Citation Nr: 18154413 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 16-45 365 DATE: November 29, 2018 ORDER New and material evidence having been received, the claim for service connection for obstructive sleep apnea is reopened. New and material evidence having been received, the claim for service connection for hypertension is reopened. Service connection for gastroesophageal reflux disease (GERD) is denied. A rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for obstructive sleep apnea, to include as secondary to PTSD, is remanded. Entitlement to service connection for hypertension, to include as secondary to PTSD, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to PTSD, is remanded. FINDINGS OF FACT 1. A June 2013 rating decision denied service connection for hypertension and for a sleep disorder; the Veteran was notified of the rating action and of his appellate rights. The Veteran did not perfect an appeal on this issue, and new and material evidence was not submitted within one year of the decision. 2. The evidence received since the June 2013 rating decision relates to unestablished facts necessary to substantiate the claims for service connection for hypertension and for a sleep disorder, and raises a reasonable possibility of substantiating the claims. 3. The Veteran’s GERD is a condition with a known clinical diagnosis and is not etiologically related to the Veteran’s active service. 4. Throughout the appeal period, the Veteran’s service-connected PTSD has not caused occupational and social impairment, with deficiencies in most areas; or worse. CONCLUSIONS OF LAW 1. The June 2013 rating decision that denied service connection for hypertension and for a sleep disorder is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2012). 2. New and material evidence has been received to reopen the previously denied claims for service connection for hypertension and for a sleep disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for service connection for GERD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 4. The criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from January 1988 to January 1992, to include service in the Southwest Asia Theater of Operations during the Persian Gulf War. New and Material Evidence Generally, a final decision issued by the agency of original jurisdiction may not thereafter be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. § 7105(c), (d)(3). However, if new and material evidence is presented or secured with respect to a claim that has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. Here, the claims for service connection for hypertension and for service connection for a sleep disorder were most-recently finally denied in a June 2013 rating decision, both on the basis that there was no medical evidence linking the conditions to active service. The June 2013 rating decision became final. The pertinent evidence received since the June 2013 denial includes private medical nexus opinions from the Veteran’s mental health provider linking the Veteran’s hypertension and sleep apnea to his service-connected PTSD. This newly submitted evidence pertains to a medical nexus between the conditions and a service-connected disability, which is an unestablished fact necessary to substantiate the claims. Thus, as this evidence was also not previously reviewed by adjudicators, these opinions constitute both new and material evidence. Thus, new and material evidence has been received, and the claims for service connection for hypertension and for a sleep disorder are reopened. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Further, service connection may be awarded on a presumptive basis to a Persian Gulf veteran who (1) exhibits objective indications; (2) of a chronic disability such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and (4) such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. Gutierrez v. Principi, 19 Vet. App. 1, 7 (2004); 38 U.S.C. § 1117; 38 C.F.R. § 3.317; 76 Fed. Reg. 81834 -81836 (Dec. 29, 2011). Objective indications of a chronic disability include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(3-4) Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b). In addition to certain chronic disabilities from undiagnosed illness, service connection may also be given for medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases)) that is defined by a cluster of signs and symptoms, as well as for any diagnosed illness that the VA Secretary determines by regulation warrants a presumption of service connection. 38 C.F.R. § 3.317 (a)(2)(i)(B). The Veteran is seeking service connection for GERD, which he has claimed should be presumptively service-connected due to his Gulf War service, specifically as a functional gastrointestinal disorder which falls in the category of a medically unexplained chronic multi-symptom illness. As previously noted above, the evidence of record reflects that the Veteran served in the Southwest Asia Theater of Operations after August 2, 1990, is therefore a Persian Gulf veteran, and thus is eligible for establishment of service connection for those qualifying chronic disabilities that became manifest during service or to a degree of 10 percent or more not later than December 31, 2021. The Veteran’s gastrointestinal symptoms, having formally been diagnosed as GERD, are not chronic symptoms of an undiagnosed illness. Such was confirmed by an August 2018 VA examiner who stated that the Veteran’s GERD was a disease with a clear and specific etiology and diagnosis. Further, in July 2018, the Court of Appeals for Veterans Claims (Court) held that GERD does not qualify as a medically unexplained chronic multi-symptom illness (MUCMI) under 38 C.F.R. §3.317. Atencio v. O’Rourke, 30 Vet. App. 74 (2018). In arriving at this conclusion, the Court reasoned that GERD is a structural gastrointestinal disease, which is explicitly excluded from being a MUCMI under § 3.317(a)(2)(i)(B)(3), and that the subsequent definition of MUCMIs in § 3.317(a)(2)(ii) cannot be used to circumvent that exclusion. Id. at 86-7. Therefore, a presumptive service connection for GERD as related to the Veteran’s service in the Persian Gulf is not warranted, as GERD is neither an undiagnosed illness nor a MUCMI. 38 C.F.R. §3.317. Regarding a direct service connection for the Veteran’s GERD, the Veteran’s service treatment records are silent as to any complaints of, treatment for, or diagnosis of a gastroesophageal condition. At his December 1991 separation physical, the Veteran was not noted as having any gastroesophageal symptoms or disorders. Further, the Veteran’s post-service medical records indicate that he was first diagnosed with GERD in 2008, more than 15 years after separating from service. Moreover, when the Veteran first sought VA medical treatment for his gastroesophageal symptoms in December 2008, he reported the symptoms having onset only six months prior. Thus, there is no evidence that the condition was onset during service, or for many years after the Veteran separated from service. As stated above, the Veteran has been diagnosed with GERD; hence the current disability prong of his claim is established. The Veteran has not identified, nor have his service treatment records revealed, any injury or disease suffered in service to which his GERD could be linked. However, as a Persian Gulf Veteran, he is presumed to have been exposed to environmental hazards while serving in Southwest Asia, and such exposure constitutes an in-service element to which his condition could be directly linked. As concerning a medical nexus linking GERD to an in-service environmental hazard exposure, the Veteran was afforded a VA examination in August 2018 to address this. The August 2018 VA examiner found that the Veteran’s GERD was less likely than not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. In support of this conclusion, the examiner stated that reputable literature sources do not support southwest Asia exposures, toxic agents, environmental or wartime hazard, or preventative medication or vaccines causing GERD. Further, she explained that, per the predominance of medical literature, GERD was a condition in which the stomach contents, including stomach acid, escape the stomach and reflux up into the esophagus. Normally, reflux is prevented by the lower esophageal sphincter, but certain things, such as alcohol use, obesity, indigestion, and eating immediately before bed, can cause this sphincter to relax, allowing the acid to reflux. There are no medical opinions of record which counter the August 2018 VA examiner’s negative nexus opinion regarding a relationship between the Veteran’s GERD and his service; nor has any medical evidence been submitted which purports to link the condition to any other element of the Veteran’s service. Thus, the Veteran’s claim for service connection for GERD fails for lack of a medical nexus. The Board notes that lay persons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, as to the etiology of gastroesophageal disabilities like GERD, the issue of causation of such a medical condition is a medical determination outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, although the Board has carefully considered the lay contentions of record suggesting that the Veteran’s GERD is related to his service, the Board has not uncovered any credible medical evidence which supports such a connection and the Veteran lacks the medical expertise to competently determine the etiology of his GERD. As described, the record does not support a finding that the Veteran’s GERD was onset in service or that it is medically linked to any element of service. Further, GERD is not a condition for which a presumptive service connection for Persian Gulf War service is allowed. Therefore, service connection is not warranted on any basis for the Veteran’s GERD, and the claim is denied. Increased Rating The Veteran was granted service connection for PTSD in a June 2010 rating decision, with a 50 percent rating assigned November 29, 2007, the day the Veteran’s claim for service connection was received. The Veteran did not perfect an appeal on this initial rating. In September 2012, the Veteran filed a claim for an increased rating for his PTSD. The Veteran’s service-connected PTSD is currently rated under Diagnostic Code 9411. Psychiatric disorders, however diagnosed, are rated under the General Rating Formula for Mental Disorders, and the criteria under this formula shall be considered no matter which diagnostic code is assigned. Under the General Rating Formula for Mental Disorders, a 50 percent evaluation is assigned when a psychiatric disability causes 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; or difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is assigned when a psychiatric disability causes 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); or an inability to establish and maintain effective relationships. A 100 percent rating is assigned when a psychiatric disability causes total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; danger of hurting self or others; intermittent inability to perform activities of living (including maintenance of minimal hygiene); disorientation to time or place; or, memory loss for names of close relatives, occupation, or own name. Id. When rating a mental disorder, VA must consider the frequency, severity, and duration of the Veteran’s psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The rating agency must assign a rating based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. When rating the level of disability from a mental disorder, the rating agency must consider the extent of social impairment, but cannot assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is the Veteran’s symptoms, but it must also make findings as to how those symptoms impact the Veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442. Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Here, the evidence of record does not establish that the Veteran’s psychiatric disability caused occupational and social impairment with deficiencies in most areas, much less total occupational and social impairment, at any time during the appeal period. The Veteran was afforded a VA PTSD examination in February 2013. The examiner noted that the Veteran had diagnoses of PTSD, alcohol abuse, and cannabis abuse, and found that it was possible to differentiate which symptoms were attributable to each diagnosis. The examiner noted that the symptoms of PTSD included insomnia, recurrent recall of traumatic incidents, hypervigilance, and nightmares. The symptoms of alcohol abuse included recurrent use of alcohol despite adverse physical and social consequences; and the symptoms of cannabis abuse included dependence on cannabis despite adverse social and medical consequences. The examiner found that the Veteran’s mental diagnoses resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran reported that he had been working full-time for a metal company hauling metal for the previous three years. He reported having a difficult time getting along with people, but disclosed that he was living with his girlfriend of four years. The examiner noted that the Veteran’s PTSD resulted in the following symptoms: anxiety, suspiciousness, and chronic sleep impairment. The examiner also observed that the Veteran was oriented to time, place, person, and purpose of the interview. He was dressed in jeans, a dress shirt, and cap, and spoke loudly and dramatically. The examiner found that the Veteran had a goal-directed thought process, fair memory for remote and recent events, fair abstract thinking, and an age-appropriate fund of information and general knowledge. The examiner stated the Veteran did not have any delusions, hallucinations, depressive symptoms, or obsessive-compulsive features, and was not suicidal or homicidal. The examiner also noted that he appeared well-developed and well-nourished, despite looking rather aloof. The examiner further remarked that the Veteran’s prognosis was guarded to poor, and his impairment was moderate. He did not appear to pose any threat of danger or injury to himself or others and was capable of managing his financial affairs. The Veteran submitted a written witness statement in March 2013 from M.T., who claimed to have known the Veteran for five years. M.T. wrote that she feared his irritable attitude and outbursts of anger. She wrote that the Veteran spoke about his upsetting memories, smells, nightmares and inability to sleep through the night. She further reported that he abused alcohol daily, causing his anger and outbursts to intensify. He was not easily calmed and did not make rational decisions. She felt he was a very untrusting person due to his PTSD and that he was a “ticking-time bomb,” often becoming disrespectful and threatening when plans did not come together as he had designed them. The Veteran submitted a written statement in June 2013 in support of his claim and in opposition to the RO proposing to reduce his PTSD evaluation from 50 percent to 30 percent. He stated that he felt his PTSD had worsened in severity, and disagreed with the recent VA examiner’s findings. He requested a new VA examination and stated that he felt the examiner did not do an in-depth evaluation. He denied having told the examiner that he smoked marijuana or that he did not get along with others. He also wrote that he was experiencing disturbances of motivation and mood and he was having memory issues that were affecting his productivity at work. The Veteran submitted a written notice of disagreement with his PTSD evaluation in April 2016. He wrote that his condition should be rated at 70 or 100 percent disabling, as his private psychiatric provider noted his condition caused severe impairment in several areas of functioning. He also cited to Cohen v. Brown, 10 Vet. App. 128, 140 (1997), and wrote that mental health professionals are experts and presumed to know the DSM requirements applicable to their practice and to have taken them into account in providing a PTSD diagnosis. As indicated in the Veteran’s notice of disagreement, he treated with a private psychiatrist for his mental health, beginning in April 2016. These treatment records are associated with the claims file, and include a thorough April 2016 initial intake assessment, in which the Veteran denied having any friends or romantic relationships. He had been married previously, but divorced in 2007. He reported having a good relationship with his children, whom he saw three times a week, and he communicated with them regularly. He also reported being close to his mother, with whom he lived. The Veteran disclosed having been charged in 2011 for assaulting a man, resulting in him spending two days in jail. He also told the provider that he spent eight days in jail in 2015 for anger outbursts with an ex-significant other, but no charges were filed against him at that time. The provider found that the Veteran appeared anxious and restless with a blunted affect and some psychomotor retardation. The Veteran was cooperative and answered questions appropriately without being spontaneous. His speech was not abnormal. The Veteran reported symptoms of anxiety, depression, and hyperarousal, and displayed an affect congruent to his mood. He denied experiencing delusions or hallucinations of any sort. His thought process did not show looseness of association or flight of ideas, but he did have some thought blocking and delayed thoughts. The Veteran reported mistrusting people generally and being uncomfortable in crowds. He reported having memory issues but was found to be alert and oriented throughout the assessment. The provider concluded that the Veteran had a major impairment in several areas of functioning, including work and house work. The Veteran reported not getting along with his supervisor or co-workers prior to having recently been fired from his job as a truck-driver for working off the clock. The provider stated the Veteran was impaired in relationships, both with friends and romantically, and felt he was always on edge and easily angered. The Veteran had reported overwhelming feelings of fear and anxiety, to the point where he could not function, and said that he always had to check his home and parameters for safety. Subsequent private treatment records did not show the Veteran reporting more severe symptoms than shown at the April 2016 assessment. The Veteran’s VA treatment records also contained psychiatric treatment during the appeal period, but did not contain evidence of an overall worsening of the Veteran’s psychiatric symptomatology at any time. Of note, the Veteran told a VA treatment provider on October 2, 2013 that he was depressed and worried he was hearing voices, but could not make out what they were saying. He also reported his PTSD symptoms had increased in severity on November 13, 2014, but reported the symptoms were only nightmares and anxiety (which were symptoms that were already of record as having resulted from his PTSD). After taking a hiatus from VA mental health care, the Veteran returned in March 2016 for a PTSD clinical psychiatric intake visit. He disclosed that he had struck his ex-girlfriend’s mother in 2012 after she had struck him. He also reported having been fired from his job in January 2016 because his employer thought he was working off the clock. Further, he stated that he had relocated in July 2015 to Henderson, NC, where he was currently living with his mother. In April 2016, he began participating in VA group therapy for PTSD. Overall, while VA treatment records may have revealed new some new evidence of psychiatric symptoms not disclosed elsewhere in the record, they did not show that the Veteran’s psychiatric symptoms were more severe than indicated at the February 2013 VA examination or April 2016 private psychiatric assessment. As described, the Veteran has clearly experienced psychiatric symptomatology as a result of his service-connected PTSD. However, the totality of the record does not establish that the Veteran’s service-connected psychiatric symptomatology resulted in occupational and social impairment with deficiencies in most areas, much less total occupational and social impairment To the contrary, the 2013 VA examiner determined that the Veteran’s psychiatric symptomology resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. As previously discussed, this is actually the specific criteria listed in the Diagnostic Code for a 30 percent rating, a rating lower than that which the Veteran has been assigned. Moreover, the Veteran has never been shown to evidence most of the symptoms severe enough to warrant a 70 percent rating, including suicidal ideations; obsessional rituals which interfere with routine activities; illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklife setting); or an inability to establish and maintain effective relationships. Although the reported instances of physical violence in the appeal period could be considered as impaired impulse control, which is explicitly contemplated by the 70 percent schedular rating criteria, it cannot be said that the total picture of the Veteran’s psychiatric symptomatology more closely approximate a 70 percent rating than a 50 percent rating. Moreover, a 50 percent rating does specifically include symptoms that include impaired judgment. Further, in 2013, the Veteran disclosed being in a four-year relationship with his girlfriend, with whom he resided. Although that relationship ended during the appeal period, the Veteran reported having good relationships with his children and being close with his mother at his April 2016 psychiatric assessment. While the Veteran also reported not having friends, difficulty in establishing and maintaining effective social relationships is contemplated by his current 50 percent rating. Conversely, a 70 percent rating contemplates an inability to establish and maintain effective relationships, which is clearly not the case as evidenced by the relationships described above. As such, the criteria for a 70 percent rating for the Veteran’s acquired psychiatric disorder have not been shown. Furthermore, the Veteran remained employed until being fired in 2015 for working off the clock, a situation which is not shown to have been a result of his psychiatric symptomatology. Thus, the record does not reflect that his psychiatric symptoms have rendered him totally occupationally impaired. The Veteran has consistently disclosed having relationships with others throughout the appeal period. Thus, it also has not been shown that he is totally socially impaired. As such, the Veteran experiences neither total occupational impairment nor total social impairment due to his psychiatric symptomatology, much less both total occupational and total social impairment, as would be required for a rating in excess of 70 percent for a psychiatric disorder. The Board also acknowledges the Veteran’s statements that his PTSD symptoms are of such severity as to warrant an increased evaluation. The Veteran, as a lay person, is competent to report some things, including symptoms of his PTSD that come to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Disability ratings, however, are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. Therefore, the Board finds that the medical findings, which directly address the criteria under which the disability is evaluated, are more probative than the Veteran’s assessments of the severity of his PTSD. Accordingly, the Veteran is not entitled to a rating in excess of 50 percent for his PTSD. To the extent the Veteran raised objections to the February 2013 VA examination or stated his symptoms were more severe than the VA examiner reported, the Board finds that a new VA examination is not warranted. Although the Veteran argued and mentioned in VA treatment records around that time that his PTSD symptoms had worsened, the Veteran subsequently submitted a private psychiatric assessment, which the Board has considered for the severity of the Veteran’s symptoms. The Veteran, himself, presented an argument in his notice of disagreement that his private psychiatric provider is apprised of the DSM requirements for assessing PTSD, endorsing his competence to assess the Veteran’s condition. Further, the private psychiatric assessment did not support a rating higher than the Veteran has been assigned throughout the appeal period. Thus, the Board is satisfied that there is sufficient evidence of record portraying the level of the Veteran’s symptomatology throughout the period on appeal, and the Veteran has not submitted evidence of symptoms worse than shown on VA examination and private assessment, or any other evidence indicating otherwise. REASONS FOR REMAND 1. Service connection for obstructive sleep apnea, hypertension, and erectile dysfunction are remanded. As to service connection for the Veteran’s obstructive sleep apnea, hypertension, and erectile dysfunction, the Veteran submitted private nexus opinions dated April 2016 from his private psychiatrist relating the conditions to the Veteran’s service-connected PTSD. Specifically, the provider opined that all three conditions were at least as likely as not aggravated by the Veteran’s PTSD. However, the provider did not provide a baseline level of severity of the conditions prior to aggravation. VA will not concede aggravation unless the baseline level of the non-service connected disability is established by medical evidence created before the onset of aggravation or by the earliest evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of non-service connected disease or disability. Thus, more information is needed before the Board can decide these claims. Specifically, new VA examinations are necessary to obtain opinions of the severity of the conditions before and after aggravation by the Veteran’s service-connected PTSD. Further, the Veteran was afforded VA examinations in July 2016 to address the etiologies of his sleep apnea, hypertension, and erectile dysfunction. Although the 2016 VA examiner opined against the conditions having been aggravated by the Veteran’s PTSD, the examiner used the incorrect legal standard for aggravation due to a service-connected condition. Thus, on remand, the VA examiners must also ensure to provide opinions as to whether the conditions were made worse by the service-connected PTSD, and not whether they were aggravated beyond their natural progressions. The matters are REMANDED for the following action: 1. Schedule the Veteran for a sleep apnea examination. The examiner should provide the following opinions: (a.) Is it at least as likely as not (50 percent or greater) that the Veteran’s obstructive sleep apnea either began during or was otherwise caused by the his military service? Why or why not? (b.) Is it at least as likely as not (50 percent or greater) that the Veteran’s obstructive sleep apnea was caused by his service-connected PTSD? Why or why not? (c.) Is it at least as likely as not (50 percent or greater) that the Veteran’s obstructive sleep apnea was aggravated (made worse) by his service-connected PTSD? Why or why not? In rendering this opinion, the examiner should address the April 2016 opinion from Dr. H.J., MD, the Veteran’s mental health provider, suggesting that the Veteran’s service-connected PTSD aggravated his sleep apnea. If aggravation is found, the examiner should identify a baseline level of severity of the sleep apnea by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the sleep apnea. If such cannot be done, it should be explained why. The examiner should also discuss the relevance, if any, of medical literature submitted by the Veteran, associated with the claims file and located in VBMS in a document labeled “NOD” dated September 19, 2016, which he asserts provides further support for a relationship between his sleep apnea and his PTSD. 2. Schedule the Veteran for a hypertension examination. The examiner should provide the following opinions: (a.) Is it at least as likely as not (50 percent or greater) that the Veteran’s hypertension either began during or was otherwise caused by the Veteran’s military service? Why or why not? (b.) Is it at least as likely as not (i.e., a likelihood of 50 percent or greater) that the Veteran’s hypertension was manifested to a compensable degree within one year of his separation from active service? Why or why not? (c.) Is it at least as likely as not (50 percent or greater) that hypertension was caused by his service-connected PTSD? Why or why not? (d.) Is it at least as likely as not (50 percent or greater) that the Veteran’s hypertension was aggravated (made worse) by his service-connected PTSD? Why or why not? In rendering this opinion, the examiner should address the April 2016 opinion from Dr. H.J., MD, the Veteran’s mental health provider, suggesting that the Veteran’s service-connected PTSD aggravated his hypertension. If aggravation is found, the examiner should identify a baseline level of severity of the hypertension by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the hypertension. If such cannot be done, it should be explained why. The examiner should also discuss the relevance, if any, of medical literature submitted by the Veteran, associated with the claims file and located in VBMS in a document labeled “NOD” dated September 19, 2016, which he asserts provides further support for a relationship between his hypertension and his PTSD. 3. Schedule the Veteran for an erectile dysfunction examination. The examiner should provide the following opinions: (a.) Is it at least as likely as not (50 percent or greater) that the Veteran’s erectile dysfunction either began during or was otherwise caused by the Veteran’s military service? Why or why not? (b.) Is it at least as likely as not (50 percent or greater) that the Veteran’s erectile dysfunction was caused by his service-connected PTSD, including any medication used to treat his PTSD? Why or why not? (c.) Is it at least as likely as not (50 percent or greater) that the Veteran’s erectile dysfunction was aggravated (made worse) by his service-connected PTSD, including any medication used to treat his PTSD? Why or why not? In rendering this opinion, the examiner should specifically address the April 2016 opinion from Dr. H.J., MD, the Veteran’s mental health provider, suggesting that the Veteran’s service-connected PTSD and medications used to treat his PTSD aggravated his erectile dysfunction. If aggravation is found, the examiner should identify a baseline level of severity of the erectile dysfunction by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the erectile dysfunction. If such cannot be done, it should be explained why. The examiner should also discuss the relevance, if any, of medical literature submitted by the Veteran, associated with the claims file and located in VBMS in a document labeled “NOD” dated September 19, 2016, which he asserts provides further support for a relationship between his erectile dysfunction and his PTSD. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Davidoski, Associate Counsel