Citation Nr: 1808751 Decision Date: 02/12/18 Archive Date: 02/23/18 DOCKET NO. 12-19 153 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for bladder cancer. 2. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for erectile dysfunction (ED). 3. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for chloracne. 4. Entitlement to service connection for prostate cancer. 5. Entitlement to service connection for bladder cancer. 6. Entitlement to service connection for obstructive sleep apnea (OSA). 7. Entitlement to service connection for hypertension. 8. Entitlement to an initial disability rating in excess of 10 percent prior to May 27, 2014, and in excess of 50 percent thereafter, for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: J. Michael Woods, Attorney ATTORNEY FOR THE BOARD J.A. Gelber, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1969 to March 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from January 2011, March 2015, and January 2016 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a Board hearing in his Form 9 substantive appeal. However, he withdrew that request in correspondence received by VA in November 2017. The Veteran was initially assigned a 10 percent rating for PTSD. An October 2014 rating decision assigned a 50 percent rating effective May 27, 2014. Although an increased rating was granted for PTSD, the issue remained in appellate status, as the maximum schedular rating had not been assigned for the entire period on appeal. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). A notice of disagreement (NOD) received by VA in October 2015 indicates the Veteran's intent to appeal the effective date of the grant of the 50 percent rating for PTSD. The Board notes that the issue of the effective date of the increased rating for PTSD is contemplated by the initial increased rating claim on appeal, and is addressed by the Board herein. The issues of whether to reopen the claim for ED and service connection for prostate cancer, bladder cancer, and hypertension are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In a January 2011 rating decision, the AOJ denied service connection for bladder cancer; a timely notice of disagreement was not filed, and no new and material evidence was received within the appeal period. 2. Additional evidence received since the January 2011 decision is new, relates to an unestablished fact necessary to substantiate the claim of service connection for bladder cancer, and raises a reasonable possibility of substantiating the claim. 3. In a January 2011 rating decision, the AOJ denied service connection for chloracne; a timely notice of disagreement was not filed, and no new and material evidence was received within the appeal period. 4. Evidence received since the January 2011 decision is either cumulative or redundant of the evidence of record at the time of the January 2011 denial and, by itself or in conjunction with the evidence previously assembled, does not relate to an unestablished fact necessary to substantiate the claim of service connection for chloracne or trigger VA's duty to assist. 5. The competent and probative evidence is at least in equipoise as to whether OSA is related to the Veteran's service-connected PTSD. 6. The competent and probative evidence is at least in equipoise as to whether the Veteran's PTSD-related symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) prior to May 27, 2014. 7. The weight of the competent and probative evidence is against finding that the Veteran's PTSD-related symptoms resulted in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood as of May 27, 2014, and prior to March 30, 2017. 8. The competent and probative evidence is at least in equipoise as to whether the Veteran's PTSD-related symptoms result in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood as of March 30, 2017. CONCLUSIONS OF LAW 1. The January 2011 decision denying the claim of entitlement to service connection for bladder cancer is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.1103 (2017). 2. New and material evidence has been received since the January 2011 decision to reopen the claim of entitlement to service connection for bladder cancer. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 3. The January 2011 decision denying the claim of entitlement to service connection for chloracne is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.1103. 4. Evidence received since the January 2011 decision is not new and material; accordingly, the claim of service connection for chloracne is not reopened. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.156(a). 5. The criteria for entitlement to service connection for OSA have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 6. The criteria for entitlement to an initial disability rating of 30 percent, but no higher, for PTSD prior to May 27, 2014, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411 (2017). 7. The criteria for entitlement to an initial disability rating in excess of 50 percent as of May 27, 2014, and prior to March 30, 2017, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, DC 9411. 8. The criteria for entitlement to an initial disability rating of 70 percent, but no higher, for PTSD as of March 30, 2017, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA sent a letter to the Veteran in January 2010, prior to adjudication of his claims of service connection for prostate cancer and PTSD. No further notice is required regarding the downstream issue of a higher initial rating for PTSD as it stems from the grant of service connection and no prejudice has been alleged. Although notice was sent subsequent to the March 2015 rating decision denying the petition to reopen the claim of service connection for chloracne, such timing error was cured by subsequent readjudication of the claim in the October 2016 statement of the case (SOC) and the opportunity to provide subsequent argument and/or evidence. See Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Accordingly, the Board finds that the Veteran was not prejudiced by the failure to provide such notice prior to initial adjudication of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015), cert. denied, 137 S. Ct. 33 (2016) ("A veteran's interest may be better served by prompt resolution of his claims rather than by further remands to cure procedural errors that, at the end of the day, may be irrelevant to final resolution and may indeed merely delay resolution."). Regarding the issues of whether to reopen the claim for bladder cancer and entitlement to service connection for OSA, as those issues are being granted in full herein, any deficiency as to VA's duties to notify and assist would be harmless error and will not be discussed. Next, VA has a duty to assist the Veteran in the development of his claims, including assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017). The Veteran's military personnel and treatment records, as well as all available, identified medical records, have been associated with the virtual file and considered. The Veteran was afforded relevant VA examinations in August 2010 and May 2014. Regarding the claim for chloracne, VA is not required to secure a medical examination or opinion in a claim to reopen a previously denied claim unless it is determined that new and material evidence has been submitted and the claim is reopened. 38 C.F.R. § 3.159(c)(4)(iii); see Woehlaert v. Nicholson, 21 Vet. App. 456, 464 (2007) (noting that once the Board decides a claim cannot be reopened, the Secretary's duty to provide the appellant with a medical examination is extinguished). When a VA examination is provided in a case where the Board denies reopening, such as here, the Board is not required to establish the adequacy of the examination on appeal. Id. In light of the foregoing, the Board will proceed to the merits of the appeal. II. New and Material Evidence Generally, a claim which has been denied in a final decision by an AOJ may not thereafter be reopened and allowed. 38 U.S.C. § 7105(b). However, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary must reopen the claim and review its former disposition. 38 U.S.C. § 5108. To be considered new, evidence cannot have been previously submitted to agency decision makers, or be cumulative or redundant of evidence of record at the time of the last prior final denial. To be material, evidence must, by itself or when considered with previous evidence of record, relate to an unestablished fact necessary to substantiate the claim, and raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). The credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). In deciding whether new and material evidence has been submitted, the Board considers evidence submitted since the time that the claim was finally disallowed on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). A. Bladder Cancer After reviewing the record, the Board finds that new evidence has been received since the final prior decision, and such evidence is material to the issue of service connection for bladder cancer. In January 2011, the AOJ denied service connection for bladder cancer, stating that the evidence is against finding that bladder cancer manifested during or is otherwise related to the Veteran's period of active service. The rating decision added that the available scientific and medical evidence does not support the conclusion that bladder cancer is associated with herbicide exposure and denied presumptive service connection. The Veteran did not file a timely notice of disagreement and no new and material evidence was received within the appeal period; therefore, the January 2011 decision became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156(b), 20.1103. Consequently, the Board will consider evidence received since the January 2011 decision. An August 2014 treatment note indicates that in 2009 the Veteran was diagnosed with prostate cancer with metastasis to the bladder. 10/07/2014, Medical-Non-Government. A similar finding is reflected in a June 2013 decision by the Social Security Administration (SSA) Appeals Council. 07/18/2013, Medical-SSA. The Board finds that this evidence is new and that it directly pertains to the basis for the prior final denial, by addressing whether bladder cancer is related to the Veteran's period of active service, to include as secondary to prostate cancer. Therefore, the claim of service connection for bladder cancer is reopened. See 38 U.S.C. § 5108; 38 C.F.R. §3.156(a). B. Chloracne In January 2011, the AOJ denied service connection for chloracne, stating that the evidence is against finding a current disability. The Veteran did not file a timely notice of disagreement and no new and material evidence was received within the appeal period; therefore, the January 2011 decision became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156(b), 20.1103. Consequently, the Board will consider evidence received since the January 2011 decision. After reviewing the record, the Board finds that evidence received since the January 2011 decision denying service connection for chloracne is either cumulative or redundant of the evidence of record at the time of the January 2011 denial and, by itself or in conjunction with the evidence previously assembled, does not relate to an unestablished fact necessary to substantiate the claim of service connection for chloracne. In July 2014, VA received copies of April 2010 and August 2010 VA examinations and articles on chloracne, including the Veteran's contention that he has all of the symptoms of chloracne. 07/16/2014, Medical-Non-Government; 07/16/2014, Web/HTML Documents. Regarding the April 2010 and August 2010 VA examinations, that evidence is not new, as it was considered by the AOJ in the January 2011 rating decision. Regarding the articles on chloracne submitted by the Veteran, to include some with hand-written notations, while the Veteran is competent to report symptoms and experiences observable by his senses, he is not competent to provide a diagnosis of chloracne. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). The Board notes that the symptoms reported by the Veteran, such as those highlighted in the newly submitted articles, were previously considered by the April 2010 and August 2010 VA examiners. As such, the Board finds that this information is redundant because it does not demonstrate that the Veteran has diagnosis of chloracne; therefore, the articles do not address a previously unestablished element of service connection and not do raise a reasonable possibility of substantiating the claim. In sum, the Board finds that evidence received since the January 2011 decision is either cumulative or redundant of the evidence of record at the time of the January 2011 denial, as it does not tend to support finding a current disability. As new and material evidence has not been received, the claim of entitlement to service connection for chloracne is not reopened. III. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). As a general matter, establishing service connection requires competent evidence of (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Alternatively, service connection may be granted on a secondary basis for a disability that is proximately due to or the result of (caused) or worsened beyond its natural progression (aggravated) by a service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439, 448-49 (1995) (en banc); 38 C.F.R. § 3.310. The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau, 492 F.3d at 1377; 38 C.F.R. § 3.159(a). In relevant part, 38 U.S.C. § 1154(a) (2012) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990). After review of the record, the Board finds that the criteria for service connection for OSA have been met. The record demonstrates competent evidence of a diagnosis of OSA, moderate. 12/10/2015, CAPRI. Thus, the Board finds that a current disability exists. In June 2017, VA received a May 2017 sleep apnea examination completed by a private physician. The physician opined that it is at least as likely as not that the Veteran's OSA was caused and has been aggravated by his service-connected PTSD. In support, the physician cited to a May 2014 VA examination noting chronic sleep impairment associated with PTSD, medical research demonstrating a relationship between PTSD and OSA, and the Veteran's report that he is unable to use his continuous positive airway pressure (CPAP) machine due to anxiety and panic attacks, which the physician noted aggravates the effects of sleep apnea. 06/07/2017, Other, p. 82. Accordingly, the Board finds that the competent and probative evidence is at least in equipoise as to whether the Veteran's OSA is secondary to service-connected PTSD. IV. Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 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 the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the course of the appeal. Id. at 126-27; Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3; see Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990). 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 (2017). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the disorder. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath, 1 Vet. App. at 593. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one disorder is not duplicative of the symptomatology of the other disorder. 38 C.F.R. § 4.14 (2017); Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau, 492 F.3d at 1377; 38 C.F.R. § 3.159(a). The Veteran contends he is entitled to an initial disability rating in excess of 10 percent prior to May 27, 2014, and in excess of 50 percent thereafter, for PTSD, evaluated under Diagnostic Code 9411. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings based on a spectrum of symptoms. "A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The United States Court of Appeals for Veterans Claims (Court) has observed that the listed symptoms are examples of the type and degree of the manifestations of a mental disability required for a given disability rating, and that "the presence of all, most, or even some, of the enumerated symptoms" is not required to support a disability rating. Mauerhan, 16 Vet. App. at 442. Accordingly, it is not sufficient for the Board to simply match the symptoms listed in the rating criteria against those exhibited by a veteran. Rather, "VA must engage in a holistic analysis" of the severity, frequency, and duration of the signs and symptoms of the veteran's mental disorder, determine the level of occupational and social impairment caused by those signs and symptoms, and assign an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula, the criteria for a 30 percent rating are as follows: 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, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. The criteria for a 50 percent rating are as follows: 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. The criteria for a 70 percent rating are as follows: 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; obsessive 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 worklike setting); and an inability to establish and maintain effective relationships. Id. The criteria for a 100 percent rating are as follows: Total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, own name. Id. A. Prior to May 27, 2014 After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating of 30 percent, but no higher, for PTSD prior to May 27, 2014, is warranted. In August 2010, the Veteran was afforded a VA examination, at which time he reported experiencing nightmares, flashbacks, sleep impairment, problems with concentration, hypervigilance, exaggerated startle response, dysphoric mood, decreased interest in pleasurable activities, and passive suicidal ideation. The Veteran reported being married for 12 years, having two or three close friends, and getting along fine with coworkers and supervisors. The examiner conducted a mental status examination and made the following findings: cooperative; normal thought process; no delusions or hallucinations; competent to conduct activities of daily living (ADLs); oriented to time, place, and person; affect appropriate but restricted; mood mildly dysphoric; below average concentration and short-term memory; and passive suicidal ideation without intention. 08/24/2010, VA Examination. Based on the foregoing, the examiner assigned a Global Assessment of Functioning (GAF) score of 45. A GAF score between 41 and 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See DSM-IV (emphases added). The Board finds the August 2010 VA examination to be competent, credible, and highly probative, as it is supported by an in-person examination, mental health expertise, review of the relevant medical records, and a sufficient rationale. Accordingly, the Board finds that competent and probative medical and lay evidence is at least in equipoise as to whether the Veteran's PTSD-related symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) prior to May 27, 2014. Specifically, the Board finds the exhibited symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss as resulting in social and occupational impairment support the finding of a higher rating. The Board engaged in a holistic analysis of the severity, frequency, and duration of the signs and symptoms of the Veteran's PTSD, but finds that his mental health symptoms do not more nearly approximate a 50 percent rating prior to May 27, 2014. In fact, the Veteran's symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss are specifically contemplated under the rating criteria for a 30 percent evaluation. See 38 C.F.R. § 4.130 Regarding employment, the Veteran reported working as a real estate broker from May 1994 to October 2009, but became too disabled to work at that time due to bladder and/or prostate cancer. 08/18/2010, Medical-SSA. The Board notes that the Veteran's specific occupation would require skills such as logical thinking, understanding complex process, and employing good judgment. Regarding social impairment, the Veteran's 30 percent rating accounts for his lack of friends and diminished interest in hobbies. The Board notes that the evidence reflects that the Veteran had been married for 12 years and had two or three close friends weighs against a higher rating as such evidence shows that he can establish and maintain effective work and social relationships. In finding that the weight of the competent evidence does not support occupational and social impairment with reduced reliability and productivity, the Board has also considered as a factor that the evidence does not demonstrate such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of long-term memory; impaired judgment; or impaired abstract thinking. See 38 C.F.R. § 4.130. The Board notes the examiner's finding that the Veteran's symptoms included suicide ideation. The Court of Appeals for Veterans Claims (Court) has noted that, "[T]he 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 with deficiencies in most areas." See Bankhead, 29 Vet. App. at 20 (affirming that suicidal ideation does not require suicidal intent, a plan, or prepatory behavior). Nonetheless, the Veteran had close friends, was married for over 10 years, and worked in real estate. The 2010 examiner noted that the Veteran was oriented and was competent to conduct his activities of daily living. Thus, when view against the totality of the medical and lay evidence, the Board finds that the Veteran's symptomatology, to include suicidal ideation, are more nearly approximated by the now assigned initial 30 percent rating All possible applicable diagnostic codes have been considered, but the Veteran could not receive a higher or separate rating for PTSD prior to May 27, 2014. See 38 C.F.R. § 4.130. Indeed, when a disorder is listed in the Rating Schedule, such as the Veteran's service-connected PTSD, rating by analogy is not appropriate. Copeland v. McDonald, 27 Vet. App. 333, 336-37 (2015). B. As of May 27, 2014, and prior to March 30, 2017 After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating in excess of 50 percent for PTSD as of May 27, 2014, and prior to March 30, 2017, is not warranted. On May 27, 2014, the Veteran was afforded a VA examination, which reflects the Veteran's report of nightmares, flashbacks, insomnia, problems with concentration, irritability and outbursts of anger, hypervigilance, dysphoria, loss of pleasure, markedly diminished interest in activities, and suicidal ideation. The examiner provided a separate diagnosis of depressive disorder in addition to PTSD and attributed several of the reported symptoms solely to depressive disorder. The examiner noted the following symptoms: depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss; disturbance of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances; and suicidal ideation. The examiner did not differentiate which of the noted symptoms are attributable solely to depressive disorder. Accordingly, the Board will give the Veteran the benefit of the doubt and consider all mental health symptoms as related to PTSD. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam) (explaining that VA must apply the benefit of the doubt doctrine and attribute the inseparable effects of a disability to the claimant's service-connected disability). The examiner indicated that the Veteran was cooperative and oriented to time, person, and place, and that there were no gross cognitive distortions. The Veteran reported a good relationship with his wife of 19 years but recently experiencing more irritability and angry outbursts, and two close friends whom he speaks with on the phone. Based on the foregoing, the examiner found that the Veteran's PTSD symptoms result in occupational and social impairment with reduced reliability and productivity. 05/27/2014, C&P Exam. The Board finds the May 2014 VA examination to be competent, credible, and highly probative, as it is supported by an in-person examination, mental health expertise, review of the relevant medical records, and a sufficient rationale. In June 2017, VA received a letter from the Veteran's spouse dated February 2017. She stated that anxiety and depression cause the Veteran to become volatile, resulting in agitation and overwhelming frustration and confusion. When this occurs, she reported, the Veteran is unable to process and concentrate on simple tasks and struggles to interact with others socially. She further stated that he has nightmares, he becomes easily confused, panic and depression often prevent him from leaving the house, and he has voiced suicidal ideation. 06/07/2017, Other, p. 91. The Board finds the statement by the spouse competent, credible, and probative as to her first-hand observations of the Veteran. Accordingly, the Board finds that the weight of the competent and probative medical and lay evidence is against finding that the Veteran's mental health symptoms resulted in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood as of May 27, 2014, and prior to March 30, 2017. The Board engaged in a holistic analysis of the severity, frequency, and duration of the signs and symptoms of the Veteran's PTSD, but finds that his mental health symptoms do not more nearly approximate a 70 percent rating as of May 27, 2014, and prior to March 30, 2017. In fact, the Veteran's symptoms of restricted affect, panic attacks, depressed mood, difficulty in understanding complex commands, impairment of short- and long-term memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships are specifically contemplated under the rating criteria for a 50 percent evaluation. See 38 C.F.R. § 4.130 Regarding social impairment, the Veteran's 50 percent rating accounts for his increased strife with his spouse, lack of friends, and diminished interest in hobbies. The Board notes that the evidence showing that the Veteran has been married for 19 years and talks to two friends on the phone weighs against a higher rating because it shows and ability to establish and maintain effective relationships. In finding that the weight of the competent evidence does not support occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, the Board has also considered as a factor that the evidence does not demonstrate symptoms such as: 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; or spatial disorientation. See 38 C.F.R. § 4.130. All possible applicable diagnostic codes have been considered, but the Veteran could not receive a higher or separate rating for PTSD as of May 27, 2014, and prior to March 30, 2017. See 38 C.F.R. § 4.130. Indeed, when a disorder is listed in the Rating Schedule, such as the Veteran's service-connected PTSD, rating by analogy is not appropriate. Copeland, 27 Vet. App. at 336-37. The Board finds that the weight of the competent and probative evidence is against finding a factually ascertainable date at which service-connected PTSD warranted a 50 percent rating prior to May 27, 2014. The record does not contain any mental health treatment records prior to May 27, 2014, other than the August 2010 VA examination discussed above. C. As of March 30, 2017 After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating of 70 percent, but no higher, for PTSD as of March 30, 2017, is warranted. In June 2017, VA received a PTSD examination completed by a private psychologist, signed on March 30, 2017. The private psychologist noted the following 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; impairment of short- and long-term memory; disturbances of motivation and mood; difficulty establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances; suicidal ideation; obsessional rituals which interfere with routine activities; impaired impulse control; restricted range of affection; irritability/angry outbursts; and difficulty concentrating. The psychologist noted that speech flow was normal, thought content was appropriate, organization of thought was goal-directed, mood was anxious and nervous, affect was restricted, and intelligence was average. The Veteran reported that he lives with his wife of 22 years but has become socially isolated and withdrawn and he denied taking medication regularly or participating in therapy. The psychologist opined that due to poor interpersonal skills and workplace trust issues, the Veteran would have increased paranoia and would struggle with appropriate workplace interaction. Based on the foregoing, the psychologist concluded that the Veteran's PTSD symptoms result in occupational and social impairment with deficiencies in most areas such as work, school, family relationships, judgment, thinking, and/or mood. 06/07/2017, Other, pp. 5-14. Accordingly, the Board finds that competent and probative medical and lay evidence is at least in equipoise as to whether the Veteran's PTSD-related symptoms result in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood as of March 30, 2017. Specifically, the Board finds that the symptoms of near continuous panic or depression affecting the ability to function independently, appropriately, and effectively, social isolation, and poor interpersonal skills and workplace trust issues leading to difficulty with appropriate workplace interaction all support a disability picture having occupational and social impairment, with deficiencies in most areas. As before, the Board engaged in a holistic analysis of the severity, frequency, and duration of the signs and symptoms of the Veteran's PTSD, but finds that his mental health symptoms do not more nearly approximate a 100 percent rating. In fact, the following symptoms are specifically contemplated under the rating criteria for a 70 percent evaluation of suicidal ideation: obsessional rituals which interfere with routine activities; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. See 38 C.F.R. § 4.130. Additionally, despite being isolated and withdrawn and showing signs of being insecure with the 2017 examiner, the Board notes that the Veteran has been married for 22 years and this weighs against total social impairment. In finding that the weight of the competent evidence does not support total occupational and social impairment, the Board has also considered as a factor that the evidence does not demonstrate such symptoms as 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; or memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130. All possible applicable diagnostic codes have been considered, but the Veteran could not receive a higher or separate rating for PTSD as of March 30, 2017. See 38 C.F.R. § 4.130. Indeed, when a disorder is listed in the Rating Schedule, such as the Veteran's service-connected PTSD, rating by analogy is not appropriate. Copeland, 27 Vet. App. at 336-37. The Board finds that the weight of the competent and probative evidence is against finding a factually ascertainable date at which service-connected PTSD warranted a 70 percent rating prior to March 30, 2017. The record does not contain any mental health treatment records between May 27, 2014, and March 30, 2017, other than the May 2014 VA examination discussed above, and the symptoms reported in the Veteran's spouse's February 2017 correspondence do not warrant a 70 percent disability rating for PTSD. ORDER New and material evidence having been received, the petition to reopen the claim of entitlement to service connection for bladder cancer is granted. New and material evidence having not been received, the petition to reopen the claim of service connection for chloracne is denied. Service connection for obstructive sleep apnea is granted. An initial disability rating of 30 percent, but no higher, for PTSD prior to May 27, 2014, is granted. An initial disability rating in excess of 50 percent for PTSD as of May 27, 2014, and prior to March 30, 2017, is denied. An initial disability rating of 70 percent, but no higher, for PTSD as of March 30, 2017, is granted. REMAND The Veteran contends that his bladder and prostate cancers are due to in-service herbicide agent exposure. The Veteran's military personnel records demonstrate that he served in Vietnam from April 1970 to February 1971. 03/31/1972, Certificate of Release. Accordingly, the Veteran is presumed to have been exposed to herbicide agents during service. 38 C.F.R. § 3.307(a)(6)(iii). The record contains competent evidence of bladder cancer. In May 2014, a VA examiner opined that the evidence does not demonstrate a diagnosis of prostate cancer. However, private treatment records in October 2010 and August 2014 reflect a diagnosis of prostate cancer. 10/21/2010, Medical-Non-Government; 10/07/2014, Medical-Non-Government. The record is also unclear as to whether such cancer originated in the bladder or the prostate. The Veteran points to a private treatment record noting prostate cancer with metastasis to the bladder. 10/07/2014, Medical-Non-Government. Accordingly, the AOJ should request that a VA oncologist provide an etiology opinion for bladder cancer and prostate cancer, if diagnosed. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (stating that "[t]his is a low threshold" for meeting the requirement to trigger VA's duty to assist to provide an examination). As the Veteran is claiming entitlement to service connection for ED as secondary to prostate cancer, the Board finds that the Veteran's request to reopen the claim for ED is inextricably intertwined with the prostate cancer claim, and will defer consideration of that matter. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (stating that two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Additionally, on remand, the VA oncologist should opine as to whether the Veteran's ED is secondary to prostate cancer. As relevant to the instant case, hypertension is not included in the list of diseases acknowledged to be presumptively related to exposure to herbicide agents. However, although VA has not conceded a relationship between hypertension and herbicide agents, it is significant to note that, prior to 2006, the National Academy of Sciences (NAS) placed hypertension in the "Inadequate or Insufficient Evidence" category. In its update in 2006, NAS elevated hypertension to the "Limited or Suggestive Evidence" category. Update 2012 provides the history of NAS changing the categorization of hypertension beginning in its 2006 Update and subsequent Updates. See 79 Fed. Reg. 20,308 (Apr. 11, 2014). Update 2012 notes that NAS has defined this category of limited or suggestive evidence to mean that the "evidence suggests an association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence." Id. at 20,309. The NAS updates are published in the Federal Register by VA, and thus VA is on notice as to the information contained therein. Accordingly, the AOJ should obtain an etiology opinion for hypertension, to include whether it is due to presumed in-service herbicide agent exposure. See McLendon, 20 Vet. App. at 83. Accordingly, the case is REMANDED for the following actions: 1. Request that a VA oncologist provide an opinion as to the etiology of bladder cancer, prostate cancer (if diagnosed), and ED. An in-person examination is not required unless deemed necessary by the clinician. The clinician should review the virtual file, including a copy of this Remand, to become familiar with the Veteran's history concerning these disorders. The clinician should address the following: a. State whether prostate cancer is currently present (or present during the period from December 29, 2009, to present). If the examiner disagrees with a diagnosis already established in the medical records, he/she should so state and explain why. b. State whether the Veteran's cancer of the bladder and/or prostate originated in the bladder or the prostate. c. Whether it is at least as likely as not (50 percent or greater probability) that bladder cancer manifested during or is otherwise related to the Veteran's period of active service, to include due to presumed herbicide agent exposure. d. If prostate cancer is diagnosed, is it at least as likely as not (50 percent or greater probability) that prostate cancer manifested during or is otherwise related to the Veteran's period of active service, to include due to presumed herbicide agent exposure. e. If prostate cancer is diagnosed and it is determined that cancer originated in the bladder, is it at least as likely as not (50 percent or greater probability) that prostate cancer was caused by bladder cancer? f. If prostate cancer is diagnosed and it is determined that cancer originated in the bladder, is it at least as likely as not (50 percent or greater probability) that prostate cancer has been aggravated (i.e., worsened beyond the normal progression of that disease) by bladder cancer? The term "aggravated" refers to a worsening of the underlying condition beyond the natural progression of the disease, as opposed to temporary or intermittent flare-ups or symptoms that resolve with return to the baseline level of disability. If aggravation is found, please state, to the extent possible, the baseline level of disability prior to aggravation. g. If it is determined that cancer originated in the prostate, is it at least as likely as not (50 percent or greater probability) that bladder cancer was caused by prostate cancer? h. If it is determined that cancer originated in the prostate, is it at least as likely as not (50 percent or greater probability) that bladder cancer has been aggravated (i.e., worsened beyond the normal progression of that disease) by prostate cancer? The term "aggravated" refers to a worsening of the underlying condition beyond the natural progression of the disease, as opposed to temporary or intermittent flare-ups or symptoms that resolve with return to the baseline level of disability. If aggravation is found, please state, to the extent possible, the baseline level of disability prior to aggravation. i. If prostate cancer is diagnosed, is it at least as likely as not (50 percent or greater probability) that ED was caused by prostate cancer? j. If prostate cancer is diagnosed, is it at least as likely as not (50 percent or greater probability) that ED has been aggravated (i.e., worsened beyond the normal progression of that disease) by prostate cancer? The term "aggravated" refers to a worsening of the underlying condition beyond the natural progression of the disease, as opposed to temporary or intermittent flare-ups or symptoms that resolve with return to the baseline level of disability. If aggravation is found, please state, to the extent possible, the baseline level of disability prior to aggravation. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. 2. Schedule the Veteran for an examination with an appropriate VA examiner to provide an opinion as to the etiology of hypertension. The examiner should review the virtual file, including a copy of this Remand. The examiner should address the following: a. Whether it is at least as likely as not (50 percent or greater probability) that hypertension manifested during or is otherwise related to the Veteran's period of active service, to include due to presumed herbicide agent exposure. b. Whether it is at least as likely as not (50 percent or greater probability) that hypertension manifested to a compensable degree within one year of March 31, 1972. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. 3. Thereafter, if any benefit sought on appeal remains denied, issue a supplemental statement of the case. Then, return the case to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ Paul Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs