Citation Nr: 18154943 Decision Date: 12/03/18 Archive Date: 11/30/18 DOCKET NO. 18-31 528 DATE: December 3, 2018 ORDER Entitlement to service connection for cervical spine degenerative changes is denied. Entitlement to service connection for hypotension is denied. Entitlement to service connection for tinnitus is denied. Entitlement to a 100 percent rating for bipolar disorder with unspecified anxiety disorder is granted subject to the law and regulations governing the award of monetary benefits. REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a sleep disorder is remanded. Entitlement to service connection for a disability to account for memory loss is remanded. Entitlement to service connection for depression is remanded. FINDINGS OF FACT 1. The Veteran does not have cervical spine degenerative changes that is due to disease or injury in service. 2. The Veteran does not have hypotension that is due to disease or injury in service. 3. The Veteran does not have tinnitus that was incurred in or a result of active military service, or manifested within one year from the date of separation. 4. The evidence is at least evenly balanced as to whether the symptoms and overall impairment caused by the Veteran’s psychiatric disability more nearly approximated total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for cervical spine degenerative changes are not met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for hypotension are not met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303 3. The criteria for service connection for tinnitus have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.309. 4. With reasonable doubt resolved in favor of the Veteran, the criteria for a 100 percent rating for bipolar disorder have been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 2004 to April 2005. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran timely appealed the denials of his claims for service connection and an increased rating. In September 2018, the Veteran submitted additional medical evidence along with a waiver of RO consideration. Therefore, a remand for the RO to review the evidence in the first instance is not necessary. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The requirement that a current disability exist is satisfied if the claimant had a disability at the time his claim for VA disability compensation was filed or during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). See also Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013) (Board erred in failing to address pre-claim evidence in assessing whether a current disability existed, for purposes of service connection, at the time the claim was filed or during its pendency). Lay persons may provide evidence of diagnosis and nexus under 38 U.S.C. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In relevant part, 38 U.S.C. § 1154(a) (2012) requires that VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). “[L]ay 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.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (“[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence”). 1. Entitlement to service connection for cervical spine degenerative changes The Veteran contends that his diagnosed cervical spine disability is related to or was incurred during service. Service treatment records (STRs) do not reflect any complaints, treatments, or diagnoses of cervical spine problems. Post-service treatment records reflect a diagnosis of mild multilevel degenerative changes in the cervical spine in May 2012. In July 2015, the Veteran reported that he had been in motor vehicle accidents (MVAs) in 2008 and 2015, and that he experienced chronic neck pain. Based on the evidence of record, the Board finds that service connection for a cervical spine disability is not warranted. In this case, the Veteran has alleged that he has a cervical spine disability related to service. While he has been diagnosed with mild degenerative changes in the cervical spine and meets the first prong of service connection, there is no evidence of any in-service cervical spine problems. To the contrary, the records reflect normal range of motion in the cervical spine in January 2011, and first documented degenerative changes in May 2012. Further, in July 2015, the Veteran reported that he had been involved in two MVAs and now experienced chronic neck pain. Lastly, STRs are silent as to any cervical spine problems during service. Therefore, the Veteran does not meet the second prong of an in-service injury, disease, or event. The Board notes that the Veteran was not afforded VA examinations or medical opinions for his claim. VA is obliged to provide an examination or obtain a medical opinion in a claim when the record contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of a current disability, the record indicates that the disability or persistent or recurrent symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. The Veteran’s reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon, 20 Vet. App. at 83. However, the duty to provide an examination is not limitless. Under the VCAA, VA must provide an examination when there is (A) competent evidence of a current disability (or persistent or recurrent symptoms thereof) that (B) may be associated with service, but (C) there is insufficient medical evidence to make a decision on the claim. 38 U.S.C. § 5103A(d). In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be competent evidence of a current disability, competent evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet the standard of subsection (B), as this would, contrary to the intent of Congress, result in medical examinations being “routinely and virtually automatically” provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. STRs and post-service medical records are devoid of evidence that the Veteran developed a cervical spine disability during service or as a post-service disorder that may be associated with service. This is so even when considering the low nexus threshold for triggering VA’s duty to provide an examination. The Veteran does not assert any in-service disease, injury, or event with which the current disabilities may be associated. In this case, an in-service disease, injury, or event is not shown, and the low threshold for purposes of triggering VA’s duty to provide an examination is not met for the claimed disabilities. McLendon, 20 Vet. App. at 79; Locklear, 20 Vet. App. at 410; Waters, 601 F. 3d at 1278. The Court in Bardwell v. Shinseki, 24 Vet. App. 36, 39 (2010), held that, while there must be competent evidence of a current disability (or persistent or recurrent symptoms thereof) and an indication (not necessarily from competent evidence) that the current disability may be associated with service, the in-service event prong of the McLendon test “does not qualify the quality of evidence necessary to meet its threshold.” Rather, the evidence must establish that there was a disease, injury, or event in service. Id. Here, for the reasons noted and discussed above, the evidence does not establish there was a disease, injury, or event in service with regard to this claim. For the foregoing reasons, the preponderance of the evidence reflects that the Veteran does not have a cervical spine disability due to disease or injury in service. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for hypotension The Veteran contends that he has hypotension that is related to or incurred in service. STRs are silent as to any complaints, treatments, or diagnoses for hypotension. Likewise, post-service treatment records are silent as to any complaints, treatments, or diagnoses for hypotension. Based on the evidence of record, the Board finds that service connection for hypotension is not warranted. In Saunders, 886 F.3d at 1364-65, the Federal Circuit held that a diagnosis is not required to meet the current disability requirement. For example, pain alone can constitute disability even if not connected to a current underlying condition, if it causes impairment in earning capacity. Id. Even considering this broad definition of disability, however, the Veteran has not met the current disability requirement. There is no lay or medical evidence in the record that the Veteran had or was ever diagnosed with hypotension. The Board notes that the Veteran was not afforded VA examinations or medical opinions for his claim. As noted above, VA is obliged to provide an examination or obtain a medical opinion in a claim when the record contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of a current disability, the record indicates that the disability or persistent or recurrent symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon, 20 Vet. App. at 79. The threshold for finding a link between current disability and service is low. Locklear, 20 Vet. App. at 410. However, the duty to provide an examination is not limitless. Under the VCAA, VA must provide an examination when there is (A) competent evidence of a current disability (or persistent or recurrent symptoms thereof) that (B) may be associated with service, but (C) there is insufficient medical evidence to make a decision on the claim. 38 U.S.C. § 5103A(d). As noted above, STRs and post-service medical records are devoid of evidence that the Veteran developed hypotension during service or as a post-service disorder that may be associated with service. This is so even when considering the low nexus threshold for triggering VA’s duty to provide an examination. Thus, the low threshold for purposes of triggering VA’s duty to provide an examination is not met for the claimed disabilities. McLendon, 20 Vet. App. at 79; Locklear, 20 Vet. App. at 410; Waters, 601 F. 3d at 1278. For the foregoing reasons, the preponderance of the evidence reflects that the Veteran does not have hypotension due to disease or injury in service. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for tinnitus At the outset, the Board finds that the evidence demonstrates that the Veteran has a current tinnitus disability. The Board notes that the military occupational specialty of the Veteran was that of an electronic equipment repairman, and an in-service August 2004 audiology report indicated no hearing protection and that the Veteran was routinely exposed to noise. Therefore, noise exposure is conceded. Thus, the question is one of nexus. Relevant to the issue of nexus, the Board notes that in claiming VA disability compensation for tinnitus, at his February 2015 VA audiology examination, the Veteran reported that the constant ringing in his ears made it difficult to go to sleep and stated that his tinnitus started after separation from service. Upon consideration of the above evidence, the Board finds that the preponderance of the evidence is against the claim for service connection for tinnitus. While the Board concedes that the Veteran was diagnosed with tinnitus, and that he was subjected to in-service noise exposure, the claim for service connection must fail because the evidence weighs against a finding that his tinnitus was caused by or otherwise due to military service. The evidence does not show a diagnosis of tinnitus during service or for many years thereafter. In fact, the Veteran first reported tinnitus in May 2013, eight years after separation from service. See Maxson v. West, 12 Vet. App. 453 (1999), aff’d, 230 F.3d 1330 (Fed. Cir. 2000) (a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim, which weighs against the claim). As tinnitus did not manifest within a year of separation from service, service connection for this chronic disease on a presumptive basis is not warranted. 38 C.F.R. §§ 3.307, 3.309; Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Next, the Board points to the Veteran’s statements that he first experienced tinnitus after service, but he did not specify when tinnitus first started. As noted above, post-service treatment records indicate that the Veteran first complained of tinnitus is May 2013. The Board finds the Veteran competent and credible in his report as to the onset of his symptoms. Further, the Board finds that the VA examiner’s opinion is probative and adequate because it considered both the lack of medical evidence for tinnitus in service and thereafter, as well as the Veteran’s report that his tinnitus had its initial onset after he was discharged from service. Accordingly, service connection for tinnitus is not warranted based upon continuity of symptoms. The evidence demonstrates no symptoms in service and the start of symptoms many years after service. Accordingly, based on the above analysis, and after consideration of all the evidence, the Board finds that the preponderance of the evidence is against the claim for service connection. The Veteran does not have tinnitus related to disease or injury incurred in or aggravated during active military service. Thus, the claim of service connection for tinnitus must be denied. The Board has considered the benefit-of-the-doubt doctrine, but finds that the record does not provide even an approximate balance of negative and positive evidence on the merits. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to an increased rating for bipolar disorder with unspecified anxiety disorder Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 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). The analysis in this decision is, therefore, undertaken with consideration of the possibility that different ratings may be warranted for different time periods. If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath, 1 Vet. App. at 589. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contends that his service-connected bipolar disorder with unspecified anxiety disorder warrants an increased disability rating higher than 50 percent under 38 C.F.R. § 4.130, DC 9413-9432. He submitted his claim for an increased rating in September 2014. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The rating agency shall 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. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA will also consider the extent of social impairment, but shall not assign a rating solely based on social impairment. 38 C.F.R. § 4.126(b). Under the General Rating Formula, a 50 percent disability rating is warranted 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. A 70 percent disability rating is warranted 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); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. 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; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with 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. A February 2015 VA examination report reflects diagnoses of bipolar disorder and anxiety disorder. The examiner opined that it was difficult to differentiate what symptoms were attributable to each diagnosis due to symptoms overlap. The Veteran reported that he lived with his wife and did not have any close friends. He stated that although he could establish friendships easily, he had problems maintaining them. He clarified that he often “chose the wrong type of people” who ended up being controlling or manipulative. He was currently unemployed and noted that it was difficult to find and keep a job because he could not handle highly demanding or fast-paced jobs. He stated that jobs that had a slower pace required certifications, which he did not have. He reported that he got “hot-headed” easily, and unless he was around certain people like his wife, he could get out of control. He reported times when he and his wife argued so loudly it could be heard down the block. He also noted that he no longer enjoyed the ham radio like he used to, he had reduced sexual satisfaction, and he had feelings of depression. He stated that he’d thought about grabbing all of his things and just walking away, but stayed put when he thought about everyone who would be affected. He acknowledged past suicidal thoughts but noted he had not had such thoughts or intents within the past two weeks or month. He reported that he got four hours of sleep when he was depressed, and that when he had insomnia he could only sleep for two hours. He noted that when he was in his manic phase, he got around seven hours of sleep. He reported that he had managed to “stay even” somewhat, unless he was under a lot of stress. He noted that he got bored easily, and had problems focusing during those times. When depressed, he would lie in bed and watch television. He explained that he was easily annoyed and was “constantly looking over his shoulder, like paranoid.” He endorsed panic attacks when in an enclosed space with a lot of people and he could not see the exits. He also stated that he was impulsive, spontaneous, overly confident, and more energetic during his manic episodes. He also acknowledged feeling more agitated during those times, particularly when his wife tried to talk him out of it. He clarified that he could get verbally abusive during those times. The Veteran’s symptoms included depressed mood, anxiety, suspiciousness, panic attacks weekly or less often, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances including work or a work like setting. The examiner found that the Veteran did not present as an imminent risk; and he denied recent suicidal or homicidal thoughts, intent, or plan. He was alert, responsive, and oriented; casually attired with good hygiene; his mood was full-range; and his affect consistent with speech. Thought processes appeared logical and well-ordered, attention and concentration appeared within normal limits, judgment and insight were fair, and there were no signs of memory problems. In July 2016, the Veteran’s wife provided a statement explaining that the Veteran suffered from severe symptoms from his bipolar disorder. He had panic attacks that caused him to shake, or sit and stare, almost every day and usually lasted about one to two hours. During his attacks, he stuttered and had difficulty walking. She stated that every few days he got angry for no reason and frequently threatened to kick her out of the house or told her to leave. She reported that he could not function independently, and she had to remind him to shower and shave every few days because he would not do it himself. She explained that if she were not there, he would not be able to maintain household chores or keep up with the finances. In October 2016, the Veteran’s mother submitted a statement explaining that she lived with the Veteran and his wife, and she saw his symptoms on a daily basis. She stated that he had not worked for over two years and had problems keeping a job. While the Veteran tried to help with chores around the house, his medication made him too sleepy and groggy. He also had anger management issues and he “exploded” for no reason on a regular basis. However, sometimes he had incredible anxiety, particularly in the car, and started stuttering and shaking. He did not do well in stressful situations or large crowds, and he would often have to leave a store and go outside to smoke a cigarette because he was too nervous. He did not have many social relationships, and although he had friends, their interactions were largely via Facebook and online because they lived in different states; he rarely went out or visited with friends. She also explained that she and his wife often had to remind the Veteran to shower, shave, and put on clean clothes. A January 2017 Disability Benefits Questionnaire by a private psychologist indicates that the Veteran had been married for six years and had one school-aged stepson. He lived with his wife and his mother, and kept his struggles to himself because he did not want to burden others. He was socially isolated and withdrawn, and his last job was in 2014 for three months for Amazon. The Veteran had symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occurred more than once a week, near-continuous panic or depression affecting his ability to function independently, chronic sleep impairment, mild memory loss, flattened effect, disturbance of motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, and intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene. The Veteran endorsed ongoing difficulty with his symptoms and remarked that he no longer enjoyed the simplest of activities. His attention was normal and his concentration was variable, but he complained of increased trouble with sort-term memory, such as struggling to remember basic information. His speech was normal, although he was brief with information; his thought content was appropriate and goal-oriented; and there was no report of overt hallucinations. His judgment was average, his mood anxious and nervous, and his affect restricted. His wife reminded him to shower, shave, and get a haircut; and he showered only two to three days per week. The psychologist noted that the severity of his symptoms related back to his September 2014 claim. The psychologist also conducted a residual functional capacity evaluation regarding the Veteran’s ability to do work-related activities based on his mental health impairment. She found that the Veteran would miss three or more days per month due to mental problems. He would need to leave early from the workplace three or more times per month due to mental problems, and he would not be able to stay focused to complete repetitive tasks more than three days per month for at least seven hours of an eight-hour workday. Further, she found that if he were subjected to the normal pressures and constructive criticisms of a job, the Veteran would respond inappropriately more than once per month in an angry manner, but would not become violent. The psychologist indicated that the Veteran could not sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his bipolar disorder. The psychologist found that the Veteran had difficulty maintaining and sustaining a steady mood, and that this inconsistent mood lead to problems in his social and work life. The Veteran reported that he had not been able to have meaningful work or social relationships, and believed that he could not let others into his life because of trust issues. He remarked that he felt nervous, worried, and irritable; and that he struggled with ongoing anxiety. The psychologist opined that his anxiety was a safety hazard on the job. Further, due to his poor interpersonal skills and workplace trust issues, the Veteran would have an increase in paranoia and would struggle with appropriate work interaction. She noted that employers found higher distractibility, absenteeism, and emotional turmoil inappropriate in the workplace. As such, the psychologist opined that the Veteran suffered from bipolar disorder that prevented him from maintaining substantially gainful employment. VA treatment records in August 2017 reflect that the Veteran had moved to South Carolina. His sleep had improved with medication and he got about seven to eight hours of sleep. He stated that he was calmer and more relaxed since the move. He was separated from his wife of seven years. He denied suicidal and homicidal ideation, as well as hallucinations. He had fair grooming, he was pleasant and cooperative, and his speech was normal. His mood was euthymic, his affect jovial and mood congruent, his thought process was goal-directed and logical, and his thought content was normal. He was alert and oriented to time, person, place and circumstance; and his insight and judgment were good. In February 2018, the Veteran had moved to Albany from South Carolina with his mother, and was divorcing his wife. His appearance and grooming were appropriate, he was cooperative, his mood was within normal limits, his affect congruent with the content of speech, his thought content normal, and his thought processes logical. He was alert and oriented to person, place, time; his insight and judgement were good; and he denied suicidal and homicidal ideation. As previously noted, the Veteran has a 50 percent disability rating. For the following reasons, a disability rating of 70 percent, but no higher, for bipolar disorder with unspecified anxiety disorder is warranted for the entirety of the appeal. The evidence shows that the Veteran was depressed and anxious. He experienced chronic sleep impairment, anger outbursts, and isolationism. He stated that although he was able to form friendships, he had difficulty maintaining them and therefore he was socially withdrawn and mostly kept to himself. In addition, he experienced panic attacks that occurred weekly or more often, and continuous panic or depression affecting the ability to function independently. During the appeal period, his relationship with his wife deteriorated and in February 2018 he stated they were divorcing. The Veteran also experienced diminished interest in activities, difficulty adapting to stressful circumstances, suspiciousness, disturbances of mood, difficulty establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationships, and intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene. In addition, statements from the Veteran’s wife and mother reflect that he experienced panic attacks, irritability and anger outburst, and did not maintain proper hygiene unless they prompted him. The Veteran thus had symptoms listed in the criteria for a 70 and 100 percent rating as well as total occupational impairment and extremely limited social interactions. The evidence is thus evenly balanced as to whether the symptoms and impairment more nearly approximated the total occupational and social impairment required for a 100 percent rating. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to a 100 percent rating for bipolar disorder with unspecified anxiety disorder is warranted. 38 U.S.C. § 5107(b) 38 C.F.R. § 4.3. The above determinations are based on consideration of the applicable provisions of VA’s rating schedule. The Board has considered the Veteran’s claim for increased rating and decided entitlement based on the evidence. Neither the Veteran nor his representative has 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). REASONS FOR REMAND 1. Entitlement to service connection for a back condition is remanded. The Veteran contends that he has a current back disability due to or related to service. STRs reflect complaints of low back pain in September 2004 and February 2005, with a diagnosis of paralumbar strain. Post-service VA treatment records in February 2012 document low back pain and x-rays were negative. Given the Veteran’s current low back pain, his allegations that it is related to his in-service diagnosis of paralumbar strain, and the fact that the Veteran has not been provided with a VA examination, the Board finds that a VA opinion to address the nature and etiology any low back disability is warranted. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 2. Entitlement to service connection for a right and left knee disability is remanded. The Veteran contends that he has a current bilateral knee disability due to or related to service. STRs reflect complaints of knee pain in March 2005. Post-service treatment records in January 2011 document mild arthritis in the bilateral knees. X-rays showed evidence of some narrowing of the joint spaces, probable meniscal degeneration. Given the Veteran’s diagnosed arthritis in the bilateral knee, his allegations that it is related to his in-service knee pain, and the fact that the Veteran has not been provided with a VA examination, the Board finds that a VA opinion to address the nature and etiology any bilateral knee disability is warranted. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. at 81. 3. Entitlement to service connection for a sleep disorder is remanded. The Veteran contends that he has a sleep disorder that is related to service. STRs are silent as to any in-service treatment, diagnoses, or complaints for a sleep disorder. Post-service medical records in August 2017 reflect that the Veteran was told he was not breathing during his sleep, but he was not tested for sleep apnea. The Board notes that the Veteran is also service-connected for bipolar disorder with unspecified anxiety disorder, and experienced symptoms of chronic sleep impairment. Given the Veteran’s statements that he was not breathing during his sleep, his service-connected bipolar disorder, and the fact that he has not been afforded a VA examination to determine the nature and etiology of any sleep disorder, the Board finds that a VA opinion to address the nature and etiology any sleep disorder is warranted. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. at 81. 4. Entitlement to service connection for a disability to account for memory loss is remanded. The Veteran contends that he has a disability that results in memory loss that is related to service. STRs in December 2004 reflect that the Veteran was running when he slowed down, and was hit in the head by another runner and fell. He did not lose consciousness, and was assessed with deconditioning. Post-service medical records in January 2011 reflect that the Veteran was in an MVA involving a moped in 2008 and that he was not wearing a helmet. He lost consciousness for approximately one hour and reported experiencing short-term memory loss since then. In July 2015, the Veteran stated that he was involved in a second moped accident in January 2015, and had traumatic brain injury from the MVA in 2008 and 2015. Nevertheless, the Board notes that the Veteran is also service-connected for bipolar disorder with unspecified anxiety disorder, and VA examination reports document symptoms of mild memory loss. Given the Veteran’s in-service injury to the head, his post-service MVAs that involved loss of consciousness, his service-connected bipolar disorder, and the fact that he has not been afforded a VA examination to determine the nature and etiology of any disability resulting in memory loss, the Board finds that a VA opinion to address the nature and etiology any disability resulting in memory loss is warranted. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. at 81. 5. Entitlement to service connection for depression is remanded. The Veteran contends that he has depression that is related to service. STRs reflect a diagnosis of adjustment disorder with mixed anxiety and depressed mood. Post-service medical records reflect depression associated with the Veteran’s service-connected bipolar disorder. However, the Board notes that there is no VA opinion addressing whether the Veteran’s current depression is a symptom of his bipolar disorder or a separate diagnosis. As such, a remand for a VA opinion to address the nature and etiology of any depression is warranted. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. at 81 The matters are REMANDED for the following action: 1. Request a medical opinion to address the nature and etiology of the Veteran’s low back disability. The entire claims file, and a copy of this remand, must be provided to and reviewed by the opinion provider. The opinion provider should address whether the Veteran’s low back pain is at least as likely as not (50 percent probability or more) related to or caused by service, to include paralumbar strain. The opinion provider must provide a detailed rationale for any opinion expressed, citing to the relevant facts in the claims file as well as any relevant medical literature. 2. Request an opinion to address the nature and etiology of the Veteran’s bilateral knee disability. The entire claims file, and a copy of this remand, must be provided to and reviewed by the opinion provider. The opinion provider should address whether the Veteran’s bilateral knee disability is at least as likely as not (50 percent probability or more) related to or caused by service, to include knee pain. The opinion provider must provide a detailed rationale for any opinion expressed, citing to the relevant facts in the claims file as well as any relevant medical literature. 3. Request an opinion to address the nature and etiology of the Veteran’s sleep disorder. The entire claims file, and a copy of this remand, must be provided to and reviewed by the opinion provider. The opinion provider should address whether the Veteran has a separate diagnosis for a sleep disorder, or whether the Veteran’s sleep disorder is a symptom of his service-connected bipolar disorder with unspecified anxiety disorder. If the Veteran has a separate diagnosis for a sleep disorder, the opinion provider should opine whether it is at least as likely as not (50 percent probability or more) related to or caused by service. The opinion provider must provide a detailed rationale for any opinion expressed, citing to the relevant facts in the claims file as well as any relevant medical literature. 4. Request an opinion to address the nature and etiology of the Veteran’s memory loss. The entire claims file, and a copy of this remand, must be provided to and reviewed by the opinion provider. The opinion provider should address whether the Veteran has a separate disability that results in memory loss, or whether the Veteran’s memory loss is a symptom of his service-connected bipolar disorder with unspecified anxiety disorder. If the Veteran has a separate disability resulting in memory loss, the opinion provider should opine whether it is at least as likely as not (50 percent probability or more) related to or caused by service. The opinion provider must provide a detailed rationale for any opinion expressed, citing to the relevant facts in the claims file as well as any relevant medical literature. 5. Request an opinion to address the nature and etiology of the Veteran’s depression. The entire claims file, and a copy of this remand, must be provided to and reviewed by the opinion provider. The opinion provider should address whether the Veteran has a separate diagnosis for depression, or whether the Veteran’s depression is a symptom of his service-connected bipolar disorder with unspecified anxiety disorder. If the Veteran has a separate diagnosis for depression, the opinion provider should opine whether it is at least as likely as not (50 percent probability or more) related to or caused by service. If it is not related to or caused by service, the opinion provider should opine whether it is (i) due to, or (ii) aggravated by, his service-connected bipolar disorder with unspecified anxiety disorder. The opinion provider must provide a detailed rationale for any opinion expressed, citing to the relevant facts in the claims file as well as any relevant medical literature. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Leifert, Associate Counsel