Citation Nr: 18157446 Decision Date: 12/12/18 Archive Date: 12/12/18 DOCKET NO. 16-22 552 DATE: December 12, 2018 ORDER Entitlement to service connection, to include on a secondary basis, for headaches is granted. Entitlement to service connection for eye condition, claimed as due to herbicide exposure, is denied. Entitlement to service connection for skin condition, claimed as due to herbicide exposure, is denied. Entitlement to service connection for a sleep disorder, to include obstructive sleep apnea (OSA), claimed as due to herbicide exposure, is denied. Entitlement to service connection for cholesterol condition, claimed as secondary to herbicide exposure, is denied. Entitlement to an effective date earlier than March 12, 2013, for the grant of service connection for coronary artery disease (CAD) is denied. Entitlement to an effective date earlier than March 12, 2013, for the grant of service connection for post-traumatic stress disorder (PTSD) is denied. Entitlement to an initial rating in excess of 60 percent disabling for CAD is denied. Entitlement to an initial rating of 70 percent, but no higher, for PTSD is granted subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. REMANDED Entitlement to service connection for lumbar spine disability is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for hypertension, claimed as due to herbicide exposure, is remanded. FINDINGS OF FACT 1. The diagnosed headache condition has been shown to be etiologically related to the Veteran’s active service. 2. The Veteran does not have a diagnosed eye condition. 3. The Veteran does not have a diagnosed skin condition. 4. The Veteran does not have a diagnosed sleep disorder, to include obstructive sleep apnea (OSA). 5. Hyperlipidemia is not a disability for which VA compensation is payable. 6. The Veteran filed Fully Developed Claims (FDC) for entitlement to service connection for CAD and PTSD on March 12, 2014, and the assigned date of service connection for those claims is March 12, 2013. 7. During the period on appeal, the Veteran’s CAD was manifested by a workload between 3 to 4 METs resulting in dyspnea and fatigue. The Veteran’s CAD was not manifested by a workload less than 3 METs, chronic congestive heart failure or left ventricular dysfunction with an ejection fraction of less than 30 percent. 8. The Veteran’s PTSD more nearly approximated occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking or mood due to such symptoms as suicidal ideation, impaired impulse control, such as unprovoked irritability with periods of violence, difficulty in adapting to stressful circumstances, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, and memory loss. 9. The Veteran is service connected for the following disabilities: PTSD rated 70 percent disabling as of March 12, 2013; and CAD rated 60 percent disabling as of March 12, 2013. 10. The Veteran is unable to secure and follow substantially gainful employment as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for headaches have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2018). 2. The criteria for service connection for an eye condition have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2018). 3. The criteria for service connection for a skin condition have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2018). 4. The criteria for service connection for a sleep disorder have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2018). 5. The criteria service connection for hyperlipidemia have not been met. 38 U.S.C. §§ 1101, 1110 (2012); 38 C.F.R. § 3.303 (2018). 6. The criteria for an effective date earlier than March 12, 2013, for the award of service connection for CAD have not been met. 38 U.S.C. §§ 5101(a), 5107, 5110 (2012); 38 C.F.R. §§ 3.1(p), 3.104, 3.151, 3.156, 3.160, 3.400 (2018). 7. The criteria for an effective date earlier than March 12, 2013, for the award of service connection for PTSD have not been met. 38 U.S.C. §§ 5101(a), 5107, 5110 (2012); 38 C.F.R. §§ 3.1(p), 3.104, 3.151, 3.156, 3.160, 3.400 (2018). 8. The criteria for an initial rating in excess of 60 percent for CAD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.104, Diagnostic Code (DC) 7005 (2018). 9. The criteria for an initial 70 disability percent rating, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1-4.7, 4.15, 4.21, 4.125, 4.126, 4.130, DC 9411 (2018). 10. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1970 to August 1971. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision by a Department of Veterans Affairs Regional Office (RO). The Board observes that additional evidence has been submitted by the Veteran following the last adjudication by the RO in the April 2016 statement of the case (SOC), including an August 2016 disability benefits questionnaires (DBQs) for PTSD and headaches, a September 2016 vocational report, private medical letters and supporting medical literature. However, as the Veteran’s substantive appeal was received in May 2016, which is after February 2, 2013, an automatic waiver of evidence submitted by the claimant or his representative is presumed. Lastly, the Board notes that a claim for a TDIU has been raised by the record and is part of the current appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be presumed for certain chronic diseases which develop to a compensable degree within one year after discharge from service, even though there is no evidence of the disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Lay evidence presented by a veteran concerning continuity of symptoms after service may not be deemed to lack credibility solely because of a lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (2006). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Additionally, if a veteran was exposed to a herbicide agent during active service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: AL amyloidosis, chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes (also known as Type II or adult-onset diabetes mellitus), Hodgkin’s disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin’s lymphoma, Parkinson’s disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea) and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). VA has determined that there is no positive association between exposure to herbicides and any other condition for which it has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341 -346 (1994); see also 61 Fed. Reg. 57586 -57589 (1996). Notwithstanding the presumption, service connection for a disability claimed as due to exposure to herbicides may be established by showing that a disorder resulting in disability or death was in fact causally linked to such exposure. See Brock v. Brown, 10 Vet. App. 155, 162-64 (1997); Combee v. Brown, 34 F. 3d 1039, 1044 (Fed. Cir. 1994), citing 38 U.S.C. § 1113(b) and 1116 and 38 C.F.R. § 3.303. 1. Headaches The Veteran asserts entitlement to service connection for headaches. Specifically, the Veteran asserts a headache condition secondary to his service-connected PTSD. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury; or, for any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of nonservice-connected condition. 38 C.F.R. § 3.310(a), (b). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Initially, the Board notes that the only medical evidence of record are private treatment records. An August 2016 DBQ shows the Veteran was diagnosed with tension headaches by Dr. HS. The Veteran reported that he began experiencing headaches approximately 5-years following service, and that his headaches coincided with his PTSD symptoms. Headaches were noted as pulsating or throbbing with pain located on both sides of the head. Pain was also found to worsen with physical activity. Other symptoms included nausea, vomiting, sensitivity to light and sound, changes in vision, sensory changes and dizziness. Dr. HS opined that it was “as likely as not” that the Veteran’s headaches were caused by his service-connected PTSD. In support of this opinion, Dr. HS cited to medical literature noting that patients with psychiatric disorders were more likely to develop headaches because pain and mood were regulated by the same part of the brain. Dr. HS further noted that the Veteran’s headaches occurred when he became “stressed out.” Accordingly, the evidence of record shows the Veteran has a currently diagnosed headache condition which a physician determined to be caused by his PTSD. Importantly, there is no medical evidence to the contrary. Therefore, the evidence of record supports a finding that the diagnosed headache condition is etiologically related to the Veteran’s service-connected PTSD. The claim is granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 2. Eye Condition, Skin Condition, Sleep Disorder The Veteran asserts entitlement to service connection for an unspecified eye condition, skin condition and sleep disorder claimed as OSA. Additionally, in a June 2014 memorandum, the Veteran appears to assert that the above-mentioned claims are due to herbicide exposure. As the facts of the above-mentioned claims are similar, they will be addressed concurrently. Initially, the Board notes that the Veteran’s service treatment records (STRs) are completely silent as to any complaints or treatment related to any eye condition, skin condition or sleep disorder. A June 2010 polysomnogram revealed an impression for snoring. The study further revealed that the Veteran did not meet the criteria for OSA. A December 2012 private medical record shows the Veteran denied skin rashes, itching, dryness or suspicious lesions. The Veteran further denied blurring vision, diplopia, irritation, discharge, vision loss, eye pain or photophobia. In June 2013, the Veteran reported that his vision had become distorted the past few months and noted that when he looked at pictures they changed shape. The Veteran was not diagnosed with an eye condition. A necessary element for establishing entitlement to service connection is the existence of a current disability; it is the cornerstone of a claim for VA disability compensation. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). For VA purposes, a current disability exists when a claimant has a disability at the time a claim is filed or at some point during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he/she files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim). Here, the Veteran has consistently claimed entitlement to service connection for an unspecified eye condition, skin condition and sleep disorder. However, the evidence of record does not show any related diagnosed conditions. With regard to his claimed sleep disorder, a June 2010 polysomnogram revealed no diagnosed sleep disorder, specifically OSA. Further, while the Veteran has reported changes in his vision, he has not submitted any evidence of a diagnosed eye condition. Importantly, the Veteran has not offered any lay evidence with regard to any specific diagnosed condition with regard to these claims on appeal. Accordingly, absent a diagnosis for an eye condition, skin condition or sleep disorder, the Board finds that the probative evidence is against the Veteran’s claims for service connection. Although the Veteran is entitled to the benefit-of-the-doubt where the evidence is in approximate balance, the benefit-of-the-doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claims for service connection. The claims are denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Cholesterol Condition The Veteran asserts entitlement to service connection for a cholesterol condition. Specifically, the Veteran asserts a cholesterol condition secondary to herbicide exposure. A review of the Veteran’s medical treatment records show he has been diagnosed with hyperlipidemia and takes medication to control his cholesterol. “Hyperlipidemia” is “a general term for elevated concentrations of any or all of the lipids in the plasma, such as hypertriglyceridemia, hypercholesterolemia, and so on.” See Dorland’s Illustrated Medical Dictionary 891 (32nd ed. 1994). A finding of hypertriglyceridemia or hyperlipidemia is a laboratory result and not, in and of itself, a disability for VA compensation purposes. 61 Fed. Reg. 20440, 20445 (May 7, 1996). Nevertheless, disabilities related to high cholesterol levels may be service-connected. In this regard, the Board observes that the Veteran is currently service connected for CAD. The Board stresses that service connection can only be granted for a disability resulting from disease or injury. See 38 U.S.C. §§ 1110. In Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the Federal Circuit held that “‘disability’ in § 1110 refers to the functional impairment of earning capacity.” Here, however, there is no evidence of record suggesting hyperlipidemia, on its own, has caused any functional impairment of earning capacity. Thus, despite the diagnosis of hyperlipidemia, this is not a disability for purposes of VA compensation and service connection for hyperlipidemia is denied. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Earlier Effective Dates The Veteran filed FDCs for CAD and PTSD on March 12, 2014. A September 2014 rating decision granted service connection for CAD and PTSD effective March 12, 2013. In his October 2014 notice of disagreement, the Veteran asserted entitlement to earlier effective dates. That issue was addressed in the April 2016 statement of the case and the Veteran perfected his appeal. In the instance case, Section 506 of Public Law (PL)112-154, Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012, applies regarding FDC. Section 506 of PL 112-154, established different rules for the assignment of effective dates that are specific to claims decided under the FDC process. Section 506 of PL 112-154 was codified as 38 U.S.C. § 5110(b)(2)(A). The rules governing the assignment of effective dates for claims decided under FDC process apply to the present claim. 38 U.S.C. § 5110(b)(2)(A) provided that “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 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. A claim of service connection submitted through the FDC process by definition meets the statutory requirement of an original claim that is fully-developed. See 38 U.S.C. § 5110(b)(2)(B). Statute 38 U.SC. § 5110(b)(2)(A) does not establish that the effective date for claims filed under the FDC process should automatically be one year prior to the date of the filing of the formal claim for service connection. Instead, the statute states that the effective date shall be fixed in accordance with the facts found, so long as the date established by the facts is not earlier than one year prior to the date of the receipt of the application for service connection. The evidence of record reflects that the Veteran originally filed service connection claims for CAD and PTSD on March 12, 2014. Thus, the earliest possible effective dates for the award of service connection could be March 12, 2013, which corresponds to the one-year period prior to the date of receipt of the claim. There is no legal basis for an earlier effective date. In reaching this decision the Board has considered the doctrine of reasonable doubt. However, the preponderance of the evidence is against the Veteran’s claims and the claims are denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, and the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 4. CAD The Veteran filed a service connection claim for a heart condition in March 2014. That claim was granted in a September 2014 rating decision and assigned a 60 percent evaluation pursuant to 38 C.F.R. § 4.104, DC 7005, effective March 2013. The Veteran has appealed the initial rating. Pursuant to DC 7005, a 60 percent rating is warranted when there is more than one episode of congestive heart failure in the past year; or a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted when there is chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005. One MET is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). Initially, the Board notes that the medical evidence of record primarily consists of private treatment records. A review of those records does not reveal a diagnosis for congestive heart failure nor do they contain diagnostic testing for MET levels. The Veteran underwent a VA examination in July 2014. The Veteran was diagnosed with CAD. The CAD was noted to require continuous medication for control. The examiner also noted a history of a myocardial infarction that occurred in 1989 with coronary artery bypass graft in 2008. The Veteran was not found to have congestive heart failure, arrhythmia, or a heart valve condition. Additionally, the examiner noted no pericardial adhesions. Testing revealed a MET level greater than 3-5 with symptoms of dyspnea and fatigue. The MET level was found solely due to the diagnosed CAD. Left ventricular ejection fraction was 55 percent. Based on the evidence of record, during the period on appeal the Veteran’s CAD has not been documented with a workload less than 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope. In addition, the evidence of record does not note chronic congestive heart failure or left ventricular dysfunction with an ejection fraction of less than 30 percent. Thus, during the period on appeal, there is no competent evidence of record showing the Veteran’s CAD was manifested by symptoms approximating a 100 percent disability rating pursuant to DC 7005. Accordingly, the Board finds that the preponderance of the evidence is against an initial disability rating in excess of 60 percent. As the preponderance of the evidence is against an increased rating, the benefit-of-the-doubt doctrine is inapplicable and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). 5. PTSD The Veteran filed a service connection claim for PTSD in March 2014. That claim was granted in a September 2014 rating decision and assigned a 50 percent evaluation pursuant to 38 C.F.R. § 4.130, DC 9411, effective March 2013. The Veteran has appealed the initial rating. Pursuant to DC 9411, a 50 percent rating is assigned for a psychiatric disorder manifested by 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. A 70 percent rating is assigned for a psychiatric disorder manifested by 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 maximum 100 percent rating is assigned for a psychiatric disorder manifested by total occupational and social impairment due to such symptoms as gross impairment in thought process 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. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. If the evidence shows that the veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (2002); Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). In June 2013, the Veteran reported hallucinations and sleep disturbances. The Veteran underwent a VA examination in July 2014. The examiner noted a diagnosis for PTSD with no other psychiatric disorder diagnosed. The Veteran’s PTSD was found manifested by occupational and social impairment with reduced reliability and productivity. The Veteran reported having been married since 1968, that he had a good relationship with his family, and that he spent his spare time with his grandchildren. The Veteran also reported having a few friends. In addition, the Veteran reported working at a car company for 31-years as a manager, that he lost his temper at work, but that his current medication kept him calm. The examiner noted the following symptoms: depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss such as forgetting names, directions or recent events; impaired judgement; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; impaired impulse control, such as unprovoked irritability with periods of violence; neglect of personal appearance and hygiene; impaired concentration; and decreased appetite and weight loss. The Veteran denied any audio or visual hallucinations, or homicidal or suicidal ideation. No delusions were expressed and his affect was full ranged. He was oriented to all spheres and his thought process logical and goal directed. An August 2016 DBQ shows the Veteran was diagnosed with PTSD with other mood disorder features. No other psychiatric disorder was diagnosed. The examining psychiatrist, Dr. RW, found the Veteran’s PTSD manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking and/or mood. The Veteran’s current occupational and social impairment was based on the following identified symptoms: depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened effect; speech intermittently illogical, obscure or irrelevant; impaired judgement; gross impairment in thought processes or communication; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; suicidal ideation; obsessional rituals which interfere with routine activities; impaired impulse control, such as unprovoked irritability with periods of violence; persistent delusions or hallucinations; neglect of personal appearance and hygiene; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; and disorientation to time or place. The Veteran reported that he did not get out much and preferred to stay by himself at home. The Veteran further reported that he became anxious and irritable traveling in vehicles or when in public places or crowds. In addition, he stated he had no friends and had minimal interactions with anyone including immediate family. He did report leaving home to shop for groceries and basic necessities. The Veteran stated he retired at the end of March 2016 due to his PTSD and heart condition which reportedly affected his stress level, job performance and work relationships. After a review of the evidence of record, the Board finds that an increased initial rating of 70 percent is warranted. Specifically, during the entire period on appeal, the Board finds that the evidence establishes that the Veteran’s PTSD was manifested by symptoms including: difficulty in adapting to stressful circumstances; impaired impulse control such as unprovoked irritability with periods of violence; neglect of personal appearance and hygiene; and memory loss. The above-mentioned symptoms are specifically contemplated by a higher 70 percent rating. Additionally, while the Veteran had denied hallucinations during the July 2014 VA examination, he did report hallucinations in June 2013. In this regard, the August 2016 DBQ also noted persistent hallucinations. As such, the June 2013 report of hallucinations is supported by the August 2016 DBQ. Accordingly, the Board finds that an initial 70 percent disability rating is warranted. The Board further finds that a higher 100 percent evaluation is not warranted. The Board recognizes the August 2016 DBQ in which Dr. RW checked the boxes for: persistent delusions or hallucinations; gross impairment in thought processes or communication; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; and disorientation to time or place. Even though these symptoms were checked on the DBQ form, Dr. RW summarized that the Veteran’s overall functioning more nearly approximated the criteria for occupational and social impairment with deficiencies in most areas. Further, the discussion of the Veteran’s symptomatology does not reflect that, socially, he is totally impaired. As noted by Dr. RW, the Veteran has been married since 1968 and he asserted that he visited his two children periodically. In this regard, during the July 2014 VA examination, the Veteran reported having a good relationship with his family and that he spent his spare time with his grandchildren. While the Veteran has reported that he was estranged from most other family members and friends outside his spouse and children, total social impairment has not been shown. In sum, the Board finds that an initial 70 percent disability rating, but no higher, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.130; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. §§ 3.340(a)(1), 4.15. “Substantially gainful employment” is that employment “which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides.” Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). “Marginal employment shall not be considered substantially gainful employment.” 38 C.F.R. § 4.16(a). In determining whether unemployability exists, consideration may be given to the veteran’s level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. A total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16(a). During the pendency of the appeal, the Veteran has been service connected for the following disabilities: PTSD rated 70 percent disabling as of March 12, 2013; and CAD rated 60 percent disabling as of March 12, 2013. The Board notes the Veteran has met the schedular rating criteria as of March 12, 2013. The evidence of record includes a July 2014 VA heart examination which found that the Veteran’s CAD impacted his ability to work due to dyspnea caused by minimal exertion. In addition, in the August 2016 PTSD DBQ Dr. RW found that the Veteran’s PTSD was mentally, emotionally and physically disabling and caused functional impairments in daily living, social and work activities. Dr. RW further found that the Veteran’s symptoms were severe enough to disable and preclude him from a substantially gainful occupation. In an August 2016 letter, Dr. HS opined that it was “more likely than not” that the Veteran’s service-connected CAD and PTSD precluded him from performing any level of substantial gainful activity. With regard to his CAD, the condition was found to limit the Veteran’s ability to stand for 45-minutes, walk one block, sit for 30-minutes or stoop for less than 2-hours. In addition, the Veteran was limited to lifting or carrying less than 10 pounds. Finally, A September 2016 vocational report found that the combination of the Veteran’s physical and emotional conditions “totally and permanently precluded [the Veteran] from performing work at a substantial gainful level due to the severity of his service-connected [CAD] and PTSD...”. The report based this assessment on a review of the claims file including VA and private examination reports. After a review of the evidence of record, the Board finds that the totality of the record indicates the functional impairments caused by the Veteran’s service-connected disabilities render him unable to secure or follow a substantially gainful occupation. First, the evidence of record indicates the functional impairments caused by the service-connected disabilities would likely prevent the Veteran from obtaining or maintaining an occupation involving physical labor. This includes his CAD disability which makes it difficult for the Veteran to exert himself including lifting heavy objects or working on his feet for a normal work day. Second, the Board finds the service-connected PTSD would likely prevent the Veteran from following a substantially gainful occupation. The evidence of record indicates the Veteran has struggled with anger, irritability and difficulty in adapting to stressful circumstances, including work or a worklike setting, and difficulty in establishing and maintaining effective work and social relationships. The Veteran has additionally struggled with memory and concentration issues. As such, the Board finds that the combined persistent functional effects of the Veteran’s PTSD would likely prevent him from being able to work around others, be effectively supervised, sustain the focus and attention to learn necessary skills, or to complete a full, productive work schedule in a substantially gainful occupation. Accordingly, based on the evidence of record, the Board finds the functional effects of the Veteran’s service-connected disabilities have rendered him unable to secure and follow a substantially gainful occupation throughout the appeal period. Therefore, entitlement to a TDIU is warranted. REASONS FOR REMAND 1. Lumbar Spine Disability. The Board notes that the Veteran submitted a memorandum in July 2014 in which he notified the AOJ that he had received treatment from Dr. DM at the Center for Spine, Joint and Neuromuscular Rehabilitation. See July 2014 Medical Treatment Record-Non-Government Facility. The Veteran also included the medical facility’s contact information. However, a review the claims file does not reflect that the AOJ has attempted to obtain these medical records. Accordingly, a Remand is necessary and further assistance to the Veteran is required in order to comply with the duty to assist as mandated by 38 U.S.C. § 5103A. 2. Bilateral Hearing Loss and Tinnitus. Initially, the Board notes that the Veteran identified private treatment records for his hearing loss disability. See July 2014 Medical Treatment Record-Non-Government Facility. However, a review of the claims file does not reflect that the AOJ has attempted to obtain these medical records. Accordingly, a Remand is necessary and further assistance to the Veteran is required in order to comply with the duty to assist. 38 U.S.C. § 5103A. 3. Hypertension The Veteran asserts entitlement to service connection for hypertension. Specifically, the Veteran asserts that his hypertension was caused by exposure to herbicides during service. A review of the evidence of record shows a current diagnosis for hypertension for which the Veteran has been prescribed medication. The evidence of record also shows that the Veteran’s in-service exposure to herbicides has been conceded. Additionally, the Veteran is currently service connected for PTSD and CAD. The Veteran’s PTSD has been shown manifested by symptoms including anxiety; suspiciousness; near-continuous panic attacks; and chronic sleep impairment. Based on the service-connected conditions and related symptoms, the Board finds that it is appropriate to expand the scope of the Veteran’s claim to include entitlement to service connection on a secondary basis. Accordingly, the Board finds that a VA examination is warranted to determine the nature and etiology of the Veteran’s claimed hypertension disability. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McClendon v. Nicholson, 20 Vet. App. 79, 86 (2006). The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran’s VA treatment facilities, and all private treatment records from the Veteran not already associated with the file, to include records from the Hearing Health Center and Center for Spine, Joint and Neuromuscular Rehabilitation identified by the Veteran. See July 2014 Medical Treatment Record-Non-Government Facility. 2. Then, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of his diagnosed hypertension condition. The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed hypertension is etiologically related to his period of service, to include as due to herbicide exposure? (b) Is it at least as likely as not (50 percent or greater probability) that any diagnosed hypertension was caused by the Veteran’s service-connected conditions, to include CAD and PTSD? Please explain why or why not. (c) Is it at least as likely as not (50 percent or greater probability) that any diagnosed hypertension was permanently worsened beyond normal progression (aggravated) by the Veteran’s service-connected conditions, to include CAD and PTSD? Please explain why or why not. If the examiner finds that the disability was aggravated by the service-connected disability, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred. (Continued on the next page)   The examiner should review pertinent documents in the Veteran’s claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Lamb, Associate Counsel