Citation Nr: 1808931 Decision Date: 02/13/18 Archive Date: 02/23/18 DOCKET NO. 12-06 593 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Sioux Falls, South Dakota THE ISSUES 1. Entitlement to service connection for diabetes mellitus, to include as due to herbicide exposure. 2. Entitlement to service connection for sleep apnea, to include as secondary to service-connected disabilities. 3. Entitlement to service connection for heart disease, to include as due to herbicide exposure and/or secondary to service-connected disabilities. 4. Entitlement to service connection for skin diseases, to include as due to herbicide exposure. 5. Entitlement to service connection for gastrointestinal disease, to include as secondary to service-connected disabilities. 6. Entitlement to service connection for nerve damage, to include as due to herbicide exposure. 7. Entitlement to an initial compensable evaluation prior to August 18, 2015, in excess of 20 percent prior to October 20, 2015, and in excess of 10 percent thereafter, for service-connected bilateral hearing loss disability. 8. Entitlement to an initial compensable evaluation for service-connected hypertension. 9. Entitlement to total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Shannon K. Holstein, Attorney ATTORNEY FOR THE BOARD K. L. Wallin, Counsel INTRODUCTION The Veteran served on active duty from March 1966 to November 1969. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Sioux Falls, South Dakota. For the sake of judicial economy, the Board has consolidated and recharacterized the service-connection issues as they appear on the cover page of the instant decision. With regard to the issue of increased evaluation for bilateral hearing loss disability, service connection was awarded by the Board in April 2015 and effectuated by the RO in an April 2015 rating decision. The RO assigned an initial noncompensable evaluation effective May 2011. The Veteran filed a notice of disagreement in June 2015 with the initial rating assigned. In a March 2016 Decision Review Officer decision, the RO increased bilateral hearing loss disability to 20 percent effective August 18, 2015, and decreased it to 10 percent effective October 20, 2015. In May 2016, the Veteran filed a notice of disagreement with the effective date of the awards and evaluation of the disability. In response, the RO issued a statement of the case in May 2016 and characterized an additional matter on appeal as entitlement to an effective date prior to August 18, 2015, for the grant of an evaluation of 20 percent disabling for bilateral hearing loss disability. However, because the Veteran's appeal originated from the April 2015 rating decision that effectuated service connection, he is actually appealing the original assignment of the disability evaluations following an award of service connection. Thus, the claim actually involves the propriety of the initial disability rating assigned during the entire appeal period. See Fenderson v. West, 12 Vet. App. 119 (1999). Thus, the issue on appeal does not include the question of entitlement to an earlier effective date for the ratings assigned subsequent to the initial rating action on appeal. The claim is as noted on the title page. In April 2015, the Board remanded the issues of entitlement to service connection for diabetes mellitus, heart disease, skin disease, gastrointestinal disease, nerve damage, sleep apnea, and TDIU for further development and adjudication. The Board notes that in the same decision, the issue of increased evaluation for posttraumatic stress disorder (PTSD) was denied in part and granted in part; thus, the matter is no longer in appellate status. As previously indicated, service connection for bilateral hearing loss disability was awarded, as was service connection for tinnitus and hypertension. The Veteran has appealed the initial noncompensable evaluation assigned for hypertension effectuated by the RO in April 2015. The matter has been listed on the cover page. The Veteran withdrew the claim of service connection for allergies. The Veteran submitted additional evidence in support of his appeal in November 2016 with a waiver of initial RO review. Consequently, it was considered in the decision below. 38 C.F.R. § 20.1304(c). The issues of increased initial evaluation for bilateral hearing loss disability, entitlement to TDIU, and service connection for nerve damage are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran in this case served on active duty from March 1966 to November 1969. 2. In November 2016, the Board received notification from the Veteran, through his authorized representative, that a withdrawal of the claim of entitlement to service connection for diabetes mellitus is requested. 3. The more probative and competent evidence shows that the Veteran's heart disease, variously diagnosed as congestive heart failure, atrial fibrillation, cardiomyopathy with left ventricular dilatation, and atrial dilatation, is secondary to his service-connected PTSD and hypertension. 4. Resolving all reasonable doubt in favor of the Veteran, his sleep apnea is secondary to his service-connected PTSD. 5. Resolving all reasonable doubt in favor of the Veteran, his skin disease (variously diagnosed as basal cell carcinoma, actinic keratosis, invasive squamous cell carcinoma, seborrheic keratosis, hemangioma, xerosis cutis, tinea pedis, and herpes simplex I/genital warts) is due to his active military service. 6. Resolving all reasonable doubt in favor of the Veteran, gastrointestinal disease (variously diagnosed as esophagitis, hiatal hernia, and duodenal ulcers) is secondary to service-connected PTSD and hypertension. 7. Throughout the appeal period, the Veteran's hypertension required continuous medication for control; however, it has not been productive of a history of diastolic pressure of 100 or more. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the claim of entitlement to service connection for diabetes mellitus by the Veteran have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 2. The criteria are met for entitlement to service connection for heart disease as secondary to the service-connected PTSD and hypertension. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 3. The criteria are met for entitlement to service connection for sleep apnea as secondary to the service-connected PTSD. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 4. The criteria are met for entitlement to service connection for skin disease. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 5. The criteria are met for entitlement to service connection for gastrointestinal disease as secondary to the service-connected PTSD and hypertension. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 6. The criteria for an initial compensable evaluation for hypertension have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.104, Diagnostic Code 7101 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist In this decision the Board is granting entitlement to service connection for heart disease, sleep apnea, skin disease, and gastrointestinal disease, so the Veteran is receiving the requested benefits in full. Thus, there is no need to discuss whether VA has complied with its duties to notify and assist him with these claims found at 38 U.S.C. §§ 5102, 5103, 5103A, 5107 and 38 C.F.R. § 3.159. The issue pertaining to hypertension arises from his disagreement with the initial disability evaluation assigned following the grant of service connection. The Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Dismissal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105 (2012). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2017). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the Veteran, through his authorized representative, has withdrawn the issue of service connection for diabetes mellitus. See November 2016 Submission of Evidence and Argument. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal and it is dismissed. Service Connection Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). In addition, service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established for a disability which is proximately due to or the result of a service-connected disease or injury. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will also be service connected. 38 C.F.R. § 3.310. Certain conditions, including cardiovascular-renal disease and ulcers, will be presumed to have been incurred in service if they manifested to a compensable degree (generally meaning to at least 10-percent disabling) within a year after the Veteran's discharge from service. This presumption is rebuttable by affirmative evidence to the contrary, however. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). There also are other presumptions warranting consideration in this appeal. If a Veteran served in Vietnam during the Vietnam era (or at certain other locations like in Thailand at certain specifically defined times and under certain specifically defined circumstances), it will be presumed that he was exposed to Agent Orange while there. Furthermore, given this presumption of exposure to an herbicide agent during active military, naval, or air service, certain diseases shall be presumptively service connected, even though there is no record of such disease during service, provided also that the rebuttable presumption provisions of 38 U.S.C. §§ 1113, 1116 and 38 C.F.R. §§ 3.307(d), 3.309(e) are met. Diseases presumptively associated with such exposure include: AL amyloidosis; chloracne or other acneform diseases consistent with chloracne; Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; Ischemic heart disease (does not include hypertension, peripheral manifestations of arteriosclerosis, or any other condition that does not quality within the generally accepted medical definition of Ischemic heart disease); all chronic B-cell leukemias; multiple myeloma; non-Hodgkin's lymphoma; Parkinson's disease; "early onset" peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). These diseases shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and "early onset" peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year, and respiratory cancers within 30 years, after the last date on which the Veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). The last date on which such a Veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the Vietnam era. Thus, service connection may be presumed for residuals of Agent Orange exposure by satisfying two requirements. First, a Veteran must show that he served in the RVN during the Vietnam War era or elsewhere outside of Vietnam where Agent Orange was used or sprayed. See 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6). Second, the Veteran must have a diagnosis of one of the specific diseases listed in 38 C.F.R. § 3.309(e). See Brock v. Brown, 10 Vet. App. 155, 162 (1997). However, the availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a Veteran from alternatively establishing entitlement to service connection with proof of direct causation linking his claimed disability to his military service. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); see also McCartt v. West, 12 Vet. App. 164, 167 (1999) (indicating the principles set forth in Combee, which, instead, concerned exposure to radiation, are equally applicable in cases involving Agent Orange exposure to establish direct causation). If no presumptions apply to a claim, there must be probative evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a correlation ("nexus") between the disease or injury in service and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether the requirements for service connection are met is based on an analysis of all of the relevant evidence of record, so both the medical and lay evidence, and an evaluation of its competency and credibility to in turn determine its ultimate probative value in relation to other relevant evidence. Baldwin v. West, 13 Vet. App. 1 (1999). In deciding these claims, the Board has reviewed all of the evidence in the Veteran's virtual record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). A) Heart Disease The Veteran asserts that he has heart disease as the result of exposure to herbicides during his active military service, but particularly while in Vietnam. He alternatively asserts the condition is secondary to the service-connected PTSD and hypertension. The Veteran served on active duty from March 1966 to November 1969, so during the Vietnam Era. He served in the Republic of Vietnam from July 1967 to November 1969. It therefore must be presumed that he was exposed to an herbicide agent like the dioxin in Agent Orange during that service. 38 U.S.C. § 1116(f). Regardless of whether the Veteran's heart disease qualifies as ischemic heart disease, which is presumptively associated with Agent Orange exposure, there is probative evidence otherwise directly attributing this disease to his service-connected hypertension and PTSD. The Veteran has been variously diagnosed with atrial fibrillation, cardiomyopathy with left ventricular dilatation, and atrial dilatation, and congestive heart failure. Thus, the question of whether the Veteran has a current disability is not in dispute. What is in dispute, however, is whether this disease incepted during his service, within a year of his discharge, or is otherwise related or attributable to his service or a service-connected disability. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). After a review of the record, a private opinion was provided in July 2016 that it was more likely than not that the Veteran's heart disorder, to include congestive heart failure, atrial fibrillation, cardiomyopathy with left ventricular dilatation, and atrial dilatation, was secondary to, related to, and/or aggravated by his service-connected PTSD and/or hypertension. The provider reasoned that the Veteran was diagnosed with hypertension in 1970 and had been prescribed continuous anti-hypertensive medications. The provider further noted the Veteran had been diagnosed with atrial fibrillation in 1997 and a cardiac sector scan revealed moderately severe dilated left ventricle. In June 2007, the Veteran was diagnosed with mild cardiomyopathy and an abnormal echocardiogram showing atrial dilatation and borderline left ventricle hypertrophy. The Veteran was diagnosed with persistent atrial fibrillation in 2010 and 2011. He was diagnosed with congestive heart failure in 2010. The provider further reasoned that medical literature documents that hypertension was a major influence on the development of cardiac structural changes and remodeling, to include left ventricle dilatation and atrial fibrillation. Medical literature also documented that hypertension and obesity lead to congestive heart failure. The major risk factors for cardiomyopathy were obesity and hypertension. Thus, the provider concluded that the Veteran's service-connected hypertension was a major risk factor for his heart condition. The provider also noted that medical literature revealed that obesity was associated with mood disorders, such as his service-connected PTSD. The Veteran was taking Celexa, which was known to promote weight gain. Thus, the provider concluded that his PTSD contributed to his obesity and therefore, also his heart condition. The Board acknowledges that in November 2015, a VA examiner opined atrial fibrillation was less likely than not caused by service, including Agent Orange exposure, as his service treatment records were negative for the condition and there was a gap in treatment following service. The examiner further reasoned that medical literature did not list chemicals such as those used in Agent Orange as a risk factor for atrial fibrillation. The examiner also opined ischemic heart disease was not identified in the record. The examiner stated that congestive heart failure and mild cardiomyopathy were directly related to new onset atrial fibrillation and resolved. The Board accords the VA medical opinion little ultimate probative weight, however, in part based the failure to address secondary causation and perhaps most importantly, that is not enough merely to conclude the Veteran does not have current or chronic congestive heart failure or cardiomyopathy or that the conditions resolved. The Veteran only instead needs to show he has had this claimed condition at some point since the filing of his claim or contemporaneous thereto, even if now resolved. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)); see also Guerieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (the credibility and weight to the attached medical opinions are within the province of the Board). As the record currently stands, there is more probative (meaning more competent and credible) evidence associating the etiology of the Veteran's heart disease with his service-connected hypertension and PTSD. Accordingly, service connection for the heart disease as secondary to service-connected hypertension and PTSD is warranted. 38 C.F.R. §§ 3.102, 4.3. B) Sleep apnea The Veteran contends that he is entitled to service connection for sleep apnea. He maintains the condition is directly related to service and/or secondary to his service-connected PTSD. The Veteran's diagnosis of sleep apnea is not in dispute. The question remains whether this disability incepted during his service or is otherwise related or attributable to his service or a service-connected disability. After review of the record, a private provider opined in July 2016 that it was more likely than not that the Veteran's sleep apnea was secondary to, related to, and/or aggravated by his service-connected PTSD; specifically, the weight gain caused by PTSD medication. The provider reasoned the Veteran had taken and/or was taking Amitriptyline and Celexa for his PTSD and medical literature supported a finding that these medications caused weight gain and obesity. The provider noted that the Veteran had gained 85 pounds from enlistment on active duty in 1966 to the time of his sleep study in February 2008. The provider further indicated that obesity was known to predispose patients to sleep apnea. The provider also stated that it was clearly evident the Veteran experienced traumatic events in service and had symptoms for many years before being formally diagnosed with PTSD. Medical records revealed the Veteran reported waking up one to two times per night to perform perimeter checks and due to flashbacks and nightmares. Thus, his sleep cycle was worse because he was waking more often than the past. The Board acknowledges that in December 2015, a VA examiner opined sleep apnea was less likely than not that related to service because service treatment records were negative for sleep apnea or symptoms and the Veteran's wife's statements were negative for sleep apnea during service. The examiner further opined sleep apnea was not proximately due to or the result of the Veteran's service-connected PTSD or medications taken for PTSD. The examiner reasoned that medical literature did not establish that PTSD and/or medications taken for the same were identified as causing or contributing factors. The examiner also found no aggravation because sleep apnea was not actively being treated and psychotropic medication started two to three years after he was diagnosed with sleep apnea. The evidence is in equipoise. In this circumstance, VA must resolve this reasonable doubt in the Veteran's favor and grant (rather than deny) the claim. 38 C.F.R. §§ 3.102, 4.3. Accordingly, service connection for sleep apnea as secondary to his service-connected PTSD is warranted. C) Skin Disease The Veteran asserts that he has skin disease as the result of exposure to herbicides during his active military service, but particularly while in Vietnam. Regardless of whether the Veteran's skin diseases qualify as chloracne, an acne form disease consistent with chloracne, and/or porphyria cutanea tarda, which are presumptively associated with Agent Orange exposure, there is probative evidence otherwise attributing skin disease directly to his military service. Through statements, the Veteran and his wife indicated that he had skin rashes when he came back from serving in Vietnam. They further assert that he has had skin problems since his discharge from service, to include as early as 1970. The Veteran indicated that such records had unfortunately been destroyed. In May 2012, Dr. JK indicated in a letter that the Veteran was treated for skin cancer of the hand in September 1970, which was surgically removed. Dr. JK further stated that between 1980 and 2007 he surgically removed small cancers of the nose, neck, hands, arms, and ears. Thereafter, Dr. JK noted that another dermatologist removed cancers of the extremities, nose and ears from 2007 to 2012. VA and private treatment records, as well as reports of VA examination, show the Veteran has been variously diagnosed with and treated for basal cell carcinoma, actinic keratosis, invasive squamous cell carcinoma, seborrheic keratosis, hemangioma, xerosis cutis, tinea pedis, and herpes simplex I/genital warts. The Board notes that the August 2011 VA examiner specifically noted the Veteran had been treated for genital warts during service in 1969, with a recurrence in 1970, and subsequent to his discharge in 1980 with no recurrence since then. The Board is cognizant of the December 2015 VA examiner's opinion that the Veteran's skin disease was not related to service because he did not treat for such diseases in service and that condyloma (genital warts) resolved during service. The examiner also discredited Dr. JK's statements as they were not more detailed regarding location, dates of treatment and types of cancers. However, the Board finds that this VA opinion has little probative value in light of the cumulative evidence of record, to include his service in Vietnam, and the continuous complaints pertaining to the Veteran's skin since his discharge. Moreover, the examiner failed to consider the Veteran's statements regarding continuous problems with his skin service, which he is competent to state. The examiner also failed to acknowledge that the Veteran's records from 1970 had been destroyed, which did not allow for more specific information, and that Dr. JK had been treating the Veteran since 1969. The Board has no reason to doubt the veracity of Dr. JK. The Veteran has been diagnosed with various skin diseases. Clearly, as delineated above, the Veteran has continuously sought treatment for skin problems since his discharge from service. The Veteran is competent to report that he had skin problems shortly after returning from Vietnam and that recurring skin disease has existed from service to the present. The Board finds the Veteran's continuity of symptomatology with respect to his skin disease following service to be credible. 38 C.F.R. § 3.303(b); Layno v. Brown, 6 Vet. App. 465 (1994); see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997). This suffices as evidence of a nexus between his skin disease and his service. Resolving any doubt in the Veteran's favor, service connection for skin disease is warranted. 38 C.F.R. § 3.102. D) Gastrointestinal disease The Veteran asserts that he has gastrointestinal disease that is secondary to the service-connected PTSD and hypertension. The Veteran has been variously diagnosed with esophagitis, hiatal hernia, and duodenal ulcers. Thus, the question of whether the Veteran has a current disability is not in dispute. What is in dispute, however, is whether this disease incepted during his service, within a year of his discharge, or is otherwise related or attributable to his service or a service-connected disability. In a May 2012 statement, Dr. JK, the Veteran's private provider, indicated that he had known the Veteran since 1969 and had treated him for stomach problems in June 1970. Dr. JK stated the Veteran had a nervous stomach due to his PTSD and took medications to control acid reflux and related stomach problems. Dr. JK further indicated that he treated the Veteran for ulcers at least six times in the period between the 1970s and 1990s. Dr. JK reported that he treated the Veteran for giardia, diverticulitis, and diarrhea. This was said to be an ongoing problem since his discharge from service. A private opinion in July 2016 indicated that it was more likely than not that the Veteran's current gastrointestinal conditions, which included esophagitis, hiatal hernia, and duodenal ulcers, were secondary to, related to, and/or aggravated by his service-connected PTSD and hypertension. The provider opined that the Veteran had been prescribed Esomeprazole (a proton pump inhibitor and an anti-ulcer agent) and Lansoprazole (a proton pump inhibitor to treat stomach ulcers and damage esophagus), which showed a chronicity of the condition since its onset. The provider also noted the Veteran had a gastrointestinal bleed in 2009, which was most likely secondary to duodenal ulcer disease. The provider reasoned that stress has been associated with the onset or symptom exacerbation in chronic disorders of the digestive system. The provider further noted medical treatise indicated there was a large body of evidence supporting the link between psychological distress and functional gastrointestinal diseases. The provider discussed the May 2012 letter from Dr. JK, which noted the Veteran had been treated for gastrointestinal problems since June 1970 and that this nervous stomach was due to PTSD. The provider further stated that Dr. JK indicated he treated the Veteran for ulcers at least six times throughout the 1970s, 1980s, and 1990s. The provider felt this supported the finding that stressful events, such as stressors and trauma the Veteran experienced during service related to his PTSD could cause or at least aggravated his gastrointestinal condition. The provider also found supporting evidence that the Veteran's medication for hypertension (Accupril) aggravated gastrointestinal bleeding . In December 2015, a VA examiner opined gastrointestinal disease was not due to or aggravated by his PTSD or medications taken for PTSD. The examiner indicated that medical treatise did not cite to psychological factors as a cause of ulcers. The examiner further indicated that ulcers did not manifest until 30 years post-service. The examiner discredited Dr. JK's statement as vague. The examiner also indicated that records were negative for continuous or recurrent abdominal symptoms. The examiner finally stated that the Veteran's gastrointestinal disease was not aggravated by his PTSD as there was minimal adjustment in medications or treatment of PTSD and that all gastrointestinal conditions were stable or resolved. The evidence is at least in equipoise. In this circumstance, VA must resolve this reasonable doubt in the Veteran's favor and grant (rather than deny) the claim. 38 C.F.R. §§ 3.102, 4.3. Accordingly, service connection for gastrointestinal disease as secondary to service-connected PTSD and hypertension is warranted. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2017). The Rating Schedule is primarily a guide in the evaluation of disabilities resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's hypertension has been rated under 38 C.F.R. § 4.104, Diagnostic Code 7101, as noncompensable. Under the General Formula for Diseases of the Heart, Diagnostic Code 7101, a 10 percent disability evaluation is warranted where diastolic pressure is predominantly 100 or more, systolic pressure is predominantly 160 or more, or the individual has a history of diastolic pressure of 100 or more and requires continuous medication for control. See 38 C.F.R. § 4.104, Diagnostic Code 7101. For the next higher 20 percent disability evaluation, diastolic pressure must be predominantly 110 or more or systolic pressure must be 200 or more. A 40 percent disability evaluation requires diastolic pressure predominantly 120 or more, and a 60 percent disability evaluation requires diastolic blood pressure to be predominantly 130 or more. Id. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.21. Having carefully considered the Veteran's claim in light of the evidence of record, as well as the applicable law and regulation, the Board finds that the currently assigned noncompensable rating is appropriate. 38 C.F.R. § 4.7. In this regard, the medical evidence shows that the Veteran's hypertension did not have a history of diastolic pressure of 100 or more, though he has required continuous medication for control. Indeed, private treatment records reveal the Veteran's blood pressure readings were variously recorded as follows: 124/78 in February 2005; 148/72 in February 2006; 126/76 in December 2007; 118/74 in December 2008; 100/62 in July 2009; 102/62 in December 2010; and 104/60 in April 2011. VA outpatient treatment records contain readings as follows: 111/61 in September 2011 and 122/76 in May 2012. On VA examination in November 2015, the examiner noted the Veteran 's hypertension required continuous medication for control. The examiner further noted the Veteran did not have a history of diastolic blood pressure elevation to predominantly 100 or more. Blood pressure readings were noted as 133/78 September 2015, 113/74 September 2015, and 108/70 October 2015. Average blood pressure reading was 118/74. The Veteran's disability picture, as described above, is found to most nearly approximate the criteria for the currently assigned noncompensable evaluation. 38 C.F.R. § 4.7. In reaching the above determination, the Board has also considered the Veteran's statements that higher ratings are warranted. In this case, the Veteran's statements are competent evidence as to his symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Indeed, these statements have been considered by both the Board and the VA examiners. His statements or his wife's, however, are not competent evidence to identify a specific level of disability relating his hypertension to the appropriate rating criteria. Importantly, the medical findings, as provided in the VA examination reports, VA outpatient and private treatment records, considered the Veteran's statements and his wife's, to include reports of blood pressure so high that he was immediately placed on medication, as to the manifestations of his hypertension, and directly addressed the criteria under which the Veteran's hypertension has been evaluated. See November 2016 Submission of Evidence and Argument. All potentially applicable diagnostic codes have been considered, and the Veteran is not entitled to a rating in excess of the noncompensable rating assigned. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Staged ratings have been considered, and are not warranted for any period of the appeal. See Fenderson, 12 Vet. App. at 125-126; see also Hart, supra. ORDER Entitlement to service connection for diabetes mellitus is dismissed. Service connection for heart disease, including congestive heart failure, atrial fibrillation, cardiomyopathy with left ventricular dilatation, and atria dilatation, as secondary to service-connected hypertension and PTSD, is granted. Service connection for sleep apnea as secondary to service-connected PTSD, is granted. Service connection for skin disease is granted. Service connection for gastrointestinal disease, including esophagitis, hiatal hernia, duodenal ulcers, as secondary to service-connected hypertension and PTSD, is granted. Entitlement to an initial compensable rating for service-connected hypertension is denied. REMAND The Board finds that additional development is needed before a final determination may be made on the issues of service connection for nerve damage and increased initial evaluation for bilateral hearing loss disability. The matter of TDIU is deferred. VA has a duty to assist veterans to obtain evidence needed to substantiate a claim. The duty to assist also includes providing a thorough and contemporaneous medical examination. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The Veteran last underwent a VA examination to assess the severity of his bilateral hearing loss disability in March 2016, which is fairly recent and contemporaneous in time. However, the Veteran's representative argued that the Veteran's hearing loss disability was much more severe than the testing indicated. The representative contends that sensorineural hearing loss does not usually fluctuate or improve, which the RO found when it reduced the hearing loss disability to 10 percent disabling. See November 2016 Submission of Evidence and Argument. The Board additionally notes the Veteran had previously argued in November 2015 that he had been informed by the October 2015 VA audiology examiner that the testing equipment had malfunctioned and instead of rescheduling, she used live voice testing. The Veteran further asserted that he was informed by the examiner that live voice testing was not as reliable as recorded word recognition. Given the claims that the Veteran's hearing is worse than it was in 2016, the allegations of inadequate examination in 2015, and for the sake of clarity to address claims of disparity in examination results, VA must provide a new examination to adequately evaluate the current state of the condition. See Olson v. Principi, 3 Vet. App. 480, 482 (1992) (citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992); Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). The Veteran contends he is entitled to service connection for nerve damage radiating from his neck to his foot as result of his herbicide exposure. The Veteran's in-service exposure to herbicides (Agent Orange) is presumed in light of his Vietnam service. 38 C.F.R. § 3.307(a)(6). Early onset peripheral neuropathy is listed as a disease presumptively associated with exposure to Agent Orange. 38 C.F.R. § 3.309(e). The Veteran has been variously diagnosed with nonspecific neuropathy (September 2010), unspecified idiopathic peripheral neuropathy (May 2012), and sciatica of the left lower extremity (May 2015). In a May 2012 statement, DR. JK indicated the Veteran had been treated for "nerve problems" in March 1970, the records of which had been destroyed. Dr. JK opined the Veteran's "nerves are service related." The Veteran was afforded a VA examination in November 2015. The examiner found that the records did not clearly document a nerve condition radiating from his neck to his foot. The examiner indicated the Veteran had only been treated for sciatica of the left leg related to degenerative changes of his lumbar spine. The examiner did not perform any diagnostic studies. When VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The examination and the opinion did not perform any diagnostic studies and failed to address the findings of nonspecific neuropathy in and unspecified idiopathic peripheral neuropathy. Moreover, the examiner did not address whether such disabilities are related to his presumed in-service herbicide exposure even though not specifically listed in 38 C.F.R. § 3.309. The availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange. See Stefl, supra; Combee, supra. In other words, a regulatory established presumption is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure. Thus, the opinions and the rationale of the examiner are not sufficient with regard to the issue of the nature and etiology of the Veteran's nerve damage claim. See Nieves-Rodriguez, 22 Vet. App. 295, 301(2008) (noting that "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion"). Given the inadequacies in the VA examination and opinion, a remand is warranted in order to afford the Veteran a new examination that addresses the questions delineated below. Finally, in the instant decision, the Board has granted service connection for heart disease, sleep apnea, skin disease, and gastrointestinal disease. As the RO must first implement the rating and effective date for these awards, and as the adjudication of the claim for TDIU could be impacted by a favorable resolution of the issue of increased initial evaluation for bilateral hearing loss disability and/or service connection for nerve damage, the Board will defer adjudication of the claim for TDIU. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue). Accordingly, the case is REMANDED for the following action: 1. The Veteran must be afforded a VA examination to determine the severity of his service-connected bilateral hearing loss disability. The electronic claim file must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. Examination findings pertinent to the Veteran's hearing loss disability should be reported to allow for application of VA rating criteria for hearing impairment, to include controlled speech discrimination test (Maryland CNC) and a puretone audiometry test results. In addition, the examiner must address the examination results from 2011, 2015, and 2016 and explain whether there is any discrepancy in the audiometric findings and/or speech discrimination tests. 2. The RO should schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's claimed nerve damage. The electronic record, including a copy of this remand, must be made available to the examiner as part of the examination, and the examiner must indicate in his/her report whether the electronic record was reviewed. All indicated tests and diagnostic imaging studies must be completed. Thereafter, the examiner should provide an opinion as to whether the Veteran currently has a disability manifested by nerve damage, including but not limited to nonspecific neuropathy and/or unspecified idiopathic peripheral neuropathy and if so, whether it is at least as likely as not (50 percent or greater probability) related or otherwise attributable to his presumed herbicide exposure regardless of whether the condition is a listed disease under 38 C.F.R. § 3.309(e). In answering this question, the examiner must discuss the findings of nonspecific neuropathy in September 2010 and unspecified idiopathic peripheral neuropathy in May 2012. The examiner must also address the May 2012 opinion of Dr. JK that the Veteran had been treated for "nerve problems" in March 1970, which were service related. Note: if the examiner concludes that there is insufficient information to provide an etiology opinion without resorting to mere speculation, the examiner should state whether the inability to provide a definitive opinion was due to a need for further information (please identify) or because the limits of medical knowledge had been exhausted regarding the etiology of the claimed conditions. 3. The examination reports must be reviewed to ensure they are in complete compliance with the directives of this remand. If a report is deficient in any manner, the RO must implement corrective procedures. 4. The RO must implement the rating and effective date for the award of service connection for heart disease, sleep apnea, skin disease, and gastrointestinal disease. If upon completion of the above action, the claims remain denied, the case should be returned to the Board after compliance with appellate procedures. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded expeditious treatment. The law requires that all issues 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). _________________________________________________ E. I. VELEZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs