Citation Nr: 1829680 Decision Date: 07/13/18 Archive Date: 07/24/18 DOCKET NO. 08-00 908 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a nasal disorder. 2. Entitlement to service connection for a neck disorder. 3. Entitlement to an extraschedular rating for posttraumatic stress disorder (PTSD). 4. Entitlement to an extraschedular total disability rating based on individual unemployability (TDIU) prior to August 18, 2008. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD E. Mine, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1967 to January 1971. This matter is before the Board of Veterans' Appeals (Board) on appeal of a September 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The September 2006 RO decision determined that new and material evidence had not been received to reopen a claim for entitlement to service connection for a nasal disorder (listed as residuals of a fractured nose), and denied service connection for a neck disorder (listed as a neck injury). The September 2006 RO decision addressed the issue of entitlement to service connection for a nasal disorder (listed as residuals of a fractured nose) on the basis of whether new and material evidence had been received. The RO determined that new and material evidence had not been received to reopen a claim for entitlement to service connection for a nasal disorder. However, in a May 2016 decision, the Board found that a prior July 2003 RO decision denying the issue of entitlement to service connection for a nasal disorder was not final because additional, relevant service treatment records were associated with the record in August 2012. As additional service department records were received relating to the Veteran's claim, VA must reconsider the Veteran's claim for entitlement to service connection for a nasal disorder without regard to the finality of the July 2003 RO decision. 38 C.F.R. § 3.156(c) (2017). In April 2009, the Veteran appeared at a personal hearing at the RO. In March 2010, the Veteran appeared at a personal hearing at the RO. In March 2013, the Veteran appeared at a Board videoconference hearing before an undersigned Veterans Law Judge. In August 2013, the Board determined that the issue of entitlement to a TDIU was raised during the Veteran's previously appealed increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board remanded the issues of entitlement to service connection for a nasal disorder (listed as residuals of a nasal fracture); entitlement to service connection for a neck disability; entitlement to an initial schedular rating higher than 10 percent for PTSD for the period from September 20, 2005 to August 17, 2008, higher than 30 percent for the period from August 18, 2008 to September 29, 2010, and higher than 70 percent thereafter; and entitlement to an effective date earlier than September 20, 2005, for service connection for PTSD, as well as the issue of entitlement to TDIU, for further development. In September 2014, the Veteran appeared at a personal hearing at the RO. While a March 2015 RO decision granted TDIU, effective September 30, 2010, in its May 2016 decision, the Board found that the issue of entitlement to TDIU for the period prior to September 30, 2010, was part of the claim for higher ratings for PTSD. Rice, 22 Vet. App. at 447. In July 2015, the Veteran appeared at a Board videoconference hearing before another undersigned Veterans Law Judge. In a May 2016 decision, the Board denied an earlier effective date for PTSD, but granted an initial rating of 30 percent for the period from September 20, 2005, to August 17, 2008, granted an increased rating of 70 percent for the period from August 18, 2008, to September 29, 2010, and denied a rating in excess of 70 percent for the period since September 29, 2010. Additionally, the Board remanded the claims for entitlement to service connection for a nasal disorder and a neck disorder to afford the Veteran VA examinations. Likewise, the Board remanded the issue of entitlement to TDIU prior to September 30, 2010, in light of the grant of increased ratings for PTSD, and directed the RO to consider whether referral for extraschedular evaluation was warranted for both PTSD and TDIU. In a July 2017 rating decision, the RO granted an earlier effective date for entitlement for TDIU, effective August 18, 2008. The RO indicated that this was a partial grant of benefits. In March 2018, the Veteran appeared before a third Veterans Law Judge via videoconference hearing. The issues of extraschedular consideration of TDIU and PTSD are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran's current nasal disorder initially manifested in service; or is etiologically related to a disease, injury, or event which occurred in service. 2. The preponderance of the evidence is against a finding that the Veteran's current neck disorder initially manifested in service; or is etiologically related to a disease, injury, or event which occurred in service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a nasal disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R §§ 3.102, 3.303, 3.307, 3.309 (2017). 2. The criteria for entitlement to service connection for a neck disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Stegall Concerns In May 2016, the Board remanded the Veteran's claims for additional evidentiary development. The Board instructed the RO to provide the Veteran VA examinations for his claimed nose and neck conditions, noting that the examiner should review the entire claims file and acknowledge and discuss the Veteran's complaints and treatment for any nasal and neck/cervical spine problems during and since service. The Board also instructed the RO to obtain updated VA treatment records from January 2015 to the present. The Veteran, in a July 2017 letter, asserted that the RO failed to comply with the Board's May 2016 remand directives. However, the Board notes that the RO associated updated treatment records with the Veteran's claims file, provided the Veteran with VA nasal and neck examinations in July 2016, and obtained an addendum VA medical opinion regarding the Veteran's nasal examination in March 2017. In both examinations, the examiner noted that the Veteran's claims file was reviewed and the examiner addressed the Veteran's complaints of and treatment for the claimed condition. Thus, the Board's prior remand instructions have been complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). II. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA's duty to notify was satisfied by letters dated in December 2002 and December 2005. See 38 U.S.C. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA has also fulfilled its duty to assist the Veteran. Service treatment records, identified post-service treatment records, Social Security Administration (SSA) disability records, and lay statements have been obtained and associated with the record. The Veteran was afforded VA examinations in July 2016. In letters dated in January 2017 and July 2017, the Veteran asserted that the July 2016 examinations were inadequate, indicating that the examiner failed to properly review the claims file, provided an inaccurate and negligent clinical assessment, and misrepresented the Veteran's statements. The Veteran further asserted that the examinations were inadequate because the July 2016 examiner did not specialize in neurology. The United States Court of Appeals for Veterans Claims (Court) has held that a VA opinion report is adequate if it is based on correct facts and sufficiently informs the Board of the medical expert's judgment on a medical question and the "essential rationale" for the opinion. The report must be "read as a whole" and a medical examiner is not required to provide a detailed review of medical history or comment on every piece of favorable evidence in the record. Monzingo v. Shinseki, 26 Vet. App. 97, 105-7 (2012); see Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that VA examiners do not have a reasons or bases requirement). Where the opinion is lacking in detail, "the Board is permitted to draw inferences based on the overall report so long as the inference does not result in a medical determination." Acevedo, 25 Vet. App. at 294. The Board finds that the July 2016 examination reports are adequate for adjudicatory purposes, as the examination report reflects that the examiner performed a thorough clinical examination to determine the nature of the Veteran's current nasal and neck disorders. As discussed in detail below, the Board does find the July 2016 examiner's opinion as related to the nasal condition inadequate; however, the July 2016 opinion as to the neck condition and the March 2017 addendum opinion as to the nasal condition are based on an accurate medical history, are unequivocally stated, and are supported by sufficient rationales. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Taken together, the July 2016 and March 2017 reports are adequate upon which to base a decision. Next, the Board is entitled to presume the competence of a VA examiner and specific challenges to a VA examiner's competency must be raised by the appellant to overcome this presumption. See Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009); Cox v. Nicholson, 20 Vet. App. 563, 569 (2007). Absent evidence or argument which called into question a VA examiner's professional competence, the Court concluded in Cox that it is not error for the Board to presume that a VA examiner is competent. Id.; see Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (extending the presumption of competence discussed in Cox and Rizzo to VA examiners). The Veteran has not provided any specific argument as to why a licensed physician does not have the appropriate expertise to examine the Veteran's neck and nose, and therefore, the burden of rebutting the Board's presumption of an examiner's competence is not met. Accordingly, the Board will address the merits of the claims. III. Service Connection Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted on a presumptive basis for certain chronic diseases, including arthritis or degenerative joint disease, if shown to be manifest to a degree of 10 percent or more within one year following the veteran's separation from active military service. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). If a disease listed in 38 C.F.R. § 3.309(a) is shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Id. However, if chronicity in service is not established or where the diagnosis of chronicity may be legitimately questioned, a showing of continuity of symptoms after discharge is required to support the claim. Id. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Id. A claimant "can benefit from continuity of symptomatology to establish service connection in the ultimate sense, but only if [the] chronic disease is one listed in § 3.309(a)." Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013). In determining the weight to be assigned to evidence, credibility can be affected by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b). The Veteran contends that he has a nasal disorder and a neck disorder that are related to service. The Veteran specifically maintains that in February 1970 he was detained by the shore patrol at U.S. Naval Station Alameda the night before leaving California to deploy to the USS Shangri-La. He has stated that he was detained at a night club because he was out of uniform. The Veteran has maintained that while in custody he was pushed into a cement column, which resulted in the Veteran breaking his nose and causing a neck injury. See, e.g. December 2002 VA treatment record; March 2003 VA treatment record; April 2009 Decision Review Officer (DRO) hearing testimony; September 2009 DRO hearing testimony; March 2013 Board hearing testimony; July 2015 Board hearing testimony. Nasal Disorder As to the first Shedden element, the Veteran has a current diagnosis of a deviated septum. See July 2016 VA nasal examination. However, turning to the second Shedden element, the weight of the evidence is against a finding of an in-service incurrence or aggravation of any disease or injury to the Veteran's nose. As noted above, the Veteran has maintained that his currently diagnosed nose disorder is related to an in-service incident in February 1970 in which he was pushed into a cement column. He has testified that he did not remember exactly what happened after the incident, but believed he may have been treated at Oakland Navy Hospital or the Naval Aid station in Mayport, Florida. He has stated that shortly after the incident, he was transported to the USS Shangri-La. The Veteran initially filed a claim in March 1971 for service connection for face and nose injures and any other illness, injuries or disease incurred while in the service. The Veteran reported that he had received treatment for his claimed injuries in February 1970 at Naval Air Station in Alameda, California. There is no evidence that the Veteran was treated for a traumatic injury to his nose in February 1970 at either Oakland Navy Hospital or the Naval Aid station in Mayport, Florida. The RO requested records related to the Veteran for treatment for a nasal fracture and head injury between February 1970 and April 1970 from the Oakland Naval Hospital. In an August 2012 response, the RO was informed that a search was conducted, but no records were located. Likewise, the RO requested records related to the Veteran for treatment for a nasal fracture and head injury between January 1970 and March 1970 from the NAS Mayport Branch Health Clinic. In a January 2015 response, the RO was informed that a search was conducted, but no records were located. Additionally, in July 2014, the William Beaumont Army Medical Center indicated that it had no treatment records for the Veteran from January 1970 to the time of the response. The RO also requested unit records of VA152 Naval Air Station Alameda between January 1970 and March 1970. However, in a January 2015 response, the RO was informed that the request had been investigated, but unit histories were not maintained. The Veteran's service treatment records are otherwise negative for any complaints or treatment related to his claimed February 1970 traumatic injury to his nose. The Veteran does not dispute that fact. In a June 2010 statement, the Veteran reported that he had gone through 10 boxes of Oakland Naval Hospital records from 1970, but had been unable to locate any records showing evidence of his claimed nose and head injury. He further stated that M.B. had looked through outpatient and inpatient records from the Oakland Naval Hospital from 1969 to 1970, as well as 1970 records from the Mayport, Florida, dispensary, but had found no evidence of his claimed nose and head injury. See also September 2016 Veteran statement. Moreover, treatment records made close in time to the Veteran's claimed injury make no reference to any trauma. On February 6, 1970, the Veteran was treated for head and chest congestion and running sinuses while aboard the USS Shangri-La. There is, however, no reference to any trauma to the Veteran's nose despite the proximity in time to the Veteran's account of a traumatic injury. In March 1970, the Veteran was treated for a fever, chills, a sore throat, and tightness in his chest while aboard the USS Shangri-La. Again, the record makes no reference to any trauma to the Veteran's nose. The Veteran has also indicated that scars on his face were the result of the claimed February 1970 incident. However, a May 1969 service treatment record shows that the Veteran was taken by the Naval Air Station ambulance for treatment after suffering a one-inch laceration under his left eye and a half inch laceration to his left eyebrow. The Veteran was treated with nylon sutures under the eye and Steri-Strips to the left eyebrow. A later September 1969 service treatment record noted that the Veteran had been punched in the left eye, and scars were noted above and below the Veteran's left eye. There was no reference to a nose injury or fracture in either treatment record. In his January 1971 separation examination, the Veteran's nose was evaluated as clinically normal. As noted above, the Veteran first filed a claim for service connection for face and nose injuries in March 1971 and was afforded a VA examination in April 1971. The examiner reported that the Veteran's complaints included, in pertinent part, sinus trouble due to a nose injury while on active duty. On examination, the Veteran was noted to have a 2-cm scar below his left eye, and 3 cm scar on his forehead, both were well healed. Examination also revealed deviation of the nasal septum to the left anteriorly and to the right posteriorly, with almost complete nostril obstruction. The examination further revealed compensation hypertrophy of both inferior turbinates, paleness of the nasal mucous membrane, clear watery secretion of each nostril, but no polypi, tumor masses or sinus discharge. The examiner reported a diagnosis of deviated nasal septum, traumatic, and specifically diagnosed no orthopedic problems. The examiner stated that the Veteran reported fracturing his nose and receiving facial lacerations during a fight with Military Police in February 1970. The Veteran also reported that he had been in a second fight approximately three weeks prior to the examination, during which his nose was broken a second time. The examiner did not offer an opinion as to the cause of the Veteran's deviated septum. In a December 2003 notice of disagreement, the Veteran disputed the examiner's report in the April 1971 VA examination that he had fractured his nose a second time. However, later, during a September 2014 DRO hearing, the Veteran testified that 17 days after initially filing his claim he got into a fight and broke his nose. VA treatment records confirm that the Veteran was treated for a broken nose in March 1971. An emergency treatment record shows that the Veteran fractured his nose and showed a marked deformity of the nasal bone, with discoloration. The record indicated that the Veteran was to be evaluated for surgical reconstruction. Based on the above evidence, the Board finds that the Veteran's assertions of an assault in February 1970 leading to nasal trauma are internally inconsistent and inconsistent with the other evidence of record and are therefore afforded little probative weight. Caluza, 7 Vet. App. 498 (1995). As there is otherwise no evidence to indicate that the Veteran received a nasal injury in service, the second Shedden element is not satisfied. The Board acknowledges statements provided by the Veteran's wife, mother, and brother, reporting that the Veteran has told them that he was pushed into a column. While the Veteran's family members are competent to report on issues of which they have first-hand knowledge, such as the presence of scars, when considered with the other evidence of record, the Board finds that the statements are not credible. Finally, considering the third Shedden element, the weight of the evidence is against a finding that the Veteran's currently diagnosed nasal disorder is etiologically related to his active duty service. The Veteran was afforded a VA nasal examination in July 2016. The examiner noted a diagnosis of deviated nasal septum dating to 1971, and at the time of the examination had a more than 50 percent blockage of his left nasal passage due to hypertrophied turbinates. The examiner opined that the Veteran's claimed injury was at least as likely as not incurred in or related to the claimed in service event. The examiner's rationale stated that because a compensation and pension examination was requested in March 1971 the Veteran must have had an injury while in service because that was still during his service. However, according to his service personnel records, the Veteran's active service ended in January 1971. As the July 2016 examiner's opinion was based on an inaccurate factual premise, it has no or little probative value. Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). In March 2017, the RO requested an addendum opinion to clarify the July 2016 examiner's statement that, "Therefore veteran must have an injury of the nose before March 10, 1971 since the date of the request for C & P was March 10, 1971. (The veteran dated it Feb. 1970) - thats [sic] still during his service. The other nose injury was March 27, 1971 as noted in the consultation. Thats [sic] after service." In a March 2017 addendum opinion, a VA examiner opined that the Veteran's claimed nasal disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that service treatment records did not show evidence of nose fracture during service. The examiner noted that there was a documented laceration to the left eyebrow and below the left eye in May 1969, but no nose injury and no ocular pathology. The examiner reiterated that although the Veteran had several clinic visits for other acute conditions, such as bronchitis, urinary tract infection, and tonsillitis, there was no complaint, evaluation, or treatment for a nose injury, between November 1969 and November 1970, there was no report of trauma to his nose. The examiner further noted that during his separation examination in January 1971, the examiner reported normal examination of the head, face, neck, nose and sinuses. Finally, the examiner stated that after a post-service injury in March 1971, the Veteran was seen by an ear, nose and throat and underwent septoplasty, and that based on a review of the service medical records, there was no injury to the Veteran's nose prior to March 1971. The examiner also noted that the July 2016 VA examiner's statement that the Veteran "must have an injury of the nose before March 10, 1971 since the date of the request for C & P was March 10, 1971. (The veteran dated it Feb. 1970)- thats [sic] still during his service," was inaccurate, as the Veteran's period of service was from November 1967 to January 1971. The Board finds this addendum report to be probative and carry much weight as it contains a thorough and accurate medial history and provides a rationale in support of the opinion. The Veteran has submitted no competent nexus evidence contrary to the March 2017 VA examiner's opinion. The Veteran has been allowed ample opportunity to furnish medical evidence in support of his claim, but he has not done so. 38 U.S.C. § 5107(a) (stating that a claimant bears responsibility to support a claim for VA benefits). The weight of the probative, competent medical evidence, to include the March 2017 VA examination, is against a finding that the Veteran's nasal disability is etiologically related to his active duty service which the Board finds to be the only competent medical evidence of record. As such, service connection must be denied. Neck Disorder As to the first Shedden element, the Veteran has current diagnoses of a number cervical spine disorders, including stenosis, herniated disc, and degenerative disc disease of the cervical spine. See, e.g., November 2000 private treatment record; December 2005 private treatment record; January 2006 private treatment record; July 2016 VA neck examination. Turning next to the second Shedden element, the weight of the evidence is against a finding of an in-service incurrence or aggravation of any disease or injury to the Veteran's neck. The Veteran has maintained that his neck disability is related to the same February 1970 incident in which he asserts he was pushed into a cement column. The Veteran states that the incident also caused a neck injury, which he was not aware of until many years later. However, for the reasons discussed above, the Board finds that there is no credible evidence of the claimed in-service injury. Moreover, while the Veteran's service treatment records show complaints of lower back pain, there is no indication of complaints of or treatment for any conditions related to the neck or cervical spine. In the Veteran's January 1971 separation examination, his spine was evaluated as clinically normal. The first medical evidence of a diagnosis related to the Veteran's neck is in a November 2000 private treatment record, in which Dr. S. B. gave a diagnosis of C5-6 spondylosis after an imaging study. Notably, the doctor's findings indicated there was no evidence of fracture or subluxation. Further, the Veteran has testified that he did not begin to experience any problems with his spine until 2000, when he experienced numbness on the left side of his body. See, e.g., July 2014 hearing testimony, July 2016 VA examination report. Likewise, in an April 2006 statement, the Veteran's wife reported the Veteran's neck began to bother him around 1999. Finally, considering the third Shedden element, the weight of the evidence is against a finding that the Veteran's currently diagnosed neck disorder is etiologically related to his active duty service. In an October 2005 private treatment record, the Veteran complained of headaches and "triple vision." Dr. D. R. opined that the Veteran had an essentially normal neurologic examination but opined that the possible cause of the Veteran's headaches was a very old trauma to the neck and head. However, the doctor's opinion does not indicate that the possible very old neck trauma was incurred in service, and, moreover, the opinion is speculative in nature, and therefore is not sufficient to support the Veteran's claim. See Bostain v. West, 11 Vet. App. 124, 127-28 (1998); McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). The Veteran was afforded a VA examination for his claimed neck disability in July 2016. The examiner noted that the Veteran had diagnoses dating to 2007 of cervical spine stenosis and degenerative disc disease of the cervical spine. The Veteran reported that he had a history of neck spine problems since 2000, when his entire left side became numb and he believed he was having a stroke. He further reported that he had been told that an x-ray of the cervical spine showed an old injury. The Veteran stated that in July 2007 he had an x-ray due to severe neck pain, which showed a large osteophyte at C5-6. The Veteran stated that prior to 2014 surgery, he had numbness and loss of sensation on the inside of his left upper extremity, which had since come back. The examiner opined that the Veteran's claimed neck condition was less likely than not incurred in or caused by the claimed in-service event or injury. The examiner explained that the Veteran had no neck condition documented in service, and there had been no documented neck symptoms, treatment, or diagnosis for a neck condition until 20 years after discharge. The examiner found that there was no other evidence to relate the Veteran's neck spine condition to his service. The Board acknowledges the Veteran's contentions that his neck disability is related to his in-service duties. However, as a layperson, his statements are not competent evidence regarding the etiology of the claimed conditions. See Barr, 21 Vet. App. at 307 (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions). While the Veteran is competent to report symptoms capable of lay observation, he has not been shown to be competent to render an opinion as to the etiology of his neck condition, as such an opinion requires medical expertise which he is not shown to possess. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In addition, the Veteran was not diagnosed with cervical spine spondylosis or degenerative joint disease (i.e. arthritis) in service or to a compensable degree within one year of discharge from service, so presumptive service connection is not warranted. However, as arthritis is a chronic disease under 38 C.F.R. § 3.309(a), continuity of symptomatology may be considered with this claim. As noted above, by the Veteran's own reports, he did not begin experiencing symptoms related to his neck until 2000, which coincides with the first diagnosis of a neck-related disability and is approximately 30 years after his active duty service. Therefore, the record does not include evidence of continuity of symptomatology, and this alternative method of establishing a nexus between his current neck disability and service is not supported by the evidence. The Veteran has submitted no competent nexus evidence contrary to the July 2016 VA examiner's opinion. The Veteran has been allowed ample opportunity to furnish medical evidence in support of his claim, but he has not done so. 38 U.S.C. § 5107(a) (stating that a claimant bears responsibility to support a claim for VA benefits). As the record contains no competent positive medical nexus opinion etiologically linking the Veteran's neck disability with his active duty service, the Board finds the only competent medical evidence of record, the July 2016 VA examination, is against a finding that the Veteran's neck disability is etiologically related to his active duty service. In sum, upon careful review and weighing of the evidence, with reasoning as detailed above, the Board finds that the preponderance of the evidence is against the claim for service connection for both his claimed nasal and neck disorders, and the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). The appeal must, therefore, be denied. ORDER Service connection for a nasal disorder is denied. Service connection for a neck disorder is denied. REMAND In its May 2016 remand, the Board directed the RO to consider whether referral for extraschedular evaluation was warranted for both PTSD and TDIU and if either remained denied, to issue a supplemental statement of the case (SSOC) and return the case to the Board. In an October 2016 rating decision, the RO increased the Veteran's ratings for PTSD pursuant to the Board's May 2016 decision. However, the RO did not consider whether an extraschedular evaluation was warranted and did not issue an SSOC for the issue. As such, remand is required. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). Likewise, while the RO readjudicated the effective date of TDIU in a July 2017 rating decision, and issued an SSOC the same month, it failed to consider whether or not extraschedular evaluation was warranted. Thus, the Board finds a remand is necessary to ensure compliance with the Board's prior remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Moreover, as any development related to the Veteran's PTSD may have an impact on the Veteran's eligibility for a TDIU, remand is necessary. Accordingly, the case is REMANDED for the following action: After conducting any other necessary development, determine whether referral for extraschedular consideration for PTSD and TDIU is warranted. If the benefits sought remain denied, the Veteran must be furnished a Supplemental Statement of the Case, to include consideration of 38 C.F.R. §§ 3.321(b), 4.16(b). The Veteran has the right to submit additional evidence and argument on matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ____________________________ _______________________________ Paul Sorisio S. HENEKS Veterans Law Judge Veterans Law Judge Board of Veterans' Appeals Board of Veterans' Appeals ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs