Citation Nr: 18158439 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 16-38 535 DATE: December 14, 2018 ORDER Service connection for headaches is denied. Service connection for diabetes is denied. Entitlement to a rating in excess of 30 percent for ischemic heart disease is denied. Subject to the law and regulations governing payment of monetary benefits, a 70 percent rating for the Veteran’s posttraumatic stress disorder (PTSD) for the period July 3, 2013 to August 29, 2016 is granted. Entitlement to a rating in excess of 70 percent for the period from August 29, 2016 is denied. Entitlement to an effective date earlier than July 3, 2013 for service-connected PTSD is denied. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for sleep apnea, to include as secondary to PTSD is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability is remanded. FINDINGS OF FACT 1. The Veteran has not been treated for a chronic headache condition or diagnosed with a headache condition. 2. The Veteran has not been diagnosed with diabetes. 3. The Veteran’s IHD symptomatology is productive of a workload of greater than three metabolic equivalents (METs), but not greater than five METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope upon testing; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 4. The evidence demonstrates that for the period from July 3, 2013 to August 29, 2016, the Veteran’s PTSD has been productive of suicidal tendencies and occupational and social impairment with deficiencies in most areas. 5. The evidence demonstrates that for the appeal period, the Veteran’s PTSD has not been 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, inability to perform activities of daily living, disorientation to time and place, and memory loss. 6. The Veteran filed his initial claim for service connection for PTSD in September 2008, which was denied in January 2009. 7. The Veteran did not appeal this decision and it became final in December 2011. 8. In July 2013, the Veteran requested to reopen the claim for entitlement to service connection for a psychiatric condition, to include PTSD. 9. The RO subsequently granted service connection for PTSD, effective July 3, 2013. 10. The effective date for service connection for PTSD is July 3, 2013, the date the Veteran requested to reopen the claim for service connection for a psychiatric condition, to include PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for headaches have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for diabetes have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1154, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 3. The criteria for a rating in excess of 30 percent for service connected ischemic heart disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7005 (2017). 4. The criteria for a 70 percent rating, not higher, for the period from July 3, 2013 to August 29, 2016 have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 5. The criteria for a rating in excess of 70 percent for service-connected PTSD, at any point during the appeal period have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 6. The criteria for an effective date earlier than July 3, 2013 for service-connected PTSD have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1967 to August 1969, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2014 and December 2014 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO). In December 2017, the Veteran raised the issue of entitlement to a TDIU through correspondence from his representative. The issue of entitlement to a total disability rating for compensation based on individual unemployability (TDIU) is part and parcel of an increased rating claim when such issue is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Service connection may also be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (2016); El-Amin v. Shinseki, 26 Vet. App. 136 (2013); Allen v. Brown, 7 Vet. App. 439 (1995). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that it was either caused or aggravated by a service-connected disability. Id. 1. Entitlement to service connection for headaches. The Veteran asserts that he is entitled to service connection for headaches. The Veteran’s service treatment records are negative for complaints, treatment or diagnosis of a chronic headache condition. There is no medical evidence to show treatment or diagnosis of migraines within one year of military service. Service connection may be granted on a presumptive basis for headaches if this condition is manifested to a compensable degree (severe enough to be evaluated at least 10 percent disabling) within a certain period after military discharge. As the medical evidence fails to show a diagnosis of headaches within the time period specified under 38 C.F.R. 3.307, service connection on a presumptive basis must be denied. The Board notes, the Veteran’s July 2010 primary care note is the only entry indicating the Veteran had headaches. The examiner stated, the Veteran “recently began CPAP: headaches went away, feels better”. The Board notes, the Veteran’s treatment records contain multiple notations indicating “no headaches”. See June 2012 Primary Care Note; and October 2014 Mental Health Outpatient Note. As noted, there is no other lay or medical evidence of record. Even the statements of the Veteran on this issue have been scant or non-existent. In this case, the evidence of record fails to show complaints, treatment, or a diagnosis for a chronic headache condition. The only report of headaches is the June 2010 post-service medical record associated with the use of a CPAP machine. Thus, the Board finds that service connection for a chronic headache condition must be denied. 2. Entitlement to service connection for diabetes. In this case, the claim must be denied as there is no diagnosis of diabetes. The Veteran asserts that he is entitled to service connection for diabetes mellitus as due to herbicide exposure in service. The Veteran served in Vietnam. Thus, he is presumed to have been exposed to Agent Orange during service. Diabetes mellitus is one of the diseases designated as being subjective to the presumption of service connection in 38 C.F.R. §§ 3.307; 3.309(a). However, he is not currently diagnosed with diabetes. The Veteran’s service treatment records are silent for complaints or a diagnosis of diabetes mellitus. The Veteran’s medical records from December 2016, noted the Veteran to be at an increased risk for developing diabetes, and still “pre-diabetic.” February 2016 and November 2016 treatment records assess the Veteran with pre-diabetes. The Board notes that none of the Veteran’s treatment records contain entries showing treatment for or a diagnosis of diabetes mellitus. Pre-diabetes is not considered a disability for VA purposes. There is no evidence record that demonstrates the Veteran has a confirmed diagnosis of diabetes mellitus type II. As the Veteran is not currently diagnosed with diabetes. The claim must be denied. 3. Entitlement to a rating in excess of 30 percent for ischemic heart disease. The Veteran asserts that his ischemic heart disease is more severe than the currently rated 30 percent disability rating. Disability ratings are determined by applying the criteria set forth in the 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 evaluations 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. 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, as well as the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. The Veteran’s service-connected ischemic heart disease has been evaluated using the criteria for arteriosclerotic heart disease found under 38 C.F.R. § 4.104, Diagnostic Code 7005. Diagnostic Code 7005 provides for a 30 percent rating is assigned when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, with evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned with more than one episode of acute congestive heart failure in the past year; when workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is assigned for chronic congestive heart failure (CHF); or when workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of less than 30 percent. 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). The Veteran’s echocardiogram from July 2014 reflects a diagnosis of ischemic heart disease. The examiner determined the Veteran had a dilated left atrial chamber, concentric left ventricular hypertrophy with normal left ventricular systolic function, ejection fraction of 55 percent and minimal mitral, tricuspid and pulmonic regurgitation. The Veteran’s September 2014 primary care examiner assessed the Veteran’s ischemic heart disease to be stable/ asymptomatic. The Veteran’s echocardiogram which showed left ventricle hypertrophy, left atrial enlargement, ejection fraction of 55 percent. The Veteran’s August 2016 VA examination demonstrated cardiac hypertrophy and METs greater than 5 but less than 7. The EKG revealed frequent ventricular premature complexes. Echocardiogram revealed ejection fraction was 60% and there was mild concentric left ventricular hypertrophy. The examiner noted that the regarding the ischemic heart disease, there is no pathology because there is no pathology to render a diagnosis. He added there is no significant findings to warrant diagnosis. The Board finds that the evidence does not show that a rating in excess of 30 percent is warranted for ischemic heart disease. The Veteran’s August 2016 VA examination found a METs level between 5 and 7. For the entire appeal period, the ejection refraction was found to be higher than 50 percent. Additionally, there is no evidence of chronic congestive heart failure, an episode of acute congestive heart failure, or a workload of less than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope during the appeal period. In considering whether the Veteran is entitled to a higher rating, the Board has carefully considered the Veteran’s contentions and assertions regarding his symptoms. In making a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for the rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran is competent to report symptoms, such as shortness of breath, because that requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). However, the Board finds that the objective evidence does not demonstrate symptoms that more nearly approximate a higher rating under Diagnostic Code 7005 at any time during the appeal period. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 30 percent for chronic ischemic heart disease, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017). 4. Entitlement to an initial evaluation in excess of 50 percent for PTSD for the period from July 3, 2013 to August 29, 2016. The Veteran asserts that he is entitled to a rating in excess of his currently rated 50 percent disability evaluation from July 3, 2013 to August 29, 2016. Disability evaluations are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. See 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321 (a), 4.1 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran’s PTSD is currently rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula for Mental Disorders, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for 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 that 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for 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; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. The symptoms listed in General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). In addition, in Mittleider v. West, 11 Vet. App. 181 (1998), the Court held that VA regulations require that when the symptoms and/or degree of impairment due to a Veteran’s service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. In July 2014 the Veteran was provided a VA examination. The VA examine summarized the Veteran’s level of impairment as occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks. The examiner observed the Veteran was well-groomed, cooperative and fully oriented. He maintained good eye contact throughout the interview. The Veteran’s mood was euthymic and his affect was stable. The examiner reported the Veteran appeared to be a reliable historian. His speech was spontaneous, articulate and easily understood. The Veteran did not report hallucinations, delusions or psychoses. The Veteran’s attention and concentration were normal. The Veteran denied suicidal or homicidal ideation. The record shows that or the relevant part of the appeal period, the Veteran’s PTSD symptomatology included suicidal thoughts. The Veteran’s March 2014 Mental Health Note reflects the Veteran endorsed passive suicidal ideation with no intention of carrying these thoughts out on the questionnaire. See March 2014 Mental Health Note. The evidence supports a finding that the Veteran’s disability picture for PTSD has more nearly approximated occupational and social impairment with deficiencies in most areas (such as work, school, family relations, judgment, thinking, or mood) for the appeal period. The frequency, severity, and duration of the Veteran’s impairment and assessing his disability picture, the Board finds that the evidence of record demonstrates that disability due to the Veteran’s psychiatric disorder has approximated the schedular criteria for an initial rating of 70 percent. See Vazquez–Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). In so finding, the Board notes that the United States Court of Appeals for Veterans Claims has held that suicidal ideation generally rises to the level contemplated in a 70 percent evaluation. See Bankhead v. Shulkin, 29 Vet. App. 10, 20 (2017) (stating the language of 38 C.F.R. § 4.130 “indicates that the presence of suicidal ideation alone, that is, a veteran’s thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment in most areas.”). Thus, resolving all reasonable doubt in the Veteran’s favor, the Board finds that the evidence supports an initial 70 percent disability rating for the Veteran’s PTSD. The evidence of record shows that Veteran has not exhibited total social impairment for the relevant portion of the appeal. As noted, the Veteran has been married for over 35 years. At the March 2014 mental health consult, the Veteran denied physical violence towards his wife and reported feeling close to her and that he can confide in her. He stated he can talk to his wife a little bit” about his traumas. The Veteran reported that he has a 24-year-old son that he doesn’t talk too much because his son is “into music and computers” and has always been independent. The Board concludes that the Veteran’s symptoms did not manifest to the degree required for a 100 percent rating as the competent and credible medical evidence of record does not indicate total occupational and social impairment at any point during the appeal period. Entitlement to a rating in excess of 70 percent from August 29, 2016. The Veteran asserts that he is entitled to a rating in excess of 70 percent for his PTSD from August 29, 2016. The Veteran is now rated at 70 percent for the entire appeal period. The Veteran’s May 2017 private examiner indicated the Veteran’s PTSD results in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The August 2016 VA examiner summarized the Veteran’s level and occupational and social impairment with regard to the Veteran’s PTSD as occupational and social impairment with reduced reliability and productivity. The examiner noted the Veteran symptoms included difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting and an inability to maintain and establish effective relationships. The Veteran has been married for 40 years. The examiner also noted the Veteran’s wife noticed the Veteran’s poor sleep patterns, irritability, agitation, reactions and desire to isolate impacts the marriage. She further noted he is socially isolative and has minimal social contacts. The evidence of record shows the Veteran has not exhibited total social impairment for any portion of the appeal period. The Board finds that the preponderance of evidence reflects that the Veteran’s PTSD symptoms are moderate to severe in nature and cause significant occupational and social impairment; however, they are not manifested by total occupational and social impairment consistent with a 100 percent evaluation under 38 C.F.R. § 4.130. As the preponderance of the evidence reflects the Veteran is not totally occupationally and socially impaired, a 100 percent rating for PTSD is not warranted. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that “the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant”); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to an effective date earlier than July 3, 2013 for service-connected PTSD. The Veteran seeks an effective date earlier than the July 3, 2013, for the award of service connection for PTSD. Generally, the effective date of an evaluation and award of compensation based on an original claim or a claim based on presumptive service connection will be, inter alia, the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (b)(2)(i), (ii). The effective date of an award of disability compensation shall be the day following separation from service or the date entitlement arose if the claim is received within one year of separation, otherwise the date of claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (b); 38 C.F.R. § 3.400 (b)(2). The Board acknowledges that VA revised the requirements for a valid claim for VA benefits effective March 24, 2015. However, as this claim for an earlier effective date pertains to a period prior to this effective date, the old version of VA regulations for claims is to be considered in the adjudication of this appeal. Prior to March 24, 2015, the VA administrative claims process recognized formal and informal claims. A formal claim is one that has been filed in the form prescribed by the Secretary. 38 C.F.R. § 3.151 (2014). Any communication or action, indicating an intent to apply for one or more benefits, under the laws administered by VA, from a claimant may be considered an informal claim. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within 1 year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. When a claim has been filed which meets the requirements of 38 C.F.R. § 3.151, an informal request for increase or reopening will be accepted as a claim. 38 C.F.R. 3.155 (2014). The provisions of 38 C.F.R. § 3.157 (2014) commence with notation of the general rule that the effective date of compensation benefits will be the date of receipt of the claim or the date when entitlement arose, whichever is the later. However, this regulation goes on to provide that receipt of clinical reports of examination or hospitalization may serve as informal claims “for increase or to reopen” where the claim is for an already service-connected condition. The date of receipt of such clinical evidence may serve to form the basis for an earlier effective date for the subsequent award of VA benefits if such benefits derive from (1) a claim for increased evaluation or (2) an application to reopen a claim for compensation denied because the service-connected disability was not of compensable degree. In this instant, the Veteran filed his initial claim for PTSD in September 2008 which was denied in a January 2009 rating decision. The Veteran did not appeal this decision and it became final in February 2010. In May 2010, the Veteran requested to reopen his claim for service connection for PTSD. The December 2010 rating decision continued the denial of PTSD. The Veteran did not appeal that decision and it became final in December 2011. In July 2013, the Veteran requested to reopen the claim for service connection for a psychiatric condition, to include PTSD. An October 2014 rating decision granted service connection for PTSD, effective July 3, 2013. The Board finds that July 3, 2013 is the earliest possible effective date permitted for the grant of service connection for PTSD. Under the law, the effective In this case, the current effective date of July 3, 2013 is based on the date the Veteran requested to reopen the claim. A thorough review of the record does not reflect the Veteran submitted any written communication from the December 2010, in which he indicated he was seeking or believed he was entitled to service connection for PTSD; i.e. he did not submit a formal or informal application to reopen this claim prior to the current effective date for which service connection has already been established. Therefore, he is not entitled to an earlier effective date for the establishment of service connection for his PTSD. REASONS FOR REMAND Entitlement to service connection for hypertension is remanded. The Veteran asserts that service connection for hypertension is warranted because the disease is either related to or had its onset in service. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). As a result of the Veteran’s service in the Republic of Vietnam, herbicide exposure has been conceded. Although hypertension is not listed as a disease associated with herbicide exposure under the applicable regulations, the National Academy of Sciences Institute of Medicine (IOM) has concluded that there is “sufficient evidence of an association” between herbicide exposure and hypertension. See http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=25137 Additionally, an article in the November 2016 Journal of Occupational and Environmental Medicine entitled Herbicide Exposure, Vietnam Service, and Hypertension Risk in Army Chemical Corps Veterans suggests that herbicide exposure history and Vietnam service status were significantly associated with hypertension risk. See https://www.publichealth.va.gov/epidemiology/studies/vietnam-army-chemical-corps.asp. Hypertension must be shown by diastolic blood pressure predominately above 90 mm. Hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. The Veteran’s treatment records reflect a diagnosis of hypertension is in May 2010. At present, a VA examination has not been conducted and the medical evidence currently of record, is insufficient to establish a nexus in this particular case. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to posttraumatic stress disorder (PTSD) is remanded. The Veteran asserts that his service-connected PTSD aided in his development of and permanently aggravated his sleep apnea. The Veteran’s treatment records show the Veteran was diagnosed with hypersomnia, with sleep apnea in April 2010. The Veteran’s August 2016 PTSD Disability Benefits Questionnaire (DBQ) includes reports of sleep disturbance and chronic sleep impairment. Clarity is needed regarding whether the Veteran’s diagnosed sleep apnea and the sleep symptoms described in the August 2016 were caused or aggravated by his service-connected PTSD. As such, a remand is warranted. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability is remanded. The Veteran asserts that his service-connected disabilities preclude him from obtaining or following substantially gainful employment. As the Veteran’s TDIU claim is inextricably intertwined with the remaining claims on appeal, appellate consideration of entitlement to a TDIU rating is deferred pending resolution of the remaining claims on appeal. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); see also Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). Additionally, the Veteran has not submitted a completed VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. The Board requests that the Veteran complete and submit a VA Form 21-8940. Accordingly, the case is REMANDED for the following action: 1. Furnish the Veteran an Application for Increased Compensation Based on Unemployability, VA Form 21-8940, and provide the Veteran an appropriate amount of time to complete and submit it. 2. Notify the Veteran that he may submit lay statements from himself and any individual who has first-hand knowledge, and/ or were contemporaneously informed of his hypertension and his sleep impairment symptoms, and the nature, extent, and severity of his service-connected disabilities and their impact on his ability to work. An appropriate amount of time should be allowed for the Veteran to respond. 3. Schedule the Veteran for a VA examination to determine the nature, extent and etiology of the Veteran’s diagnosed hypertension. The examiner is asked to review evidence of record, as well as the medical studies referenced in this remand. After reviewing the claims file, please answer the following questions: a. Is it at least as likely as not that the Veteran’s hypertension is related to his active duty service, to include herbicide exposure? b. Is it at least as likely as not that the Veteran’s hypertension was caused by his service-connected PTSD or ischemic heart disease. c. Is it at least as likely as not that the Veteran’s hypertension has been aggravated by his service-connected PTSD or ischemic heart disease. If the examiner finds that the Veteran’s hypertension was not caused by his PTSD or ischemic heart disease or any of the medications taken to treat those conditions, but has been aggravated by them, then he/she should state the baseline level of severity of the hypertension, established by the earliest available medical evidence, and describe the extent to which the condition was permanently worsened by the Veteran’s PTSD, or ischemic heart disease or any prescribed medications. A response regarding both direct causation and aggravation must be provided or the examination report will be returned as inadequate. 4. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any sleep disorder, to include sleep apnea, found to be present. The examiner is asked to review evidence of record, as well as the medical studies referenced in this remand. After reviewing the claims file, please respond to the following: a. Diagnose all sleep conditions found to be present. The Board notes, the Veteran has a previous diagnosis of hypersomnia, with sleep apnea. b. Is it at least as likely as not that the Veteran’s sleep apnea was caused by his service-connected PTSD? c. Is it at least as likely as not that the Veteran’s sleep apnea has been aggravated by his service-connected PTSD. If the examiner finds that the Veteran’s sleep apnea was not caused by his PTSD or any of the medications taken to treat that condition, but has been aggravated by them, then he/she should state the baseline level of severity of the apnea, established by the earliest available medical evidence, and describe the extent to which the condition was permanently worsened by the Veteran’s or any prescribed medications. A response regarding both direct causation and aggravation must be provided or the examination report will be returned as inadequate. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jacquelynn M. Jordan, Associate Counsel