the January 2011 VA treatment record, the Veteran indicated that he has difficulty concentrating and that he was very disorganized when he was employed, due to his PTSD. A December 2010 VA treatment shows that the VA treatment provider found that the Veteran’s PTSD significantly impairs his ability to engage in work, social, and family relationships. In February 2012, the Veteran was afforded a VA examination. He reported irritability and difficulty concentrating. He stated that he has a good relationship with his wife. He does not have a good relationship with his siblings. He attends bible study with his friends and he sees them on a weekly basis at church. The Veteran stated that he has been retired/ unemployed since 2004. The examiner noted that the Veteran did not report any problems during the course of his employment. The VA examiner found that the Veteran arrived to the examination appropriately dressed and groomed. He was orientated to person, place, date, and situation. The examiner found that the Veteran’s judgement and insight were good. The February 2012 examiner found that the Veteran is not socially impaired. In an August 2018 VA PTSD examination report, the examiner provided an opinion regarding the severity of the Veteran’s PTSD from 1998. The examiner found that the Veteran’s service connected psychiatric disability from February 1998 through June 3, 2015, appears stable and without an increase in severity of the disability. The examiner explained that the Veteran’s VA records show no in-patient treatment or periods of exacerbation. His medication classification remained stable and dosages remained within moderate range. The examiner further indicated that throughout his psychiatric treatment, there has been no acute distress, no feelings of worthlessness, no feelings of hopelessness and that the Veteran has effectively employs coping techniques and strategies to manage anxiety and mood. See treatment records dated from August 2014 and December 2014. To support the VA examiner’s findings, she cited to the Veteran’s VA treatment records. Specifically, she indicated that a December 2014 VA treatment record notes that the Veteran’s mood is “about the same as last time,” “a little depressed”. The examiner further indicated that in January 2013, the VA treatment provider noted that the Veteran is stable. An April 2015 VA treatment record notes the Veteran’s statement that his medication helps him. The examiner concluded that the when the Veteran was employed, he reported of work-related difficulties. For the following reasons, entitlement to an initial rating of 70 percent, but no higher, for PTSD from February 27, 1998, to June 3, 2015, is warranted. The Veteran’s symptoms and overall impairment caused by his PTSD more nearly approximated occupational and social impairment with deficiencies in most areas. For instance, as to social impairment, the evidence shows that although the Veteran has been married for many years and appears to have a good relationship with his wife, he has consistently reported that he has no friends, he is socially withdrawn, and avoid public places. He indicated that he has no relationship with his siblings. He has also reported that he has difficulty trusting others and relating to others. Furthermore, the December 2010, indicated that the Veteran’s PTSD causes social impairment. Specifically, the December 2010 VA treatment provider found that the Veteran’s PTSD significantly impairs his ability to engage in social and family relationships. As to occupational impairment, the Veteran has been unemployed since June 2004. He was previously employed as a correctional officer. The Veteran submitted evidence indicated that when he was employed, he missed several days of work. Additionally, the Veteran has reported that his PTSD causes difficulty with concentration and that he is disorganized. Furthermore, the December 2010 VA treatment provider indicated that the Veteran’s PTSD causes occupational impairment. Specifically, the December 2010 VA treatment provider found that the Veteran’s PTSD significantly impairs his ability to engage in work and relationships. Here, although there are no psychiatric treatment records prior to 2010, the Veteran’s statements have sufficiently established that his PTSD symptoms have consistently remained the same from 1998 to 2015. For instance, the Veteran’s reports during a January 2011 VA treatment visit, that he has experiences PTSD symptoms, such as chronic sleep impairment and irritability, since 1970. Also, since 1998, his marital status and relationship with his wife has remained the same. Importantly, the August 2018 examiner found that Veteran’s service-connected PTSD from February 1998 through June 3, 2015, appears stable and without an increase in severity of the disability. Therefore, a 70 percent throughout the appeal period is appropriate. Entitlement to an initial rating higher than 70 percent for a PTSD from February 27, 1998, to June 3, 2015, is not warranted because the Veteran’s symptoms and overall impairment caused by the PTSD have not more nearly approximated the criteria for the next higher rating of 100 percent, total occupational and social impairment. For instance, although the Veteran indicated that he has no friends and that he is socially he has been married for decades and has a good relationship with his wife. Moreover, he reported that he attends bible study with his friends and that he sees them on a weekly basis. In addition, the above evidence reflects that there was no gross impairment in thought processes, delusions or hallucinations, grossly inappropriate behavior, that the Veteran was a persistent danger to hurt himself, or that he was unable to perform activities of daily living. He was oriented on all examinations and did not have memory loss. He was not found to be persistent danger to hurt others. Therefore, the evidence does not reflect that the symptoms and overall impairment more nearly approximate the total social impairment required for a 100 percent rating. The evidence is thus at least evenly balanced as to whether the symptoms and impairment caused by the Veteran’s PTSD more nearly approximated occupational and social impairment with deficiencies in most areas. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, an initial 70 percent rating from February 27, 1998, to June 3, 2015, is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. As the preponderance of the evidence is against any higher rating, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 2. Entitlement to an initial compensable rating for bilateral hearing loss. The Veteran seeks entitlement to an initial compensable rating for bilateral hearing loss. Hearing loss is evaluated under 38 C.F.R. §§ 4.85, 4.86, DC 6100, Tables VI, VIA, and VII of VA’s rating schedule. VA disability compensation for impaired hearing is derived from the application in sequence of two main tables. See 38 C.F.R. § 4.85; Table VI; and Table VII (also DC 6100). Table VI correlates the average pure tone threshold (derived from the sum of the 1000, 2000, 3000, and 4000 Hertz thresholds divided by four) with the ability to discriminate speech, providing a Roman numeral to represent the correlation. The table is applied separately for each ear to derive the values used in Table VII. Table VII is used to determine the disability rating based on the relationship between the values for each ear derived from Table VI. See 38 C.F.R. § 4.85. Table VII is subject to 38 C.F.R. § 3.383 (2017). Section 3.383 pertains to special consideration for paired organs. Compensation is payable for certain combinations of service-connected and non-service-connected disabilities as if both disabilities were service connected, provided the non-service-connected disability is not the result of the Veteran’s own willful misconduct. 38 C.F.R. § 3.383(a). The provision applies when hearing impairment in one ear is compensable to a degree of 10 percent or more as a result of service-connected disability and hearing impairment as a result of non-service-connected disability meets the provisions of § 3.385 in the other ear. 38 C.F.R. § 3.383(a)(3). There are provisions in the rating schedule allowing special consideration to cases of exceptional patterns of hearing impairment. This occurs when there are pure tone thresholds of 55 decibels or more in each of the specified frequencies or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. See 38 C.F.R. § 4.86 (2017). In such cases, the rating specialist is to determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. Id. The assignment of a rating for hearing loss is achieved by a mechanical application of the rating schedule to the numeric designations assigned after audiometric valuations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). However, in Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007), the United States Court of Appeals for Veterans Claims (Court) held that in addition to dictating objective test results in a VA audiology examination, a VA audiologist should describe the functional effects caused by a hearing disability in his or her final report. In a February 2012 VA audiology examination, audiometric testing revealed the following pure tone thresholds, in decibels: HERTZ 1000 2000 3000 4000 Average RIGHT 30 45 60 60 49 LEFT 20 40 60 70 48 Speech recognition ability was measured at 94 percent in both ears. The examiner opined that the Veteran’s hearing loss does not impact his ordinary conditions of daily life, including his ability to work. The provisions in the rating criteria for exceptional patterns of hearing impairment are inapplicable, as the February 2012 audiological pure tone thresholds did not result in 55 decibels or more in each of the specified frequencies or pure tone threshold of 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. Therefore, Table VI is appropriate in this case. See 38 C.F.R. § 4.86. After applying the pure tone averages and speech recognition scores from the February 2012 examination to Table VI, the right ear translates to a level I and the left ear translates to a level I. 38 C.F.R. § 4.85, Table VI. Intersecting level I and level I under Table VII results in a 0 percent rating under the applicable criteria. 38 C.F.R. 4.85, DC 6100. In an October 2017 VA audiology examination, the Veteran reported that he has difficulty hearing in groups and in the presence of background noise. The VA audiologist found that the Veteran’s bilateral hearing loss impacts his ordinary conditions of daily life, including his ability to work. The VA audiologist reasoning was based on the Veteran’s reports that he has difficulty hearing in groups and in background noise. Audiometric testing revealed the following pure tone thresholds, in decibels: HERTZ 1000 2000 3000 4000 Average RIGHT 30 35 60 65 48 LEFT 15 35 70 70 48 Speech recognition ability was measured at 94 percent in right ear and 82 percent in the left ear. Here, the provisions in the rating criteria for exceptional patterns of hearing impairment are inapplicable, as the October 2017 audiological pure tone thresholds did not result in 55 decibels or more in each of the specified frequencies or pure tone threshold of 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. Therefore, Table VI is appropriate in this case. See 38 C.F.R. § 4.86. After applying the pure tone averages and speech recognition scores from the October 2017 examination to Table VI, the right ear translates to a level I and the left ear translates to a level II. 38 C.F.R. § 4.85, Table VI. Intersecting level I and level II under Table VII results in a 0 percent rating under the applicable criteria. 38 C.F.R. 4.85, DC 6100. Accordingly, the evidence demonstrates the Veteran’s bilateral hearing loss warrants no more than a noncompensable rating. 38 C.F.R. §§ 4.7, 4.385. The Board in no way discounts the difficulties that the Veteran experiences as a result of his bilateral hearing loss. However, the disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designation assigned after audiometry results are obtained. Hence, the Board must base its determination on the results of the pertinent VA audiology studies. See Lendenmann, 3. Vet. App. at 345. In other words, the Board is bound by law to apply VA’s rating schedule based on the Veteran’s audiometry results. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Based on the application of the criteria to the audiometric findings above, and the record presents no basis for assignment of a compensable disability rating for the Veteran’s bilateral hearing loss. In Martinak, 21 Vet. App. At 447, the Court addressed a challenge to VA’s audiological testing practices, specifically, whether VA’s policy of conducting all audiometry testing of hearing loss claimants in a sound-controlled room was valid. The Court also addressed the requirements for an adequate VA audiological examination report. The Court upheld VA’s policy of conducting audiometry testing in a sound controlled room. The Court also held that, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. As to the facts in this case, during the October 2017 VA examination, the Veteran reported that that he has difficulty hearing in groups and in the presence of background noise. This is sufficient to comply with Martinak. The applicability of the benefit of the doubt doctrine has been considered; however, given the mechanical method in which ratings for hearing loss are derived, that doctrine is not applicable. See 38 U.S.C.§ 5107 (b); 38 C.F.R. §§ 3.102, 41.3; Gilbert,1 Vet. App. at 55-56. 3. Entitlement to an initial rating higher than 10 percent for residuals of TBI. The Veteran’s residuals of a TBI are rated under 38 C.F.R. § 4.124a, DC 8045. DC 8045 states that there are three main areas of dysfunction that may result from a TBI and have profound effects on functioning: cognitive, emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, DC 8045. The types of physical dysfunction set forth in the revised criteria do not encompass all possible residuals of a TBI. For residuals not listed in DC 8045 that are reported on an examination, VA is to evaluate under the most appropriate diagnostic code. Each condition is to be evaluated separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under 38 C.F.R. § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified” table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. An evaluation is to be assigned based upon the highest level of severity for any facet of cognitive impairment and other residuals of TBI not otherwise classified as determined on examination. Only one evaluation is assigned for all the applicable facets. A higher evaluation is not warranted unless a higher level of severity for a facet is established on examination. Physical and/or emotional/behavioral disabilities found on examination that are determined to be residuals of TBI are evaluated separately. At the outset, in October 2017, a VA TBI examination was conducted to assess the severity of the Veteran’s service-connected residuals of TBI with post concussive disorder. Although the examiner acknowledged that the Veteran reported multiple symptoms that he attributed to his TBI (including headaches, memory and concentration problems, and dizziness), the examiner explained why it was believed that none of these symptoms were attributable to the in-service TBI, that the complaints were nonspecific, and that they could have multiple causes. Hence, the examiner did not provide any information as to the nature and severity of any of the Veteran’s reported TBI symptoms and essentially found that he did not experience any impairment associated with his service-connected TBI with post concussive disorder. In light of the lack of information provided in the October 2017 examination report and the inconsistency between this report and the other pertinent evidence of record, the October 2017 examination is found inadequate for rating the severity of the Veteran’s residuals of a TBI and will not be addressed further. In February 2012, June 2015, and August 2018 the Veteran was afforded VA examinations to assess the severity of his service-connected TBI. Below, are the Veteran’s reported symptoms (at the worst) during the examinations. A level of severity of 3 was indicated for the memory, attention, concentration, executive functions facet, indicating that the examiner found that there was objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment. See VA examination report dated June 2015. The next highest level of severity is total and is not warranted unless an examiner finds objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment. A level of severity of 1 was indicated for the judgment facet, indicating that an examiner found evidence of mildly impaired judgment, including an occasional inability to identify, understand, and weigh the alternatives; understand the consequences of choices; and make a reasonable decision with regard to complex or unfamiliar decisions. A higher level of severity of 2 is not warranted unless an examiner finds evidence of moderately impaired judgment. For complex or unfamiliar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, although has little difficulty with simple decisions. A level of severity of 1 was indicated for the social interaction facet, indicating that an examiner found evidence that social interaction is routinely appropriate. See VA examination reports dated February 2012, June 2015, and August 2018. A higher level of severity of 2 is not warranted unless an examiner finds evidence that social interaction is inappropriate most or all the time. A level of severity of 0 was indicated for the orientation facet, indicating that an examiner found evidence such as always oriented to person, time, place, and situation. Id. A higher level of severity of 1 is not warranted unless an examiner finds evidence of occasional disorientation to one of the four aspects of orientation (person, time, place, and situation). level of severity of 0 was indicated for the motor activity (with intact motor and sensory system) facet, indicating that an examiner found evidence of motor activity normal. Id. A higher level of severity of 1 is not warranted unless an examiner finds evidence such as motor activity normal most of the time, but mildly slowed at times due to apraxia (inability to perform previously learned motor activities, despite normal motor function). A level of severity of 0 was indicated for the visual spatial orientation facet, indicating that an examiner has found evidence of normal visual spatial orientation. Id. A higher level of severity of 1 is not warranted unless an examiner finds evidence such as mildly impaired visual spatial orientation (i.e., occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions, but is able to use assistive devices such as global positioning system (GPS)). A level of severity of 1 was indicated for the subjective symptoms facet, indicating that the examiner found evidence of three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family, or other close relationships (examples of findings that might be seen at this level of impairment are: intermittent dizziness, daily mild to moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light). Id. The symptoms were described as headaches, tinnitus, anxiety, and insomnia. A higher level of severity of 2 is not warranted unless the examiner finds evidence of three or more subjective symptoms that moderately interfere with work; instrumental activities of daily living or work family or other close relationships. Examples of findings that might be seen at this level of impairment are marked fatigability, blurred or double vision, and headaches requiring rest periods during most days. A level of severity of 1 was indicated for the neurobehavioral effects facet, reflecting that the examiner found evidence of one or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both, but do not preclude them. See VA examination report dated June 2015. A higher level of severity of 2 is not warranted unless an examiner finds evidence of one or more neurobehavioral effects that interfere with or preclude workplace interaction, social interaction, or both on most days or that occasionally require supervision for safety of self or others. A level of severity of 0 was indicated for the communication facet, indicating that the examiner found evidence such as ability to communicate by spoken and written language (expressive communication), and to comprehend spoken and written language. See VA examination reports dated February 2012, June 2015, and August 2018. A higher level of severity of 1 is not warranted unless an examiner finds evidence of occasional impairment of comprehension or expression, or both, of either spoken language or written language, but the Veteran can communicate complex ideas. The August 2018 examiner indicated that the Veteran has a residual attributable to TBI, namely headaches. Under DC 8045, this residual is to be evaluated separately, which will be addressed below. In sum, the evidence shows that the Veteran’s severity of his residuals of a TBI has ranged (on the level of impairment) from a 3, at the worst, to a 0. Most of his symptoms were at the level of impairment of a 0 or a 1. DCs 8045 only allowed for one 10 percent rating for all purely subjective complaints recognized as symptomatic as brain trauma. As such, a separate, compensable rating is not authorized under the rating criteria. Based on the above evidence, the Veteran is not entitled to a rating higher than 10 percent for his TBI residuals. 4. Entitlement to a compensable, separate rating for headaches, as a residual of TBI. As indicated above, the August 2018 examiner indicated that the Veteran has a residual attributable to TBI, namely headaches. Under DC 8045, this residual is to be evaluated separately. Headaches are rated under DC 8100. 38 C.F.R. §§ 4.27, 4.124a, DC 8100. Under DC 8100, migraines are rated as follows: a 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one in two months over the last several months; a 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average of once a month over the last several months; and a 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. The rating criteria do not define “prostrating”. Dorland’s Illustrated Medical Dictionary defines “prostration” as “extreme exhaustion or powerlessness.” Dorland’s Illustrated Medical Dictionary 1554 (31st ed. 2007). VA’s Adjudication Procedures Manual (M21-1) defines prostrating under DC 8100 as “causing extreme exhaustion, powerlessness, debilitation or incapacitation with substantial inability to engage in ordinary activities.” See M21-1, pt. III, Subpt. iv, Ch. 4, Sec. G(7)(b). The Adjudication Manual is not binding on the Board, DAV v. Sec’y of Veterans Affairs, 859 F.3d 1072, 1077 (Fed. Cir. 2017) (“The M21-1 Manual is binding on neither the agency nor tribunals”), but provides useful guidance in defining this term. For the following reasons, entitlement to an initial, separate, rating of 10 percent, but no higher, for headaches, as a residual of the TBI, is warranted. In August 2018, the Veteran was afforded a VA examination. The examiner diagnosed headaches as a residual to TBI. The Veteran reported that he has had headaches since his military service. He described that he has headaches that last less than one day. He indicated that his headaches worsen with physical activity. The examiner indicated that the Veteran does not have characteristic prostrating attacks of migraine or very prostrating and prolonged attacks of migraines pain that are productive of severe economic inadaptability. The examiner concluded that the Veteran’s headaches impact his ability to work, as he has poor concentration when he experiences headaches and reduced productivity. The Veteran has described that his headaches have been consistent since his military service. The Veteran indicated that his headaches do not last longer than one day and that they worsen with physical activity. The Veteran is not entitled to an initial rating higher than 10 percent, as the Veteran did not report that he has headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months. Notably, he denied prostrating attacks of migraine or very prostrating and prolonged attacks of migraines pain that are productive of severe economic inadaptability. The evidence is thus at least evenly balanced as to whether the Veteran’s headache symptoms meet each of the criteria for a 10 percent rating under DC 8100. See Johnson v. Wilkie, No. 16-3808, 2018 U.S. App. Vet. Claims Lexis 1253 (Sept. 19, 2018) (the criteria of DC 8100 are successive). As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to initial rating of 10 percent rating for the Veteran’s headaches under DC 8100 is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The Board has considered the Veteran’s initial rating claims and decided entitlement based on the evidence. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claim. 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). TDIU Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities; provided that, if there is only one such disability, this disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a) (2017). For purposes of one 60 percent disability or one 40 percent disability in combination, disabilities of a common etiology or from a single accident are considered to be one disability. Id. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Id. Factors such as employment history, as well as educational and vocational attainments, are for consideration. Id. For VA purposes, the term “unemployability” is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The word “substantially” suggests an intent to impart flexibility into a determination of overall employability, as opposed to requiring the appellant to prove that he is 100 percent unemployable. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). Here, the evidence of record raises the issue of entitlement to a TDIU, prior to June 4, 2015, as part and parcel of the Veteran’s claim for an initial higher rating for PTSD. Prior to June 4, 2015, the Veteran was service-connected for PTSD (now rated 70 percent disabling); sleep disorder (rated 30 percent disabling); maxillary ridge atrophy (rated 30 percent disabling); diabetes mellitus (rated 10 percent disabling from November 14, 2012, and 20 percent from July 20, 2014); tinnitus (rated 10 percent disabling); residuals of TBI (rated 10 percent disabling); anemia (rated 10 percent disabling); hypertension (rated 10 percent disabling); peripheral neuropathy of the right lower extremity (rated 10 percent disabling); bilateral hearing loss (rated 10 percent disabling); headaches (rated 10 percent disabling); pseudophakia (rated noncompensable); erectile dysfunction (rated noncompensable); residuals of shrapnel wound of the right elbow (rated noncompensable); residuals scars from shrapnel wound of the face(rated noncompensable); and residuals scar from shrapnel wound to the right elbow (rated noncompensable). His combined evaluation for compensation was 90 percent, prior to the award for an initial higher rating, granted herein, for a 70 percent rating for PTSD. Here, the Veteran has at least one service-connected disability that is ratable as 60 percent or more, that is his service-connected PTSD. Therefore, the threshold criteria for consideration of a TDIU are met. 38 C.F.R. §§ 4.16 (a), 4.25. The evidence reflects that the Veteran was last employed on June 1, 2004, as a correctional officer at the New York Department of Correction. See Social Security Administration (SSA) disability benefits records dated February 2006. Since separation from service, the Veteran has been employed as a correctional officer; he was employed as a correctional officer for, approximately, 32 years. See VA treatment records dated January 2011. He has a GED. He has some college education; however, he did not receive a college degree. Id. He receives SSA disability benefits for a psychiatric disability. In the Veteran’s SSA records, he reported that he was too disabled to work due to his psychiatric disability. Notably, in a May 2006 SSA report, M.M. PhD., indicated that the Veteran has difficulty focusing, and he becomes paranoid in social situations and adjusting to change. As noted above, the Veteran submitted evidence indicated that when he was employed, he missed several days of work. See Memorandum of counseling session- time abuse status dated October 2003. He has consistently reported that his PTSD causes difficulty with concentration and that he is disorganized. Also, as illustrated above, the Veteran’s VA treatment provider indicated that the Veteran’s service-connected PTSD causes occupational impairment. Specifically, the December 2010 VA treatment provider found that the Veteran’s PTSD significantly impairs his ability to engage in work. With respect to the Veteran’s other service-connected disabilities, in an October 2017 VA audiology examination, the VA audiologist found that the Veteran’s bilateral hearing loss impacts his ability to work, as he has difficulty hearing in the presences of groups. In the February 2012 VA examination report for residuals of a TBI, the examiner indicated that the Veteran has symptoms that mildly interfere with work. The examiner also found that the Veteran’s residuals of a TBI, such as his psychiatric disorder and hearing loss, impact his ability to work. The examiner reasoned that the Veteran reported that when he was employed, he missed several days of work due to his residuals of a TBI, such as his psychiatric disorder and hearing loss. In addition, the Veteran is service-connected for multiple disabilities that impact him physically and mentally. In sum, the evidence shows that the Veteran has suffered a longstanding history of PTSD symptoms and residuals of a TBI. He has been unemployed since June 2004. He has a limited educational and work history. He has a GED and has worked only one job since his military service. Moreover, his employment history of a correctional officer would involve physical and mental tasks. The Veteran’s multiple service-connected disabilities would physically and mentally limit his capabilities in the work force. The evidence is thus at least evenly balanced as to whether as to whether the Veteran’s service-connected disabilities precluded him from securing and following substantially gainful employment consistent with his education and occupational experience. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to a TDIU prior to June 4, 2015 is warranted. From that date, the Veteran is in receipt of a 100 percent rating and special monthly compensation pursuant to 38 U.S.C. § 1114(s). Consequently, the Board in its May 2018 decision, dismissed the issue of entitlement to a TDIU from that date as moot. See Buie v. Shinseki, 24 Vet. App. 242 (2010); Bradley v. Peake, 22 Vet. App. 280 (2008) (a 100 percent schedular rating is not moot when it could render the Veteran eligible for special monthly compensation benefits pursuant to 38 U.S.C. § 1114(s)). REASONS FOR REMAND 1. Entitlement to service connection for a skin disability is remanded. The Veteran claims that his skin disability is due to his military service and that he has had skin symptoms since service. Specifically, he asserts that his skin disability is due to his Agent Orange exposure while stationed in Vietnam. The Veteran has a current skin disability, namely, hypopigmentation. See VA examination report dated July 2017. The Veteran’s service records indicate that he served in the Republic of Vietnam. Thus, Agent Orange exposure is conceded based on the circumstances of the Veteran’s military service. See 38 U.S.C. § 1116(f). In August 2014, the Veteran submitted a medical article that suggested that exposure to Agent Orange can cause altered skin color. Pursuant to the May 2018 Board remand, the Veteran was afforded a VA examination. The examiner diagnosed a skin tag, located on the left thigh, and opined that the Veteran’s current skin tag is less likely as not relates to his military service, to include as due to Agent Orange. The examiner provided a rationale as to why the Veteran’s current skin is unrelated to his skin tag noted in his STRs. The August 2018 VA opinion is flawed, as the examiner did not address the Veteran’s diagnosed hypopigmentation, the submitted medical article that suggested that exposure to Agent Orange can cause altered skin color, and the Veteran’s statements of skin symptoms since service. Therefore, a remand is necessary to obtain an opinion to address the etiology of the Veteran’s skin disability, specifically his diagnosed hypopigmentation. 2. Entitlement to service connection for GERD is remanded. The Veteran claims that his GERD is due to his in-service military stress, and his exposure to Agent Orange while stationed in Vietnam. See Veteran’s notice of disagreement dated May 2013. Alternately, he asserts that his GERD is due to his service-connected PTSD. Unfortunately, the Veteran’s service connection claim for GERD has been remanded twice to obtain an opinion to address the etiology of the Veteran’s GERD. However, the evidence of record is absent an opinion with a rationale that addresses whether the Veteran’s GERD had its onset in service or is otherwise related to service. 1. Most recently, the Veteran’s claim was remanded in May 2018 to obtain an opinion to address the etiology of the Veteran’s GERD. In August 2018, the Veteran was afforded a VA examination. The VA physician, who (specialized in internal medicine) opined that the Veteran’s GERD is less likely than not incurred in or caused service, had its onset on service, nor is related to exposure to Agent Orange during service. The physician also opined that the Veteran’s GERD is less likely as not proximately due to or the result of his service-connected PTSD. As to the opinion on a direct service connection basis, the physician reasoned that “the medical literature does not show a correlation between herbicide exposure and a motility gastrointestinal condition, the condition is less likely.” However, a medical opinion that relies on the absence of general medical literature supporting nexus without discussing the specific facts of the case is inadequate. Bailey v. O’Rourke, 30 Vet. App. 54, 60 (2018). As the May 2018 physician did not explain why the Veteran’s GERD did not have its onset in or is related to his military service based on the facts of this case, a new opinion should be obtained to specifically address whether this veteran’s GERD is related to his military service. 2. Entitlement to service connection for hiatal hernia is remanded. The Veteran claims that his hiatal hernia is due to his military service, to include as due to his Agent Orange exposure while stationed in Vietnam. Alternately, he asserts that his hiatal hernia is due to his service-connected PTSD. The Veteran’s April 1967 enlistment examination report is absent any complaints or diagnosis of a hiatal hernia. In July 2017, the Veteran was afforded a VA examination. The VA examiner diagnosed hiatal hernia and opined that it was less likely than not related to Agent Orange exposure, but was more likely due to congenital abnormality. In the May 2018 remand, the Board requested clarification as to whether the Veteran’s hiatal hernia is a development/congenital defect or disease. Furthermore, the Board requested an opinion to address if a disease, then to opine whether it is at least as likely as not that the disease was aggravated (there was an increase in underlying disability) in service. Pursuant to the May 2018 remand, in August 2018, the Veteran was afforded a VA examination. The VA physician, who (specialized in internal medicine) opined that the Veteran’s hernia is a specific disease, as “there is nothing thing in the [v] eteran history, physical exam or in the medical record suggests that the condition is developmental or congenital.” The physician opined that it is less likely than not that the Veteran’s hiatal hernia was an “ongoing chronic condition during the military service years”, or incurred in or was caused by service. The physician also opined that the Veteran’s hernia is less likely as not proximately due to or the result of his service-connected PTSD. The physician also opined that the Veteran’s PTSD did not aggravate the Veteran’s hernia. Furthermore, the physician concluded that the Veteran’s “hiatal hernia which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service illness, event, or injury.” No rationale was provided for the claim on a direct service connection basis; however, the physician provided a more detailed rationale for the negative opinion rendered for the service connection claim on a secondary basis. In sum, the May 2018 physician indicated that the Veteran’s hernia is not a congenital disease but did not provide any rationale as to why the Veteran hernia is not related to his military service or whether his hernia was due to his presumed Agent Orange exposure. Furthermore, as to the physician’s statement indicating that the Veteran’s hiatal hernia clearly and unmistakably existed prior to service, the Veteran’s enlistment examination is absent notation of hernia. Notably, the August 2018 VA examination report (benefits questionnaire report) noted, apparently as an error, that the Veteran’s hiatal hernia clearly and unmistakably existed prior to service and requested the physician to address whether the Veteran’s hiatal hernia, which clearly and unmistakably existed prior to service was aggravated during service. However, given that the Veteran’s hiatal hernia is not a congenital disease and nothing was noted in this regard at entry into service, the Veteran is presumed to have been in sound condition when he entered service. 38 U.S.C. § 1111. In light of the above inadequacies, upon remand, a VA opinion must be obtained, by an appropriate physician, to determine whether the Veteran’s hiatal hernia is related to service. The matters are REMANDED for the following action: 1. Request an opinion from an appropriate specialist physician to determine the etiology of the Veteran’s skin disability. The claims file, including a copy of this remand, must be made available to the specialist for review. The VA specialist should opine whether the Veteran’s current skin disability, diagnosed as hypopigmentation and skin tag, is at least as likely as not (i.e., a 50 percent probability or greater) had its onset inservice or is otherwise related to his military service, to include his presumed exposure to an herbicide agent (Agent Orange) in the Republic of Vietnam. In rendering the opinion above, the specialist should specifically address the article submitted in August 2014, titled “Agent Orange Symptoms and Effects,” which indicates that exposure to Agent Orange can cause altered skin color, as well as the reports of the Veteran and his wife that the Veteran has experienced skin symptoms since at least 1971. The specialist should provide a complete rationale for any opinion given. The absence of evidence of treatment for specific skin problems in the Veteran’s service treatment records cannot, standing alone, serve as the basis for a negative opinion. Also, the fact that the Veteran’s current skin problems are not on the list of diseases presumed to be associated with exposure to Agent Orange should not be the basis for a negative opinion. 2. Request an opinion from an appropriate specialist, such as a gastroenterologist, to determine the etiology of the Veteran’s GERD and hiatal hernia. The claims file, including a copy of this remand, must be made available to the specialist for review. The VA specialist should opine whether the Veteran’s current GERD and hiatal hernia are at least as likely as not (i.e., a 50 percent probability or greater) had their onset in service or is otherwise related to his military service, to include his presumed exposure to an herbicide agent (Agent Orange) in the Republic of Vietnam. In rendering the opinion above, the specialist should address the Veteran’s contentions that his GERD is the result of his in-service military stress. The absence of evidence of treatment for GERD and hiatal hernia in the Veteran’s service treatment records cannot, standing alone, serve as the basis for a negative opinion. Also, the fact that GERD and hiatal hernia are not on the list of diseases presumed to be associated with exposure to Agent Orange should not be the basis for a negative opinion. Finally in this regard, the specific facts of this case should be addressed rather than relying on only general medical literature. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Castillo, Associate Counsel