Citation Nr: 18159945 Decision Date: 12/21/18 Archive Date: 12/20/18 DOCKET NO. 18-50 139 DATE: December 21, 2018 ORDER Service connection for a lumbosacral spine disability, diagnosed as degenerative joint disease, is granted. An initial rating higher than 40 percent for fibromyalgia is denied. An initial rating higher than 10 percent for tinnitus is denied. A total disability rating based on individual unemployability (TDIU) is granted, subject to the laws and regulations governing the payment of monetary awards. An effective date earlier than May 29, 2012, for service connection for posttraumatic stress disorder (PTSD) is denied. An effective date earlier than May 29, 2012, for service connection for headaches is denied. An effective date earlier than May 29, 2012, for service connection for irritable bowel syndrome is denied. An effective date earlier than May 29, 2012, for service connection for fibromyalgia is denied. An effective date earlier than December 3, 2012, for service connection for tinnitus is denied. REMANDED Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a right leg disability is remanded. Entitlement to service connection for a left leg disability is remanded. Entitlement to service connection for right carpal tunnel syndrome is remanded. Entitlement to service connection for left carpal tunnel syndrome is remanded. Entitlement to service connection for a gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for a sinus disorder, to include sinusitis, is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for a skin disorder is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to an initial rating higher than 70 percent for PTSD is remanded. Entitlement to an initial higher (compensable) rating for headaches is remanded. Entitlement to an initial higher (compensable) rating for irritable bowel syndrome is remanded. Entitlement to special monthly compensation (SMC) based upon the need for regular aid and attendance of another person or by reason of being housebound is remanded. FINDINGS OF FACT 1. A lumbosacral spine disability, diagnosed degenerative joint disease, had its onset in service. 2. The Veteran’s fibromyalgia is manifested by no more than constant symptoms, or nearly so, and refractory to therapy. 3. The Veteran’s tinnitus is assigned a 10 percent rating, the maximum rating authorized under Diagnostic Code 6260. 4. The Veteran’s service-connected disabilities are of such severity so as to preclude substantially gainful employment. 5. The Veteran did not submit a claim, either formal or informal, for service connection for PTSD until May 29, 2012. 6. The Veteran did not submit a claim, either formal or informal, for service connection for headaches until May 29, 2012. 7. The Veteran did not submit a claim, either formal or informal, for service connection for irritable bowel syndrome until May 29, 2012. 8. The Veteran did not submit a claim, either formal or informal, for service connection for fibromyalgia until May 29, 2012. 9. The Veteran did not submit a claim, either formal or informal, for service connection for tinnitus until December 3, 2012. CONCLUSIONS OF LAW 1. The criteria for service connection for a lumbosacral spine disability, diagnosed degenerative joint disease, have been met. 38 U.S.C. §§ 101(24), 1101, 1110, 1112, 1113, 1117, 1131, 1137, 1154(a), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2018). 2. The criteria for an initial rating higher than 40 percent for fibromyalgia not been met. 38 U.S.C. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5025 (2018). 3. The criteria for an evaluation in excess of 10 percent for tinnitus are not met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. § 4.87, Diagnostic Code 6260 (2017). 4. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2018). 5. The criteria for an effective date earlier than May 29, 2012, for service connection for PTSD, have not been met. 38 U.S.C. §§ 5101, 5110, 7104 (West 2014); 38 C.F.R. §§ 3.1(p), 3.400 (2018). 6. The criteria for an effective date earlier than May 29, 2012, for service connection for headaches, have not been met. 38 U.S.C. §§ 5101, 5110, 7104 (West 2014); 38 C.F.R. §§ 3.1(p), 3.400 (2018). 7. The criteria for an effective date earlier than May 29, 2012, for service connection for irritable bowel syndrome, have not been met. 38 U.S.C. §§ 5101, 5110, 7104 (West 2014); 38 C.F.R. §§ 3.1(p), 3.400 (2018). 8. The criteria for an effective date earlier than May 29, 2012, for service connection for fibromyalgia, have not been met. 38 U.S.C. §§ 5101, 5110, 7104 (West 2014); 38 C.F.R. §§ 3.1(p), 3.400 (2018). 9. The criteria for an effective date earlier than December 3, 2012, for service connection for tinnitus, have not been met. 38 U.S.C. §§ 5101, 5110, 7104 (West 2014); 38 C.F.R. §§ 3.1(p), 3.400 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on verified active duty in the Army from February 2003 to June 2004, including service in Kuwait and Iraq. She also had additional service in the Tennessee Army National Guard. This matter is before the Board of Veterans’ Appeals (Board) on appeal of September 2013 and May 2018 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The September 2013 RO decision granted service connection and a 70 percent rating for PTSD, effective May 29, 2012; granted service connection and a noncompensable rating for headaches, effective May 29, 2012; granted service connection and a noncompensable rating for irritable bowel syndrome, effective May 29, 2012; and granted service connection and a 10 percent rating for tinnitus, effective December 3, 2012. By this decision, the RO also denied service connection for a lumbosacral spine disability (listed as arthritis, claimed as arthritis of the back, neck, and shoulders); a cervical spine disability (listed as arthritis, claimed as arthritis of the back, neck, and shoulders); a right shoulder disability (listed as arthritis, claimed as arthritis of the back, neck, and shoulders); a left shoulder disability (listed as arthritis, claimed as arthritis of the back, neck, and shoulders); a right leg disability (listed as right leg pain); a left leg disability (listed as left leg pain); right carpal tunnel syndrome; left carpal tunnel syndrome; GERD (listed as GERD, claimed as acid reflux); a sinus disorder, to include sinusitis (listed as a sinus condition); sleep apnea; a skin disorder (listed as skin rashes); and for bilateral hearing loss. The RO further denied claims for a TDIU and for SMC based upon the need for regular aid and attendance of another person or by reason of being housebound. The May 2018 RO decision found that there was clear an unmistakable error (CUE) in the September 2013 RO decision (noted above) that denied service connection for fibromyalgia. The RO granted service connection and a 40 percent rating for fibromyalgia, effective May 29, 2012. 1. Lumbosacral Spine Disability 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. See 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). The term “active military, naval, or air service” includes active duty, any period of active duty for training during which the individual was disabled or died from a disease or injury incurred in or aggravated in the line of duty, and any period of inactive duty training during which the individual was disabled or died from an injury incurred in or aggravated in the line of duty. 38 U.S.C. § 101 (24). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 C.F.R. § 3.310 (2015); see also Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War, on or after August 2, 1990. 38 U.S.C. § 1110. Therefore, service connection may also be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under those provisions, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1). Under 38 C.F.R. § 3.317, compensation may be warranted on a presumptive basis for disabilities due to undiagnosed illness as well as medically unexplained chronic multisymptom illnesses. See 38 C.F.R. § 3.317 (a). This means that even if a Veteran’s symptoms are attributed to a known clinical diagnosis, the presumptive provisions related to Gulf War service still apply. In particular, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, or disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). Therefore, even if a multisymptom illness has a diagnosis, consideration should still be given as to whether the disability has no known etiology, or has a known, partially understood etiology. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran’s demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). The Veteran contends that she has a lumbosacral spine disability that is related to service. She specifically maintains that she fell off a truck and injured her head and back during her period of active duty in 2003. She reports that she has suffered from low back pain since that time. The Veteran essentially asserts that she had lumbosacral spine problems during and since service. The service treatment records for her period of active duty from February 2003 to June 2004 show treatment for low back problems on multiple occasions. On a medical history form at the time of a February 2003 examination, the Veteran reported that she pulled a muscle in her back. The notations from the reviewing examiner were not of record. The objective February 2003 examination report includes a notation that the Veteran’s spine and other musculoskeletal systems were normal. A May 2004 post-deployment health assessment report notes that the Veteran reported that she had back pain during her deployment and currently. There was a notation that the Veteran had questions about problems, including joint pain. A diagnosis was not provided at that time. On a medical history form at the time of a May 2004 examination, the Veteran reported medical problems, including joint pain. The reviewing examiner indicated that the Veteran had low back pain. The objective May 2004 examination report was not of record. A May 2004 hospital treatment report notes that the Veteran complained of problems including back pain. The impression included back pain. A subsequent May 2004 hospital treatment report indicates that the Veteran had degenerative joint disease of the lumbosacral spine. The impression included chronic arthritic changes. Post-service private and VA treatment records, including an examination report, show treatment for low back pain; lumbar strain; and a history of arthritis since 2010 based on x-rays, with most complaints in the neck and lumbar back regions. The Board notes that the Veteran was diagnosed with arthritis of the lumbosacral spine during her period of active duty from February 2003 to June 2004. The Board notes that post-service treatment records show current treatment for arthritis in the lumbar back region. The Board notes that degenerative joint disease of the lumbosacral spine is a chronic disease subject to presumptive service connection, provided that it is manifest to a compensable degree within one year after separation from service. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a), 3.384; Groves v. Peake, 524 F.3d 1306, 1309 (Fed. Cir. 2008). As a compensable lumbosacral spine disability, diagnosed as degenerative joint disease, was diagnosed during service, and the Veteran currently is diagnosed as having that disability, service connection is warranted. Therefore, service connection for a lumbosacral spine disability, diagnosed as degenerative joint disease, is granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As the Board has granted direct service connection in this matter, it need not address other theories of service connection. 2. Initial Rating Higher than 40 Percent for Fibromyalgia Ratings for service-connected disabilities are determined by comparing the veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2018). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings 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 (2018). 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 (2018). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009). The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2015). It should also be noted that use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2015). Fibromyalgia with widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms that requires continuous medication for control warrants a 10 percent rating. When the symptoms of fibromyalgia are episodic, with the exacerbations often precipitated by environmental or emotional stress or by overexertion, but are present more than one-third of the time, a 20 percent rating is assigned. A 40 percent rating, the maximum rating available under this code, is warranted when fibromyalgia is constant, or nearly so, and refractory to therapy. “Widespread pain” means pain in both the left and right sides of the body that is both above and below the waist, and that affects both axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities. 3 8 C.F.R. § 4.71a, Diagnostic Code 5025. The Veteran essentially contends that her fibromyalgia is worse than contemplated by her currently assigned disability rating and that a higher rating is therefore warranted for that service-connected disability. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). A May 2013 VA fibromyalgia examination report includes a notation that the Veteran’s claims file was reviewed. The Veteran reported that she was diagnosed with fibromyalgia in September 2011. She stated that she was diagnosed with fibromyalgia at a VA rheumatology clinic. She indicated that she had suffered pain since 2003. The Veteran related that the pain started in isolated areas like her knees, shoulders, and her back. She maintained that the pain started while she was deployed in Iraq, and that after she returned home, the pain worsened. The Veteran indicated that she had generalized pain all over her body, which was getting more intense. She reported that she was given Cymbalta for her fibromyalgia, but that she could not tolerate it. The examiner reported that continuous medication was required for control of the Veteran’s fibromyalgia symptoms. It was noted that the Veteran was presently taking Meloxicam, Hydrocodone, and Gabapentin. The examiner stated that the Veteran was currently undergoing treatment for her fibromyalgia and that her symptoms were refractory to therapy. The examiner indicated that the Veteran stated that her symptoms were slightly better, but that she continued to suffer. The examiner reported that the Veteran had findings, signs, or symptoms attributable to her fibromyalgia that included widespread musculoskeletal pain; stiffness; muscle pain, with generalized pain all over her extremities and trunk, as well as feeling weak in her arm muscles; fatigue; sleep disturbances; paresthesias; headaches; depression; anxiety; and irritable bowel syndrome. The examiner indicated that the Veteran had tiredness all the time, but that she did not sleep well. It was noted that the Veteran was suspected to have sleep apnea per a rheumatological note. The examiner maintained that the Veteran had paresthesias in her feet and daily headaches. The examiner reported that the Veteran suffered from depression, anxiety, and bowel disease, and that she was currently under treatment. The examiner indicated that the Veteran’s fibromyalgia symptoms were constant or nearly constant, and that they were often precipitated by environmental or emotional stress or overexertion. It was noted that heat or stressful situations could cause the Veteran’s symptoms. The examiner stated that the Veteran’s tender points for pain were all tender points, bilaterally. The diagnosis was fibromyalgia. The examiner reported that the Veteran’s fibromyalgia impacted her ability to work. The examiner stated that the Veteran finished school and got her degree as a licensed practical nurse. The examiner reported that the Veteran maintained that she was not able to work because of her pain. It was noted that the Veteran reported that she could not walk and be on her feet, which was required for her job. The examiner specifically stated that the Veteran had fibromyalgia, that she was symptomatic and currently being treated, and that she was not able to work because of her current condition. The Board notes that the current 40 percent disability rating is the maximum rating allowed for fibromyalgia under Diagnostic Code 5025 and it contemplates symptoms that are constant, or nearly so, and refractory to therapy. As the Veteran is already receiving the highest rating for this disability, a schedular increase is not warranted. Moreover, the Board finds that the Veteran’s fibromyalgia should not be rated under another Diagnostic Code because Diagnostic Code 5025 specifically compensates Veteran’s appellants for fibromyalgia. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (holding that the assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.”). The Board further finds that the Veteran has not identified, nor does the record reflect, any symptoms as a result of her fibromyalgia that are not contemplated by the schedular rating criteria. See Doucette v. Shulkin, 28 Vet. App. 366 (2018). Therefore, the preponderance of the evidence is against the claim for an initial rating higher than 40 percent for fibromyalgia; there is no doubt to be resolved, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. 3. Initial Rating Higher than 10 Percent for Tinnitus The Veteran claims that her tinnitus warrants a rating greater than 10 percent. In a September 2013 rating decision, the RO granted service connection and a 10 percent rating for tinnitus, effective December 3, 2012. The Veteran’s tinnitus is rated under Diagnostic Code 6260, which allows for a maximum schedular rating of 10 percent. The version of Diagnostic Code 6260 in effect since June 13, 2003 provides that only a single evaluation can be assigned for recurrent tinnitus, whether the sound is perceived in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note (2). This interpretation of the diagnostic code was affirmed by the United States Court of Appeals for the Federal Circuit (Federal Circuit) in the case of Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). In that case, the Federal Circuit concluded that VA’s interpretation of 38 C.F.R. § 4.25 and Diagnostic Code 6260, which limit a veteran to a single disability rating for tinnitus, regardless of whether the tinnitus is unilateral or bilateral, was permissible and her symptoms are contemplated by the schedular criteria. As such, a higher rating is denied. 4. TDIU The provisions of 38 C.F.R. § 4.16(a) provide for a TDIU when, due to service-connected disability, a veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, or at least one disability rated 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, “entitlement to TDIU is based on an individual’s particular circumstances.” Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, in adjudicating a TDIU claim, VA must take into account the individual Veteran’s education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (considering Veteran’s experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran’s 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering Veteran’s master’s degree in education and his part-time work as a tutor). The Veteran essentially contends that her service-connected disabilities prevent gainful employment, warranting a TDIU. She reports that all of her service-connected disabilities, prevent her from securing or following any substantially gainful occupation. The Veteran’s current service-connected disabilities are PTSD (rated 70 percent); headaches (rated 0 percent); irritable bowel syndrome (rated 0 percent); fibromyalgia (rated 40 percent); and tinnitus (rated 10 percent). The combined disability is 80 percent, which clearly meets the schedular requirements to be considered for a TDIU. Additionally, as discussed above, the Board has granted service connection for a lumbosacral spine disability, diagnosed as degenerative joint disease, that has not been rated by the RO at this time. The remaining question is whether the Veteran is unemployable due to her service-connected disabilities alone, taking into consideration her educational and occupational background. The record reveals that the Veteran completed one year of college and that she has not worked full-time since January 2010. The Veteran has described his previous employment as a “stacker.” She is also a licensed practical nurse. The Board observes that there are multiple VA examination reports of record, to include an April 2013 VA psychiatric examination report and an April 2013 VA fibromyalgia examination report, as well as a July 2018 psychiatric examination report from H. Henderson-Gallagher, PhD., that include statements addressing the Veteran’s unemployability. Based upon the evidence of record, and resolving reasonable doubt in the Veteran’s favor, the Board concludes that the Veteran’s service-connected disabilities in combination with each other have rendered her unable to secure or follow a substantially gainful occupation. 5. Earlier Effective Dates for Service Connection for PTSD, Headaches, Irritable Bowel Syndrome, Fibromyalgia, and for Tinnitus The Veteran essentially contends that service connection for her PTSD, headaches, irritable bowel syndrome, and fibromyalgia, should be effective earlier than May 29, 2012. She also asserts that service connection for her tinnitus should be effective earlier than December 3, 2012. See Scott, 789 F.3d at 1375. The Veteran’s claims arise from her disagreement with the effective dates assigned following the grant of service connection for PTSD, headaches, irritable bowel syndrome, fibromyalgia, and for tinnitus. The basic facts are not in dispute. As the RO noted, the Veteran’s initial applications for service connection for PTSD, headaches, irritable bowel syndrome, and for fibromyalgia were filed with VA on May 29, 2012. The Veteran’s initial application for service connection for tinnitus was filed with VA on December 3, 2012. Indeed, the Veteran does not contend otherwise. Unless specifically provided otherwise in the statute, the effective date of an award based on an original claim for compensation benefits shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400. 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.A. § 5110(b); 38 C.F.R. § 3.400(b)(2). A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C.A. § 5101(a); 38 C.F.R. § 3.151(a). The term “claim” or “application” means a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). Any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA, from a veteran or his representative, may be considered an informal claim. Such informal claim must identify the benefit sought. 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 one year from the date it was sent to the veteran, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155. Here, the RO granted service connection and a 70 percent rating for PTSD, granted service connection and a noncompensable rating for headaches; granted service connection and a noncompensable rating for irritable bowel syndrome; and granted service connection and a 40 percent rating for fibromyalgia, all effective on the date that the Veteran’s original claims for service connection for PTSD, headaches, irritable bowel syndrome, and for fibromyalgia, were filed with VA. The RO also granted service connection and a 10 percent rating for tinnitus effective the date the Veteran’s original claim for service connection for tinnitus was filed with VA. An effective date of an award of service connection is not based on the earliest medical evidence showing a causal connection, but on the date that the application upon which service connection was eventually awarded was filed with VA. Lalonde v. West, 12 Vet. App. 377, 382 (1999). Because the Veteran did not file formal or informal applications for service connection for PTSD, headaches, irritable bowel syndrome, and for fibromyalgia prior to May 29, 2012, VA is precluded, as a matter of law, from granting effective dates, respectively, prior to May 29, 2012, for service connection for PTSD, headaches, irritable bowel syndrome, and for fibromyalgia. Additionally, as the Veteran did not file a formal or informal application for service connection for tinnitus prior to December 3, 2012, VA is precluded, as a matter of law, from granting an effective date prior to December 3, 2012, for service connection for tinnitus. As such, these claims must be denied because the RO has already assigned the earliest possible effective dates, respectively, provided by law. REASONS FOR REMAND The remaining issues on appeal are entitlement to service connection for a cervical spine disability; entitlement to service connection for a right shoulder disability; entitlement to service connection for left shoulder disability; entitlement to service connection for a right leg disability; entitlement to service connection for a left leg disability; entitlement to service connection for right carpal tunnel syndrome; entitlement to service connection for left carpal tunnel syndrome; entitlement to service connection for GERD; entitlement to service connection for a sinus disorder, to include sinusitis; entitlement to service connection for sleep apnea; entitlement to service connection for a skin disorder; entitlement to service connection for bilateral hearing loss; entitlement to an initial rating higher than 70 percent for PTSD; entitlement to an initial higher (compensable) rating for headaches; entitlement to an initial higher (compensable) rating for irritable bowel syndrome; and entitlement to SMC based upon the need for regular aid and attendance of another person or by reason of being housebound. The Veteran contends that she has a cervical spine disability; right and left shoulder disabilities; right and left leg disabilities; right and left carpal tunnel syndrome; GERD; a sinus disorder, to include sinusitis; sleep apnea; a skin disorder, and bilateral hearing loss, that are all related to service. She further contends that many of such disorders are the result of her service in Southwest Asia and should be considered under the provisions of 38 C.F.R. § 3.317 (2018). The Veteran is competent to report having cervical spine and or neck problems; right and left shoulder problems; right and left leg problems; right and left wrist problems; gastrointestinal problems; sinus problems; sleep problems; skin problems, and hearing problems during service and since service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran served on verified active duty in the Army from February 2003 to June 2004, including service in Kuwait and Iraq. She also had additional service in the Tennessee Army National Guard. The Veteran’s service treatment records for her period of active duty from February 2003 to 2004 show treatment for neck problems; shoulder problems; left knee problems; painful joints; complaints of a runny nose; complaints of numbness and tingling of the hands; and a skin rash. Such records do not specifically show treatment for right and left carpal tunnel syndrome; GERD; sinusitis; sleep apnea; or hearing problems. Post-service private and VA treatment records show treatment for cervical spondylosis; degenerative arthritis of the left shoulder; right and left leg complaints; right carpal tunnel syndrome; left carpal tunnel syndrome; GERD; sinusitis; sleep apnea; a skin rash; and hearing loss. An April 2013 VA neck conditions examination report includes a notation that the Veteran’s claims file was reviewed. The diagnosis was cervical spondylosis. The examiner indicated that the claimed condition was less likely as not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner reported that the Veteran appeared to have degenerative disease of the cervical spine, which was a common and multi-factorial condition that may be caused by aging, genetics, activities of daily living, and sports. The examiner maintained that, therefore, it was highly unlikely that her cervical complaints in the military caused her cervical degenerative disease. The Board observes that the examiner did not provide much in the way of a rationale for his opinion that the Veteran’s cervical spine degenerative disease was not caused by her military service. The examiner also did not address the Veteran’s reports of cervical spine problems during and since service. See Davidson, 581 F.3d at 1313. The Board notes that the examiner also did not address whether the Veteran’s diagnosed cervical disability was a result of her service in Southwest Asia and should be considered under the provisions of 38 C.F.R. § 3.317. An April 2013 VA shoulder and arm conditions examination report includes a notation that the Veteran’s claims file was reviewed. The examiner stated that the Veteran did not have, and never had, shoulder and/or arm conditions. The examiner indicated that the claimed condition was less likely as not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner reported that based upon his examination and review of x-rays, the Veteran did not have arthritis of the shoulders. The examiner maintained that, therefore, it was impossible that her military service could have caused a condition that currently did not exist. The Board notes that the examiner indicated that the Veteran did not have, and never had, shoulder and/or arm conditions. The Board notes, however, that an August 2009 radiology report from Baptist Memorial Hospital, as to the Veteran’s left shoulder, relates an impression that included mild acromioclavicular degenerative arthritis. The Board notes that the “current disability” requirement for service connection is satisfied if a claimant has a disability at any time during the pendency of a claim, even if the disability resolves prior the adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The examiner also did not address the Veteran’s treatment for shoulder complaints during service, and her reports of shoulder problems during and since service. See Davidson, 581 F.3d at 1313. The Board notes that the Veteran was not afforded VA examinations as to her claims for service connection for a right leg disability; a left leg disability; right carpal tunnel syndrome; left carpal tunnel syndrome; and a sinus disorder, to include sinusitis. An April 2013 VA esophageal conditions examination report includes a notation that the Veteran’s claims file was reviewed. The diagnosis was GERD. The examiner indicated that GERD was a medical condition easily diagnosed with a known etiology and that it was less likely than not secondary to Gulf War service. The Board notes that the examiner did not address whether the Veteran’s diagnosed GERD was secondary to any of her service-connected disabilities, to include PTSD and irritable bowel syndrome. In El-Amin v. Shinseki, 26 Vet. App. 136 (2013), a decision issued by the United States Court of Appeals for Veterans Claims (Court), the Court vacated a decision of the Board where a VA examiner did not specifically opine as to whether a disability was aggravated by a service-connected disability. The Board notes that an April 2013 VA Gulf War examination report includes a notation that the claims file was reviewed. The examiner reported that the Veteran mentioned as skin rash in May 2004. The examiner stated that despite a careful review of the claims file, he was not able to locate that note and that only one VA treatment entry mentions a skin rash. The examiner indicated that since no rash had been seen, he could not speculate on its etiology or any relationship to the Veteran’s Gulf War service. The examiner indicated that other medical conditions of obstructive sleep apnea, hearing loss, and arthritis all had known etiologies and no other chronic multisymptom illnesses with unknown or partially known etiologies were identified. The Board observes that the examiner did not provide much in the way of rationales for his various opinions. Additionally, the examiner did not specifically address the Veteran’s reports of skin problems during and since service and any reports of sleep problems during and since service. See Davidson, 581 F.3d at 1313. An April 2013 VA audiological examination report includes a notation that the Veteran’s claims file was reviewed. The examiner solely reported test results for the Veteran’s right ear. The examiner indicated that test results were not reported for the Veteran’s left ear because there was a conductive hearing loss. The diagnosis was normal hearing in the right ear and conductive hearing loss in the left ear. The examiner indicated that she could not provide a medical opinion regarding the etiology of the Veteran’s hearing loss without resorting to speculation. The examiner further stated that no opinion was warranted for the Veteran’s right ear because the Veteran had normal hearing, but that an opinion from an ears, nose, and throat examination should be obtained for the left ear due to the nature of the hearing loss. A May 2015 VA ear disease examination report includes a notation that the Veteran’s claims file was reviewed. The examiner maintained that the Veteran’s otalgia was likely a function of having her ear operated on, and that there might be some irritation in the middle ear from having a perforation of the tympanic membrane. The examiner stated that the traumatic perforation did not occur as a result of her military service. The Board notes that the examiner, pursuant to the May 2015 VA ear disease examination report, did not specifically address the Veteran’s left ear hearing loss. Additionally, subsequent VA treatment records refer to hearing loss. See McClain, 21 Vet. App. 319, 321 (2007). In light of the above, the Board finds that the Veteran should be afforded a VA examination, or examinations, with the opportunity to obtain responsive etiological opinions, following a thorough review of the record, as to her claims for service connection for a cervical spine disability; a right shoulder disability; a left shoulder disability; a right leg disability; a left leg disability; right carpal tunnel syndrome; left carpal tunnel syndrome; GERD; a sinus disorder, to include sinusitis; sleep apnea; a skin disorder; and bilateral hearing loss. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (an adequate VA medical examination must consider the Veteran’s pertinent medical history). As to the Veteran’s claims for higher ratings for PTSD; headaches; and irritable bowel syndrome, the Board notes that the Veteran was last afforded respective VA examination reports in April 2013. Since that time, the Veteran has received additional treatment. The Board observes that the Veteran has not been afforded VA examinations, as to her service-connected PTSD; headaches; and irritable bowel syndrome, in well over four and a half years. Additionally, the record raises a question as to the current severity of those service-connected disabilities. As such, a remand is necessary to remand these matters to afford her an opportunity to undergo contemporaneous VA examinations. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Additionally, as the Veteran’s claim for SMC based upon the need for regular aid and attendance of another person or by reason of being housebound is inextricably intertwined with her claims for service connection and higher ratings, action on the issue is deferred. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Ask the Veteran to identify all medical providers who have treated her for cervical spine problems; right and left shoulder problems; right and left leg problems; right and left carpal tunnel syndrome; GERD; a sinus disorder, to include sinusitis; sleep apnea; skin problems; hearing problems; PTSD; headaches; and irritable bowel syndrome, since March 2018. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise her that she may obtain and submit those records himself. 2. Notify the Veteran that she may submit lay statements from herself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of her in-service and post-service symptoms of her claimed cervical spine disability; right shoulder disability; left shoulder disability; right leg disability; left leg disability; right carpal tunnel syndrome; left carpal tunnel syndrome; GERD; sinus disorder, to include sinusitis; sleep apnea; skin disorder; and bilateral hearing loss, as well as the nature, extent, and severity of her PTSD; headaches; and irritable bowel syndrome and the impact of those conditions on her ability to work. She should be afforded an appropriate amount of time to submit this lay evidence. 3. Schedule the Veteran for a VA examination(s) to determine the nature, onset and etiology of her claimed cervical spine disability; right shoulder disability; left shoulder disability; right leg disability; left leg disability; right carpal tunnel syndrome; left carpal tunnel syndrome; GERD; sinus disorder, to include sinusitis; sleep apnea; skin disorder; and bilateral hearing loss. The claims file must be reviewed by the examiner(s). Based on the results of the examination, the examiner(s) is (are) asked to address each of the following questions: (a) Please state whether the symptoms of each claimed condition are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had any such condition, when did that condition resolve? (b) Is the Veteran’s disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? (c) If, after examining the Veteran and reviewing the claims file, it is determined that the Veteran’s disability pattern is either (1) a diagnosable chronic multisymptom illness with a partially explained etiology, or (2) a disease with a clear and specific etiology and diagnosis, then please provide an expert opinion as to whether it is related to presumed environmental exposures experienced by the Veteran during service in Southwest Asia. (d) Is it at least as likely as not that any diagnosed disorder had its onset directly during the Veteran’s service or is otherwise causally related to any event or circumstance of his service, including environmental exposures during service in Southwest Asia during the Persian Gulf War? (e) If not directly related to service on the basis of questions (b)-(d), is any medical condition proximately due to, the result of, or caused by any service-connected disability(ies)? (f) If not caused by another medical condition, has any disorder been aggravated (made permanently worse or increased in severity) by any service-connected disability(ies)? If yes, was that increase in severity due to the natural progress of the disease. In responding to the above inquiries, please acknowledge and discuss the Veteran’s treatment for neck problems; shoulder problems; left knee problems; painful joints; complaints of a runny nose; complaints of numbness and tingling of the hands and a skin rash during service, and any reports of the Veteran of treatment for her claimed disabilities during and since service. 4. Schedule the Veteran for an appropriate VA examination to determine the extent and severity of her service-connected PTSD. The entire claims file, to include all electronic files, must be reviewed by the examiner. All indicated tests must be conducted and all symptoms associated with the Veteran’s service-connected condition must be described in detail. 5. Schedule the Veteran for an appropriate VA examination to determine the extent and severity of her service-connected headaches. The entire claims file, to include all electronic files, must be reviewed by the examiner. All indicated tests must be conducted and all symptoms associated with the Veteran’s service-connected condition must be described in detail. 6. Schedule the Veteran for an appropriate VA examination to determine the extent and severity of her service-connected irritable bowel syndrome. The entire claims file, to include all electronic files, must be reviewed by the examiner. All indicated tests must be conducted and all symptoms associated with the Veteran’s service-connected condition must be described in detail. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. D. Regan, Counsel