Citation Nr: 18152839 Decision Date: 11/27/18 Archive Date: 11/26/18 DOCKET NO. 16-25 625 DATE: November 27, 2018 ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for high cholesterol is denied. Entitlement to an initial compensable rating for bilateral hearing loss is denied. Entitlement to an initial rating higher than 10 percent for tinnitus is denied. Entitlement to an effective date earlier than April 22, 2014 for the award of service connection for hearing loss is denied. Entitlement to an effective date earlier than April 22, 2014 for the award of service connection for tinnitus is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include depression, is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to a total disability rating based on individual unemployability is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that hypertension was demonstrated during or is related to the Veteran’s active duty service, or that it was compensably disabling within one year after separation from active duty. 2. High cholesterol is a laboratory finding and not a disease or disability under VA law and regulations. 3. The Veteran’s bilateral hearing loss has not manifested by worse than Level I in either ear. 4. The Veteran is in receipt of the maximum schedular evaluation assignable for tinnitus. 5. A June 2011 rating decision rating decision which denied entitlement to service connection for bilateral hearing loss and tinnitus is final. 6. After the June 2011 rating decision, the Veteran did not submit any correspondence prior to April 23, 2014 indicating an intent to claim entitlement to service connection for bilateral hearing loss or tinnitus. 7. The Veteran’s claims of entitlement to service connection for bilateral hearing loss and tinnitus submitted on April 23, 2014 were claims to reopen previously denied claims, and not eligible for consideration under the Fully Developed Claims Program. CONCLUSIONS OF LAW 1. Hypertension was not incurred or aggravated in service, and it may not be presumed to have been so incurred. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309. 2. High cholesterol is not a disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 3. The criteria for a compensable initial rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.10, 4.85, Diagnostic Code 6100. 4. The criteria for a rating higher than 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.321, 4.87, Diagnostic Code 6260. 5. The criteria for entitlement to an effective date for the award of service connection for bilateral hearing loss prior to April 22, 2014 have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.151, 3.155, 3.158, 3.400. 6. The criteria for entitlement to an effective date for the award of service connection for tinnitus prior to April 22, 2014 have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.151, 3.155, 3.158, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran has verified active duty service from January 1986 to February 1990. Hypertension The Veteran has submitted a claim of entitlement to service connection for hypertension. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Under 38 C.F.R. § 3.303(b), service connection may be established by demonstrating continuity of symptomatology. Continuity may be established if a claimant can demonstrate (1) that a condition was “noted” during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. The provisions of 38 C.F.R. § 3.303(b) only apply to diseases recognized by VA as “chronic.” See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.309(a). Hypertension is a “chronic” disease for VA purposes. 38 U.S.C. § 1101. Chronic diseases that become manifest to a degree of 10 percent within one year of termination of active duty may be presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In this case, while the evidence shows that the Veteran has a current diagnosis of hypertension, the preponderance of the evidence does not indicate that the disorder began in service or that it was compensably disabling within one year of separation from active duty. Moreover, there is no medical evidence relating hypertension to his active duty service. A review of the Veteran’s service treatment records reveals that the appellant’s blood pressure was 110/90 on one occasion in January 1989. At no other time was the claimant’s blood pressure indicative of hypertension. See 38 C.F.R. § 4.104, Diagnostic Code 7101. At the Veteran’s separation examination his blood pressure was within normal limits. VA treatment records show that the Veteran has been diagnosed with hypertension and takes medication for the treatment of his high blood pressure. The Board is unable to find that entitlement to service connection is warranted. There is no evidence whatsoever of any in-service disease or injury that led to the later development of hypertension, and no probative and competent medical evidence suggesting that the Veteran’s hypertension is related to service. The Veteran has not indicated that he has ever been told by any medical professional that his hypertension was related to service. The Board also cannot grant entitlement to service connection for hypertension as a presumptive chronic disease, as the earliest medical evidence of record showing hypertension is from 2010, and the Veteran has not alleged that his hypertension was compensably disabling within a year of his separation from active duty. He has also not identified medical evidence which would show a diagnosis of hypertension to a compensable degree within that timeframe. The Veteran has not actually presented any argument regarding why he believes his hypertension is related to service. To the extent that his claim of entitlement to service connection for hypertension indicates that he believes the disorder to have been caused by his military service, his assertion does not constitute competent and probative medical evidence towards a nexus opinion. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, the Veteran’s assertions are not probative medical evidence towards such a complex question as the etiology of hypertension. In sum, the evidence preponderates against finding entitlement to service connection for hypertension. There are no probative medical opinions relating the Veteran’s hypertension to service, and no evidence indicating that hypertension began in service or that it was compensably disabling within one year of separation from active duty. As the preponderance of the probative and competent evidence weighs against the claim, it is denied. In reaching this determination, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the appellant’s claim, the doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). High Cholesterol The Veteran claims entitlement to service connection for high cholesterol. The Veteran’s service separation examination noted hypercholesterolemia, and VA treatment records show that he has high cholesterol, for which he takes medication and has been recommended to follow a low cholesterol diet. This condition, however, is not a disability in and of itself for which VA compensation benefits are payable. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (Diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities. They are, therefore, not appropriate entities for the rating schedule.). While high cholesterol may be evidence of underlying disability or may later cause disability, service connection may not be granted for a laboratory finding alone. A disability for VA compensation purposes refers to an impairment of earning capacity due to a disease or injury, rather than to a disease or injury itself. See Allen v. Brown, 7 Vet. App. 439 (1995). In this case, while there is evidence that the Veteran’s nonservice connected hypertension may have contributed to a prior stroke or other vascular disease, the Veteran has not presented any claim that these disorders are due to service to include due to high cholesterol. As high cholesterol is a laboratory result and does not represent a disability in and of itself, the Board finds that service connection must be denied. Increased Rating Bilateral Hearing Loss The Veteran claims entitlement to a compensable rating for bilateral hearing loss. Disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by puretone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85. To evaluate the degree of disability from defective hearing, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. §§ 4.85, Tables VI and VII, Diagnostic Code 6100. An exceptional pattern of hearing impairment occurs when the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). The Veteran attended a VA examination in August 2014. He reported missing certain sounds, like ringing phones, and having to listen to the television too loudly, which disturbed his neighbors. Puretone threshold testing showed the following results, in decibels:   HERTZ 1000 2000 3000 4000 Average RIGHT 25 35 60 85 51 LEFT 20 30 35 40 31 The average puretone thresholds were 51 decibels in the right ear and 31 decibels in the left ear. Speech audiometry revealed speech recognition ability of 94 percent in the left ear and 96 percent in the right ear. Applying the findings from the August 2014 examination to Table VI in 38 C.F.R. § 4.85 yields a finding of Level I hearing in both ears. Where hearing loss is at Level I in both ears, a noncompensable rating is assigned. Id. The Veteran’s VA treatment record do not show any treatment for hearing loss or any indication of hearing acuity levels which are worse than those shown at the VA examination. While the Veteran’s March 2011 examination noted a right ear hearing loss since service, physical evaluations in May 2014 and July 2015 were negative for any hearing loss or tinnitus. The Veteran has not indicated that he has received any private treatment for his hearing loss, and he has not indicated that his hearing loss has worsened since the August 2014 examination. The functional effects of hearing loss on the Veteran’s daily life activities and occupational functioning were discussed by the Veteran at his VA examinations and have been taken into consideration by VA. See 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007). The Veteran has reported having trouble hearing certain sounds and the television; this is reflective of the types of functional difficulty that would be expected to be caused by a hearing loss, but is not indicative that a compensable rating would be warranted. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (Manifestations such as difficulty hearing sounds are the types of difficulties contemplated by the schedular criteria for hearing loss.). Accordingly, the August 2014 VA examination of record is sufficiently in compliance with the provisions of VA regulations, and it is assigned great probative value in determining the Veteran’s level of hearing impairment. The most probative medical evidence as to the nature of the appellant’s hearing loss are the audiometric findings, and those discussed above reveal that the Veteran’s hearing loss does not warrant a compensable rating. The noncompensable rating is continued. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; the preponderance of the evidence is against the Veteran’s claim, and the doctrine is not applicable. 38 U.S.C. § 5107(b). Lastly, the Board notes that the question of entitlement to referral for consideration of an extraschedular rating is neither an issue argued by the claimant nor reasonably raised by the record through evidence of the collective impact of the claimant’s service-connected disabilities, and will not be discussed at this time. Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). Tinnitus The Veteran has also requested an increased rating for tinnitus. At an August 2014 VA examination, the Veteran reported that his tinnitus began while he was still in service. The examiner found that the Veteran’s tinnitus did not impact the ordinary conditions of daily life, including the ability to work. Tinnitus is evaluated under the criteria of 38 C.F.R. § 4.87, Diagnostic Code 6260, which provides that a single 10 percent rating is assigned for tinnitus, whether the sound is perceived as being in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note 2. The Veteran is already assigned a 10 percent evaluation, which is the maximum scheduler evaluation for tinnitus. As such, he is not entitled to any higher schedular rating for his tinnitus. The Veteran has not identified any additional symptoms associated with tinnitus for which he believes a separate rating or extraschedular rating would be warranted. There is no indication in the Veteran’s VA treatment records that he has any additional symptoms relating to tinnitus, and in May 2014 and July 2015 evaluations, the Veteran’s system was negative for any tinnitus. The symptoms of the claimant’s tinnitus are manifested by ringing in the ears, and those symptoms are accurately reflected by the schedular criteria. Without any evidence reflecting that the Veteran’s disability picture is not sufficiently contemplated by the rating schedule, referral for a determination of whether his disability picture requires the assignment of an extraschedular rating is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). The record before the Board does not suggest that tinnitus requires frequent hospitalization or causes a marked interference with employment or otherwise suggests that referral for an extraschedular consideration under 38 C.F.R. 3.321 is indicated. The claim is denied. Earlier Effective Date In September 2010, the Veteran submitted claims of entitlement to service connection for hearing loss and tinnitus. The Veteran submitted a letter stating that he had served as a marksmanship instructor in the Marine Corps from 1987 to 1990 and that he now had hearing loss and ringing in his ears. In a June 2011 rating decision, entitlement to service connection for bilateral hearing loss and tinnitus was denied. The rating decision stated that the Veteran had reported having military noise exposure, but there was then no evidence of a current hearing loss disability and no evidence in the medical records of any complaints or diagnoses of tinnitus. The rating decision noted that they had scheduled a VA examination for the Veteran in June 2011, but he did not attend the examination and did not contact VA with an explanation for missing the appointment. The Veteran did not submit a timely notice of disagreement with this decision, and it is final. See 38 U.S.C. § 7105(b),(d); 38 C.F.R. §§ 20.204, 20.302, 20.1103. On April 23, 2014, the Veteran submitted a new claim of entitlement to service connection for hearing loss and tinnitus. After receiving positive nexus opinions from a VA examiner in August 2014, the claims of entitlement to service connection for hearing loss and tinnitus were granted in a September 2014 rating decision. A previously denied claim may be reopened by the submission of new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. While VA found that there was adequate evidence to reopen and grant the claim in the September 2014 rating decision, the June 2011 rating decisions remains final, and cannot be considered as a basis for assigning an earlier effective date absent a finding of clear and unmistakable error in that decision. As the Veteran has not alleged any clear and unmistakable error in the June 2011 rating decision, and there is no indication that this decision is still pending for any reason, the decision is final and an effective date prior to April 22, 2014 cannot be assigned. See id. The effective date for direct service connection is the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service; otherwise, it will be the date of receipt of the claim, or date entitlement arose, whichever is the later. 38 C.F.R. § 3.400(b)(2)(i). The statutory and regulatory provisions in effect at the time that the Veteran submitted his 2010 claim required that VA look to all communications from the appellant, which may be interpreted as applications or claims—formal and informal—for benefits. In particular, VA was required to identify and act on informal claims for benefits. 38 U.S.C. § 5110(b)(3); 38 C.F.R. §§ 3.1(p), 3.155(a) (2010); see Servello v. Derwinski, 3 Vet. App. 196 (1992). In this case, after the June 2011 rating decision, no correspondence was received from the Veteran which could be construed as a formal or informal claim for benefits prior to his April 23, 2014 claim. The Veteran also has not asserted that he actually submitted a claim prior to that date or that any tinnitus or hearing loss claims had been pending. The Board acknowledges that VA must liberally construe all documents filed by a claimant. See EF v. Derwinski, 1 Vet. App. 324, 326 (1991). In this case, however, there are no documents submitted by the Veteran which could constitute a claim of entitlement to service connection for bilateral hearing loss or tinnitus, and the appellant has not identified any correspondence which he believes constitutes an earlier claim. The Veteran’s attorney has also argued that under Public Law 112-154, which allowed that when a Fully Developed Claim was submitted between August 5, 2013 and August 6, 2015, an effective date of one year prior to the date of filing could be awarded. The attorney therefore requests an effective date of April 22, 2013. The claim submitted by the Veteran in April 2014 was on a Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, which included notice that the claim could be considered under the Fully Developed Claim Program. According to 38 U.S.C. § 5110(b)(2)(A), “The effective date of an award of disability compensation to a veteran who submits an application therefor that sets forth an original claim that is fully-developed (as determined by the Secretary) as of the date of submittal shall be fixed in accordance with the facts found, but shall not be earlier than the date that is one year before the date of receipt of the application.” An “original claim is an initial claim filed by a veteran for disability compensation.” 38 U.S.C. § 5110(b)(2)(B). The law is very clear that the Fully Developed Claims program is intended to apply to initial claims only. It does not apply to requests to reopen claims that were previously denied. 38 U.S.C. § 5110(b)(2); see also M21-1 Adjudication Procedures Manual, III.i.3.B.4.a. The Board is therefore unable to assign the Veteran an effective date of one year prior to April 22, 2014, because his claims pertaining to hearing loss and tinnitus were not initial claims for benefits. As such, they were not eligible for consideration under the Fully Developed Claims Program. In sum, there is no pending or valid claim that can permit assigning an effective date earlier than April 22, 2014 for the awards of service connection for bilateral hearing loss and tinnitus. The Board is bound by applicable regulations regarding when an effective date may be assigned. In the absence of any claim, either formal or informal, of entitlement to service connection for hearing loss or tinnitus since June 2011 and prior to April 2014, there is no basis under law to assign an earlier effective date, and the claims must be denied. See Sabonis v. Brown, 6 Vet. App. 426 (1994). REASONS FOR REMAND Acquired Psychiatric Disorder The Veteran’s VA treatment records show that he has been diagnosed with depressive disorder. He also shows some traumatic brain injury/stroke residuals which affect his psychiatric and cognitive functioning. At an April 2010 social worker evaluation, the Veteran was found to have depression, mood swings, and sleep disturbance related to a recent stroke. The Veteran has submitted a July 2016 Disability Benefits Questionnaire and an October 2016 evaluation from psychologist H.H. which diagnose a depressive disorder due to another medical condition. The psychologist wrote that the Veteran’s depressive disorder was emotionally debilitating, and was secondary to medical conditions and social impairment. She wrote that the Veteran’s psychiatric disorder was affected by the claimant’s sleep impairment and physical limitations, and that “tinnitus and bilateral hearing loss, in turn, continue to manifest as a depressive disorder.” She concluded that the Veteran’s tinnitus and hearing loss more likely than not caused the claimant’s depressive disorder. Unfortunately, the evaluations from H.H. do not appear to be consistent with the Veteran’s medical records and documented medical history. VA treatment records clearly show that the Veteran stopped working after he had a hemorrhagic stroke at age 45. The stroke caused the Veteran to lose fine motor control of his hands, making writing more difficult, and caused psychiatric and cognitive impairment. The Veteran’s depression has been attributed to his stroke residuals on multiple occasions, and at no time has the claimant complained of hearing loss or tinnitus in his VA psychiatric care. The Board therefore remands this issue in order to obtain a VA examination to address the etiology of any diagnosed psychiatric disorder and its relationship to service and to any service-connected disabilities. Sleep Apnea The Veteran has submitted an October 2016 Disability Benefits Questionnaire from physician H.S. which stated that the claimant’s sleep apnea was more likely than not partially caused by and then aggravated by his depressive disorder. Because the Veteran’s claim of entitlement to service connection for an acquired psychiatric disorder, to include depressive disorder, is being remanded, this issue is intertwined with the preceding issue and must be deferred. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue may have a “significant impact” upon another, the two claims are inextricably intertwined). Total Disability Rating Based on Individual Unemployability The October 2016 evaluation from psychologist H.H. stated that the Veteran’s hearing loss and tinnitus caused a depressive disorder, and that together, these disabilities prevent the claimant from maintaining substantially gainful employment. Although the Veteran has not yet submitted a formal claim of entitlement to a total disability rating based on individual unemployability, when entitlement to a total disability rating is raised in connection with an increased rating claim for one or more of those service-connected disabilities, the Board has jurisdiction over the issue because it is part of the claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). This issue is therefore remanded in order to provide the Veteran with adequate notice regarding this claim and the opportunity to provide additional information regarding his history of employment. The matter is REMANDED for the following action: 1. Obtain all available records from the Tennessee Valley Healthcare System in Nashville and the Alvin C. York Murfreesboro Campus since February 2016. If any such records cannot be located, specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. Then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 2. Provide the Veteran with another opportunity to submit a completed release form (VA Form 21-4142) authorizing VA to request any additional, relevant private treatment records. The Veteran should be advised that he can also submit those records himself, including any private evaluations he has attended. If the Veteran provides a completed release form, then request the identified treatment records. At least two attempts should be made to obtain any records, and all attempts to secure those records must be documented in the Veteran’s claims file. He and his attorney should be notified of any unsuccessful efforts 3. After completing directives one and two, schedule the Veteran for a VA psychiatric examination with a psychiatrist or psychologist to determine the nature and etiology of any diagnosed psychiatric disorder. The examiner must be provided access to all files in Veteran’s VBMS and Virtual VA/Legacy files, and must specify in the report that these files have been reviewed. The examiner is to provide a detailed review of the Veteran’s pertinent medical history, current complaints, and the nature and etiology of any diagnosed psychiatric disability. The examiner must then address: What are the Veteran’s current psychiatric diagnoses? For each and every diagnosed psychiatric disorder, address whether it is at least as likely as not that the disorder had its onset during or is related to the Veteran’s active military service. For each and every diagnosed psychiatric disorder address whether it is at least as likely as not that the disorder (i) was caused or (ii) is aggravated (worsened beyond the natural progression) by the Veteran’s tinnitus and bilateral hearing loss. Please discuss the July and October 2016 evaluations from private psychologist H.H. which state that the Veteran’s depression is secondary to his hearing loss and tinnitus, as well as the VA treatment records showing depression and cognitive impairment following a stroke. A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed. 4. If, and only if, it is determined that an acquired psychiatric disorder is due to service, or if it is determined that an acquired psychiatric disorder is caused or aggravated by a service connected disorder, then the appellant must be scheduled for a VA examination by a sleep specialist. The examiner must be provided access to all files in Veteran’s VBMS and Virtual VA/Legacy files, and must specify in the report that these files have been reviewed. The examiner is to provide a detailed review of the Veteran’s pertinent medical history, current complaints, and the nature and etiology of any diagnosed sleep disorder. The examiner must then address whether it is at least as likely as not that any diagnosed sleep disorder is caused by hearing loss and tinnitus. The examiner must also address the role, if any, that an acquired psychiatric disorder played in the development of any diagnosed sleep disorder. A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed. 5. Thereafter, conduct all necessary development and then adjudicate the issue of entitlement to a total disability rating based on individual unemployability. Notify the appellant and his attorney of VA’s duties to notify and assist in the development of that claim and provide him with a VA Form 21-8940. The Veteran should be specifically asked to provide information regarding the date that he stopped working full time and whether he is currently employed in gainful employment. DEREK R. BROWN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Mary E. Rude, Counsel