Citation Nr: 1827294 Decision Date: 05/01/18 Archive Date: 05/14/18 DOCKET NO. 13-33 807 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected type II diabetes mellitus. 2. Entitlement to service connection for a cardiac disability, to include as secondary to service-connected PTSD. 3. Entitlement to service connection for a skin disability. 4. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected type II diabetes mellitus. 5. Entitlement to service connection for tinnitus. 6. Entitlement to a higher initial rating for PTSD, rated 10 percent disabling prior to August 20, 2016 and 30 percent disabling since that date. REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD B. Elwood, Counsel INTRODUCTION The Veteran served on active duty from January 1966 to December 1967, which includes service in the Republic of Vietnam. He received the Combat Infantryman Badge. These matters initially came before the Board of Veterans' Appeals (Board) from May 2013 and July 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In the May 2013 decision, the RO denied service connection for high blood pressure and a heart condition and granted service connection for PTSD and assigned an initial 10 percent disability rating, from January 7, 2013. In the July 2014 decision, the RO denied the Veteran's petition to reopen a claim of service connection for a skin disability as new and material evidence had not been submitted and denied service connection for erectile dysfunction and tinnitus. In June 2016, the Board granted the Veteran's petition to reopen the claim of service connection for a skin disability, denied service connection for erectile dysfunction and tinnitus, and remanded the underlying claim of service connection for a skin disability, the claims of service connection for hypertension and a cardiac disability, and the appeal for a higher initial rating for PTSD for further development. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In September 2016, the RO assigned a 30 percent disability rating for PTSD, from August 20, 2016, creating a staged rating as indicated on the title page. In an August 2017 Memorandum Decision, the Court set aside the Board's June 2016 decision, in part, and remanded the case for readjudication in compliance with directives specified in the Court's decision. The Court specified that only that part of the Board decision that denied service connection for erectile dysfunction and tinnitus was being set aside. The remainder of the June 2016 Board decision, which included, inter alia, a denial of an earlier effective date for the award of service connection for PTSD and a denial of service connection for sleep apnea, was affirmed. The Board notes that additional VA treatment records pertinent to the claims of service connection for hypertension and erectile dysfunction have been added to the record and this evidence has not been considered by the agency of original jurisdiction (AOJ) in conjunction with these matters. As the Board is granting the claims of service connection for hypertension and erectile dysfunction, however, a waiver is not required and the Veteran is not prejudiced by the Board's limited consideration of the additionally received evidence for the purpose of adjudicating these service connection claims. See 38 C.F.R. § 20.1304 (c) (2017) (providing that the Board may initially review evidence, if the benefit sought on appeal is fully granted). Finally, the matter of the Veteran's entitlement to service connection for alcohol abuse, as secondary to service-connected PTSD, was raised in the Veteran's July 2013 notice of disagreement and a June 2015 statement from his representative. However, as this matter has not been adjudicated by the AOJ, the Board does not have jurisdiction over it, and it must be referred to the AOJ for appropriate action, to include informing the Veteran and his representative that a claim for benefits must be submitted on the application form prescribed by the Secretary of VA and providing such forms. See 38 C.F.R. § 19.9 (b) (2017). See also 38 C.F.R. § 3.150 (a) (2017) (providing for furnishing of appropriate application form upon request for VA benefits); 38 C.F.R §§ 3.160 and 20.201 (2017) (requiring that claims and notices of disagreement be filed on standard forms). The issues of entitlement to service connection for a cardiac disability, a skin disability, and tinnitus are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's current hypertension was caused by his service-connected type II diabetes mellitus. 2. The Veteran's current erectile dysfunction was caused by his service-connected type II diabetes mellitus. 3. Since January 7, 2013, the Veteran's PTSD has resulted in no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension, secondary to service-connected type II diabetes mellitus, are met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 2. The criteria for service connection for erectile dysfunction, secondary to service-connected type II diabetes mellitus, are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for an initial 30 percent rating, but no higher, since January 7, 2013 for PTSD, are met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). As the Board is granting the claims of service connection for hypertension and erectile dysfunction, the claims are substantiated and there are no further VCAA duties as to these issues. Wensch v. Principi, 15 Vet App 362, 367-68 (2001); see also 38 U.S.C. § 5103A (a)(2) (Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"); VAOPGCPREC 5-2004; 69 Fed. Reg. 59989 (2004) (the notice and duty to assist provisions of the VCAA do not apply to claims that could not be substantiated through such notice and assistance). As for the appeal for a higher initial rating for PTSD, this appeal arises from the Veteran's disagreement with the initial rating assigned after the grant of service connection for this disability. The courts have held, and VA's General Counsel has agreed, that where an underlying claim has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (2003). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159 (c)(4). VA has obtained the Veteran's service treatment records, all pertinent service personnel records, and all of the identified relevant post-service VA treatment records. The Veteran has not reported, and the evidence does not otherwise indicate, that he has received any relevant post-service private medical treatment for a psychiatric disability. In addition, the Veteran was afforded VA examinations to assess the severity of his service-connected psychiatric disability. Neither the Veteran nor his representative has raised any issues with regard to the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Analysis A. Service Connection Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the current disability and an in-service precipitating disease, injury or event. 38 U.S.C. § 1110; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection is also provided for a disability which is proximately due to, the result of, or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310. 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 or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In this case, the reports of VA hypertension and male reproductive organ examinations dated in April 2018 reveal that the Veteran has been diagnosed as having hypertension and erectile dysfunction. Thus, current hypertension and erectile dysfunction have been demonstrated. As for the etiology of the currently diagnosed hypertension and erectile dysfunction, the physician who conducted a February 2018 VA diabetes examination indicated that these disabilities were likely ("at least as likely as not"/"at least a 50 percent probability") due to diabetes mellitus. Although the examiner did not provide any detailed rationales for these opinions, the examiner nonetheless concluded based upon an examination of the Veteran and a review of his medical records and reported history that his current hypertension and erectile dysfunction were due to his service-connected type II diabetes mellitus. The February 2018 opinions are therefore entitled to some probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). There are no medical opinions contrary to that of the February 2018 opinions with respect to whether the Veteran's claimed hypertension and erectile dysfunction were caused by his diabetes mellitus. Therefore, the evidence indicates that the Veteran's current hypertension and erectile dysfunction were, at least in part, the result of his service-connected type II diabetes mellitus. There are no medical opinions contrary to this conclusion. Hence, service connection for hypertension and erectile dysfunction, as secondary to service-connected type II diabetes mellitus, is granted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. B. Higher Initial Rating Disability ratings are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4 ) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Where service connection has been granted and the assignment of an initial rating is disputed, separate ratings may be assigned for separate periods of time based on the facts found. In other words, the ratings may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. 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. 38 C.F.R. § 4.21. 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. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a). When evaluating the level of disability from a mental disorder, VA will also consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). The schedular criteria for rating psychiatric disabilities incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). See 38 C.F.R. §§ 4.125, 4.130. The Veteran's PTSD is rated under 38 C.F.R. § 4.130, DC 9411. This disability is rated according to the General Rating Formula for Mental Disorders (General Rating Formula). Under the General Rating Formula, a 10 percent disability rating is warranted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms are controlled by continuous medication. 38 C.F.R. § 4.130, DC 9411. A 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is warranted when there is 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, or own name. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004); Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The Board notes, parenthetically, that VA updated its regulations to incorporate, in lieu of the DSM-IV, references to the Fifth Edition of the DSM (DSM-5). These changes apply to claims that were certified for appeal to the Board on or after August 4, 2014. See 80 Fed. Reg. 14,308 (March 19, 2015) (Applicability Date). In this case, the DSM-5 is applicable. See March 2015 "Certification of Appeal" form (VA Form 8). In this case, VA treatment records dated from October 2012 to March 2013 indicate that the Veteran experienced sleep impairment, infrequent intrusive thoughts of Vietnam, nightmares associated with events in Vietnam, hypervigilance, a hyperstartle response, depression, anhedonia, anxiety, loss of interest in activities he once enjoyed, a feeling of being distant or cut off from other people, emotional numbness, a sense of a foreshortened future, and impaired concentration. He was retired, had been married to his third wife since 1994, had re-established contact with his children from his first marriage, and was not particularly estranged from his friends and family. He was restricted emotionally, however, and his wife reported that he always kept things to himself. The Veteran did not experience any flashbacks or anxiety attacks and he enjoyed yard work and mechanical work. Overall, his PTSD symptoms made it somewhat difficult for him to take care of things at home or get along with other people. Examinations revealed that the Veteran's grooming and hygiene were good, that his motor behavior was normal, that his eye contact was good, that his facial expression was normal and responsive, and that his attitude was cooperative. His mood was neutral, his affect was appropriate/variable, his speech was relevant and spontaneous, his thought processes were logical and goal-directed, and his thought content was relevant. Also, his insight was adequate, his sensorium was clear, and he did not experience any homicidal or suicidal ideation. Diagnoses of PTSD and alcohol dependence were provided. The Veteran reported during a March 2013 VA psychiatric examination that he was married to his third wife and that they had been married since 1994. He had four children from his previous marriages and maintained contact with all of his children. He had some friends with whom he watched sporting events and went to the casino, but they otherwise left him alone. He had been unemployed since December 2007, at which time he stopped working due to a knee replacement. He spent his time working in the yard and around the house or going to the casino and he took medications to treat his psychiatric symptoms. Examination revealed that the Veteran was appropriately dressed and groomed and that although he was rather reserved, he was cooperative and pleasant and answered questions in a brief and straightforward manner. He described his mood as "probably anxious, and sometimes depressed . . . hyper." He was fully oriented and his attention, concentration, memory, insight, and judgment were all intact. He was able to get to sleep very well, but would awaken after an hour or two and would take approximately a half hour to an hour to get back to sleep. Upon awakening he would be sweating and thinking about things that happened during service. He experienced nightmares and his wife had reported that he would "thrash around" in his sleep. There were certain triggers that reminded him of experiences in service and he was bothered by sudden noises. Although he had a history of using alcohol to help him sleep, he had been avoiding alcohol after beginning new medications. As for PTSD symptoms specifically, the Veteran experienced recurrent distressing dreams of in-service trauma, an inability to recall an important aspect of the trauma, markedly diminished interest or participation in significant activities, a restricted range of affect (e.g., unable to have loving feelings), difficulty falling or staying asleep, hypervigilance, and an exaggerated startle response. The psychologist who conducted the March 2013 examination noted that although the Veteran reported some other subjective mental health symptoms, these symptoms did not rise to a sufficient level of chronicity and/or were not objectively identified on mental status examination. The Veteran was diagnosed as having PTSD, alcohol abuse, and cannabis abuse. The examiner noted that it was not possible to differentiate what symptoms were attributable to each diagnosis and that the symptoms of PTSD and alcohol and cannabis abuse were inextricably interwoven. Overall, the level of occupational and social impairment caused by the Veteran's psychiatric disability met the criteria for a 10 percent rating under the General Rating Formula. Statements from the Veteran's son and wife dated in March 2013 (VA Form 21-4138) and VA treatment records dated from April to May 2013 indicate that the Veteran had divorced in 1984 due to his constant talk about Vietnam, nightmares, alcohol abuse, and fighting. He was restless in his sleep and spent most of the night tossing and turning and occasionally making noises. If awakened, he was usually sweating heavily and breathing hard and would be unable to get back to sleep. He abused alcohol and was able to sleep through the night after drinking. Also, he experienced loss of interest in activities he once enjoyed, a feeling of being distant or cut off from other people, emotional numbness, a sense of a foreshortened future, irritability/outbursts of anger, impaired concentration, hypervigilance, and a hyperstartle response. Overall, his PTSD symptoms made it somewhat difficult for him to take care of things at home or get along with other people. Examinations revealed that the Veteran's grooming and hygiene were good, that his motor behavior was normal, that his eye contact was good, that his facial expression was normal and responsive, that his attitude was cooperative, that his mood was neutral, and that his affect was appropriate/variable. Moreover, his speech was relevant and spontaneous, his thought processes were logical and goal-directed, his thought content was relevant, his insight was adequate, his sensorium was clear, and he did not experience any homicidal ideation. The Veteran was diagnosed as having PTSD. The Veteran reported on a statement dated on June 4, 2013 that he experienced anger, anxiety, chronic sleep problems, depression, drug abuse, emotional numbing, flashbacks, guilt, heavy use of alcohol, inappropriate behavior, lack of emotions, nervousness, panic attacks, problems with communication, suspiciousness, and inability to share feelings. He also noted that he took medications for his psychiatric symptoms, but he did not provide any specific discussion or explanation concerning the nature and severity of his reported symptoms. VA treatment records dated from July 2013 to October 2014 reflect that the Veteran remained married to his third wife of 30 years, that their marriage was "going well," and that he had a good relationship with his children. He was retired and reported hard alcohol consumption 1 to 2 times each week socially with friends. He took medications to treat his psychiatric symptoms and his depression, insomnia, nightmares, and flashbacks had improved due to such treatment. He did not experience any suicidal/homicidal ideation, mood swings/manic symptoms, visual/auditory hallucinations, or delusions. Examinations revealed that the Veteran had fair grooming and hygiene and that his mood was slightly anxious. His motor behavior was normal, his eye contact was good, his facial expression was normal and responsive, his attitude was cooperative, his affect was appropriate/variable, and he was not psychotic. Also, his speech was relevant and spontaneous, his thought processes were logical and goal-directed, his thought content was relevant, and his sensorium was clear. The Veteran's insight was limited regarding substance use, but it was otherwise good. Diagnoses of PTSD, unspecified depressive disorder by history, and alcohol use disorder were provided. The report of a VA psychiatric examination dated in February 2015 reflects that the Veteran reported that he remained married to his third wife and that he maintained relationships with his children. He occasionally went to the movies with his wife, but did not "deal much with friends" because a lot of his friends had gotten older, some had passed away, and some had left town. He did not participate in any clubs or organizations and did not attend church with his wife. He had been unemployed since December 2007, at which time he went out on disability due to elbow surgery and a knee replacement. He spent his time taking walks during the winter when possible and performing yard work and going fishing during the summer. He had attended some group therapy since the last VA psychiatric examination (but stopped attending therapy because it brought up more memories of stressors) and took medications to treat his psychiatric symptoms. Examination revealed that the Veteran was appropriately dressed and groomed, pleasant, open, and cooperative. His responses to questions were brief and non-elaborative, he was fully oriented, and his attention and concentration were intact. He described his mood as "not happy all of the time, but [he was] not sad." It was a depressing time of year for the Veteran because it was around the anniversary of when one of his sons had died from medical problems. He generally did not show any emotion since being in the military, but his son's death was different and he could not be near any events that were held in remembrance of his son's death. His insight, judgment, and memory were all intact. He was able to fall asleep without a problem, but woke up every hour or two to check on things and would remain awake until sunrise if he was thinking about Vietnam. He avoided situations and places where there were a lot of people and if people were behind him he would experience anxiety. He continued to use some alcohol (although not as much as he had in the past) and occasionally used marijuana. With respect to PTSD symptoms specifically, the Veteran experienced recurrent, involuntary, and intrusive distressing memories of traumatic events in service; recurrent distressing dreams in which the content and/or effect of the dreams were related to the traumatic events; avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic events; avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that aroused distressing memories, thoughts, or feelings about or closely associated with the traumatic events; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; hypervigilance; an exaggerated startle response; and sleep disturbance. The Veteran reported other subjective mental health symptoms, but the examiner explained that those symptoms did not rise to a sufficient level of chronicity, were transient, and/or were not objectively identified on mental status examination. Diagnoses of PTSD, alcohol use disorder, and cannabis use disorder were provided. The psychologist who conducted the February 2015 examination noted that it was not possible to differentiate what symptoms were attributable to each diagnosis because the alcohol use disorder and cannabis use disorder were interwoven with the PTSD. Also, the level of occupational and social impairment caused by the Veteran's psychiatric disability met the criteria for a 10 percent rating under the General Rating Formula. The Veteran reported during an August 2016 VA psychiatric examination that his social, marital, and family history had remained the same since the time of the February 2015 VA examination and that he was still living with his wife. There were no changes in his occupational history and he spent his time "hanging around the house." He did not like to go out much to socialize and only had two good friends. He continued to drink socially approximately once a week, but he had cut down on his alcohol use during the previous year and did not drink to the point of intoxication. He only used cannabis when other people were smoking. With respect to PTSD symptoms, the Veteran experienced recurrent distressing dreams in which the content and/or effect of the dreams were related to traumatic events in service; avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic events; avoidance of or efforts to avoid external reminders (people, places, conversation, activities, objects, situations) that aroused distressing memories, thoughts, or feelings about or closely associated with the traumatic events; an inability to remember an important aspect of the traumatic events; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; hypervigilance; an exaggerated startle response; sleep disturbance/chronic sleep impairment; and anxiety. Examination revealed that the Veteran was casually dressed. He appeared anxious, but was cooperative and had good eye contact. His speech was relevant, thought content was negative for psychosis, there was no suicidal or homicidal ideation, he was fully oriented, and his memory was intact. The Veteran was diagnosed as having PTSD and alcohol use disorder. The psychiatrist who conducted the August 2016 examination explained that it was possible to differentiate what symptoms were attributable to each diagnosis in that the Veteran's hypervigilance and arousal symptoms belonged to PTSD. He reported that he had not used alcohol heavily for many months, no active symptoms associated with alcohol use disorder were reported, and there were limited to no resultant alcohol use symptoms impacting his functioning. His PTSD symptoms of isolation and anxiety would affect his pace and persistence in any full time employment. Overall, the level of occupational and social impaired caused by the Veteran's PTSD met the criteria for a 30 percent rating under the General Rating Formula. The above evidence reflects that since the effective date of service connection, the Veteran has experienced symptoms of PTSD that have most closely approximated the criteria for a 30 percent rating under the General Rating Formula. In particular, his symptoms have included anxiety, depression, nightmares, occasional panic attacks, and chronic sleep impairment. Although he has been unemployed during the entire claim period, the examiner who conducted the August 2016 VA examination indicated that the Veteran's PTSD symptoms of isolation and anxiety would affect his pace and persistence in any full time employment. Despite the fact that the examiners who conducted the March 2013 and February 2015 VA examinations concluded that the level of impairment caused by the Veteran's psychiatric disability met the criteria for a 10 percent rating under the General Rating Formula, the evidence reflects that symptoms and overall impairment experienced during the claim period have most closely approximated the criteria for a 30 percent rating. 38 C.F.R. § 3.100(a) (2017) (delegating the Secretary's authority "to make findings and decisions ... as to the entitlement of claimants to benefits" to, inter alia, VA "adjudicative personnel"); 38 C.F.R. § 4.2 ("It is the responsibility of the rating specialist to interpret reports of examination ... so that the current rating may accurately reflect the elements of disability present."); VA Adjudication Procedures Manual, M21-1, Part III, Subpart. iv, Chapter 3, Section A.7.i (updated Oct. 28, 2015) ("Do not request a medical authority to make conclusions of law, which is a responsibility inherent to the rating activity"). Hence, an initial 30 percent rating for PTSD is warranted since the effective date of service connection. An initial rating higher than 30 percent for PTSD is not warranted at any time since the effective date of service connection because the Veteran has experienced few symptoms listed in the criteria for ratings higher than 30 percent and his overall occupational and social impairment does not approximate the level of impairment contemplated by the higher ratings. For instance, he has not experienced a flattened affect, his speech has consistently been normal, and his thought processes, memory, and judgment have all remained intact. There is evidence of some occasional panic attacks. For example, the Veteran identified panic attacks as one of his symptoms on his June 2013 statement without further elaboration. Nevertheless, there is no other explicit evidence of any specific panic attacks during the claim period, there is no evidence that panic attacks occur more than once a week, and a 30 percent rating under the General Rating Formula contemplates occasional panic attacks (weekly or less often). Although there has been evidence of disturbances of motivation and mood, such symptoms are also contemplated by a 30 percent rating under the General Rating Formula. Moreover, the Veteran has always been appropriately groomed and dressed, calm, cooperative, alert, and fully oriented, he has not experienced any suicidal/homicidal ideation, delusions, or hallucinations, and he has maintained the ability to perform his activities of daily living. As for employment, the Veteran has been unemployed during the entire claim period. He has not reported, and the evidence does not otherwise indicate, that he experienced any problems while employed due to his psychiatric disability, he stopped working due to physical disabilities (e.g., elbow and knee disabilities), and there is no evidence that he has been unable to obtain new employment due to his psychiatric disability. Although the examiner who conducted the August 2016 VA examination indicated that the Veteran's PTSD symptoms of isolation and anxiety would affect his pace and persistence in any full time employment, occupational impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks is contemplated by a 30 percent rating. With respect to social impairment, there is evidence that the Veteran's prior marriages were impacted by his psychiatric symptoms and he has reported decreased socialization due to his psychiatric disability. Regardless, he has remained married to his third wife since 1994, he maintains relationships with his children, he has not reported any marital or family problems during the claim period due to his psychiatric disability, and he has maintained some friendships. Hence, there has been no evidence of any significant impairment at work or with respect to family relations. The Board finds that the overall symptoms reported by the Veteran, those symptoms that have been observed during examinations, and the assessments of his overall occupational and social functioning are consistent with impairment that most closely approximates the criteria for a 30 percent rating under the General Rating Formula during the entire period since the effective date of service connection. The Veteran has been able to maintain effective social relationships with his family, he has not reported any significant occupational impairment due to his psychiatric disability, and he has not experienced most of the symptoms listed as examples in the criteria for ratings higher than 30 percent. In sum, the Board finds that, overall, the Veteran has not exhibited most of the symptoms listed as examples of the type and extent, frequency or severity, as appropriate, in the criteria for ratings higher than 30 percent under the General Rating Formula at any point since the January 7, 2013 award of service connection for PTSD. Rather, the Veteran's psychiatric symptoms have most closely approximated the criteria for a 30 percent rating under the General Rating Formula during the entire claim period. See 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.130, DC 9411. The Board further finds that, in conjunction with the appeal for a higher initial rating for PTSD, neither the Veteran nor his representative has raised any other related issues, nor have any other such issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Entitlement to service connection for hypertension, secondary to service-connected type II diabetes mellitus, is granted. Entitlement to service connection for erectile dysfunction, secondary to service-connected type II diabetes mellitus, is granted. Entitlement to an initial 30 percent rating for PTSD, since January 7, 2013, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial rating higher than 30 percent for PTSD is denied. REMAND The Veteran contends that he developed and sought treatment for skin problems in 1968 (within a year of his separation from service) and that he has continued to experience skin problems in the years since that time. In support of his claim, he submitted an August 2014 statement from a friend (G.T.) who reported that he had known the Veteran since 1961 and confirmed that the Veteran had been "dealing with his skin problem since 1968." A VA skin examination was conducted in September 2016 and the Veteran was diagnosed as having seborrheic dermatitis. The physician who conducted the examination explained that the Veteran's medical records from his private physicians only go back to possibly the early 2000s. Therefore, there is a large timeframe without specific records to review. One of the physicians who had treated the Veteran in the past had died and other physicians have moved or retired. Although a letter from Dr. Stoller noted that the Veteran's skin problems began in 1968, this was only based on the Veteran's recall and not on any prior records. Therefore, the Veteran's history was not well supported, despite his statements. The examiner concluded that based on the lack of documents over time, it would be resorting to speculation to state that the Veteran's seborrheic dermatitis is specifically due to or the result of Agent Orange exposure, as this is unknown. Despite the brief history from Dr. Stoller, prior information would be helpful, but such information was not available. Thus, many years of no records made it difficult to provide any determination and any determination would be speculative. Additional testing or examination would not provide more information, as maximum medical information has been achieved. The September 2016 skin opinion is adequate to the extent that it is accompanied by a specific rationale addressing why a definitive conclusion as to etiology of the Veteran's claimed skin disability could not be made. See Jones v. Shinseki, 23 Vet. App. 382 (2010). Nevertheless, the examiner stated that an opinion could not be provided without resort to speculation and this statement weighs neither for nor against the claim. Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). In addition, the opinion is entirely based on the absence of clinical evidence of treatment for skin problems for many years following service. The examiner discounted, without explanation, the lay reports of continuous skin problems since shortly following the Veteran's separation from service. In this regard, a medical opinion is inadequate if it is based solely on the absence of documentation in the record and does not take into account the Veteran's reports of symptoms and history. Buchanan v. Nicholson, 451 F.3d 1331, 1336, n. 1 (Fed. Cir. 2006) (noting that VA's examiner's opinion, which relied on the absence of contemporaneous medical evidence, "failed to consider whether the lay statements presented sufficient evidence of the etiology of [the veteran's] disability such that his claim for service connection could be proven without contemporaneous medical evidence"). Hence, a remand is necessary to obtain a new opinion as to the etiology of the Veteran's current skin disability, which takes into consideration the credible evidence of skin symptoms since shortly following his separation from service. As for the claim of service connection for tinnitus, the Veteran contends that he has current tinnitus caused by noise exposure in service. His representative claimed in the August 2014 notice of disagreement that tinnitus began in service and has continued in the years since that time, but there is some evidence to the contrary. For instance, there is no evidence of any tinnitus or hearing problems in the Veteran's service treatment records, his December 1967 separation examination was normal other than for a right thigh scar, there is no clinical evidence of tinnitus or hearing problems for decades following service, and the Veteran has provided information that is inconsistent with a continuity of tinnitus symptomatology in the years since service. In January 2016, a VA otolaryngologist reviewed the Veteran's claims file. She explained, in pertinent part, that there is medical literature (which she specifically cited in her opinion) that supports the idea that noise induced hearing loss may not be detected immediately on audiogram and may take years to manifest. Given these findings, the otolaryngologist concluded that "tinnitus related to noise exposure hearing loss may also take years to manifest." She also indicated, however, that the preponderance of research still supports the concept that hearing loss from noise exposure is relatively immediate and measurable on audiogram. Tinnitus from noise-induced hearing loss is also relatively immediate and described as a symptom by the patient. The otolaryngologist concluded that the Veteran's normal hearing from service strongly suggested that any reported tinnitus was not likely ("less likely) to be from noise exposure. Thus, the Veteran's tinnitus was not likely ("less likely as not") caused by or a result of military noise exposure. The Court explained in its August 2017 Memorandum Decision that the January 2016 opinion is insufficient because the physician did not reconcile her finding that tinnitus associated with noise exposure may take years to manifest with her ultimate conclusion which essentially indicates that the Veteran's tinnitus was not likely caused by military noise exposure because he had normal hearing in service and his tinnitus did not have its onset until many years following service. In light of this fact, a remand is necessary to obtain a new opinion as to the etiology of the Veteran's tinnitus. Moreover, the VCAA requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (c), (d). The VCAA's duty to assist includes a duty to help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody. 38 C.F.R. § 3.159 (c)(4). An October 2014 VA primary care clinic note and the report of a September 2016 VA cardiac examination indicate that the Veteran continued to receive relevant treatment from Dr. Stamm and that he underwent a cardiac evaluation with Dr. Diamantis. The most recent treatment records that have been obtained from Dr. Stamm are only dated to August 2013. Also, the AOJ has not attempted to obtain any relevant treatment records from Dr. Diamantis. Thus, a remand is also necessary to attempt to obtain any additional relevant private treatment records. Updated VA treatment records should also be secured upon remand. Accordingly, the claims remaining on appeal are REMANDED for the following action: 1. Ask the Veteran to identify the location and name of any VA or private medical facility where he has received treatment for a cardiac disability, a skin disability, and tinnitus, to include the dates of any such treatment. Ask the Veteran to complete authorizations for VA to obtain all records of his treatment for a cardiac disability, a skin disability, and tinnitus from Dr. Stamm dated since August 2013 (see the October 2014 VA primary care clinic note), Dr. Diamantis (see the September 2016 VA cardiac examination report), and any other sufficiently identified private treatment provider from whom records have not already been obtained. The AOJ shall attempt to obtain any relevant private treatment records for which a sufficient release is received. All efforts to obtain these records must be documented in the file. If unable to obtain any identified records, take action in accordance with 38 C.F.R. § 3.159 (e). 2. Obtain and associate with the file all outstanding VA records of the Veteran's treatment from the VA Nebraska-Western Iowa Health Care system dated since March 2018; and all such relevant records from any other sufficiently identified VA facility. All efforts to obtain these records must be documented in the file. Such efforts shall continue until the records are obtained or it is reasonably certain that they do not exist or that further efforts to obtain them would be futile. If unable to obtain any identified records, take action in accordance with 38 C.F.R. § 3.159 (e). 3. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, all relevant electronic records (including a copy of this remand along with any records obtained pursuant to this remand) should be referred to a VA physician with appropriate expertise to review and provide an opinion as to the etiology of the Veteran's current skin disability. Only arrange for the Veteran to undergo further examination by an appropriate physician if one is deemed necessary in the judgment of the individual designated to provide the opinion. The opinion provider should identify all skin disabilities that have been diagnosed since approximately July 2013 (even if the disability is currently in remission or has completely resolved) and answer the following question: Is it at least as likely as not (50 percent probability or more) that the current skin disability had its onset during service, is related to the Veteran's presumed exposure to herbicide agents in service, is related to his warts in service in May and July 1967, or is otherwise the result of a disease or injury in service? In answering the above questions, the opinion provider should acknowledge and discuss any skin disabilities diagnosed since approximately July 2013, the Veteran's presumed exposure to herbicide agents in service, any instances of treatment for skin problems in his service treatment records (to include the treatment for warts in May and July 1967), and the reports of the Veteran and his friend (see the September 2014 statement from G.T.) that the Veteran has experienced skin problems ever since 1968. The opinion provider must provide reasons for each opinion given. The opinion provider is advised that the Veteran is competent to report his symptoms and history and that others are competent to report their observations of his symptoms, and such lay statements must be specifically acknowledged and considered in formulating any opinions. The absence of clinical evidence of treatment for specific skin problems in the Veteran's service treatment records or for many years after service cannot, standing alone, serve as the basis for a negative opinion. 4. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, all relevant electronic records (including a copy of this remand along with any records obtained pursuant to this remand) should be referred to a VA physician with appropriate expertise to review and provide an opinion as to the etiology of the Veteran's current tinnitus. Only arrange for the Veteran to undergo further examination by an appropriate physician if one is deemed necessary in the judgment of the individual designated to provide the opinion. For any tinnitus experienced since approximately July 2013, the opinion provider should answer the following question: Is it at least as likely as not (50 percent probability or more) that the current tinnitus had its onset during service, is related to the Veteran's conceded noise exposure in service, or is otherwise the result of a disease or injury in service? In answering the above question, the opinion provider should reconcile the finding of the otolaryngologist who provided the January 2016 opinion that tinnitus associated with noise exposure may take years to manifest with her ultimate conclusion that the Veteran's tinnitus was not likely caused by military noise exposure because he had normal hearing in service and his tinnitus did not have its onset until many years following service. The opinion provider must provide reasons for each opinion given. The opinion provider is advised that the Veteran is competent to report his symptoms and history, and the Veteran's statements must be specifically acknowledged and considered in formulating any opinions. 5. If any benefit sought on appeal remains denied, the AOJ should issue an appropriate supplemental statement of the case. After the Veteran is given an opportunity to respond, the case should be returned to the Board. 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). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs