Citation Nr: 1809213 Decision Date: 02/13/18 Archive Date: 02/23/18 DOCKET NO. 13-18 634 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating higher than 50 percent for posttraumatic stress disorder (PTSD) with major depressive disorder (MDD). 2. Entitlement to an initial compensable rating for erectile dysfunction. 3. Entitlement to an initial compensable rating for a right knee scar. 4. Entitlement to an initial compensable rating for a left wrist scar. 5. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD with major depressive disorder. 6. Entitlement to an earlier effective date than May 20, 2010, for the grant of service connection for degenerative disease of the lumbar spine with spondylolisthesis L5-S1(low back disability). 7. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Ralph J. Bratch, Attorney at Law ATTORNEY FOR THE BOARD Ashley Castillo, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1967 to June 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2011, June 2012, and April 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In the May 2011 rating decision, the RO granted service connection for PTSD with a major depressive disorder and assigned a 30 percent rating; right knee scar and assigned a noncompensable rating; left wrist scar and assigned a noncompensable rating, all ratings effective May 20, 2010, the date of the Veteran's claim. In the June 2012 rating decision, the RO granted service connection for erectile dysfunction and denied service connection for hypertension. The Veteran timely disagreed with the initial ratings and the denial of service connection for hypertension. In this case, the evidence of record reflects that the Veteran's PTSD impairs his ability to maintain employment; therefore, entitlement to a TDIU claim has been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that, when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a TDIU will be considered part and parcel of the claim for benefits for the underlying disability). In May 2015, the Board granted entitlement to service connection for a low back disability and remanded the remaining claims on appeal for further evidentiary development. In the April 2016 rating decision, the RO implemented the Board's May 2015 grant of service connection for a low back disability and assigned a 20 percent disability rating, effective May 20, 2010. The Veteran timely disagreed with the effective date assigned for the low back disability. In January 2017, the RO increased the assigned rating for the PTSD with major depressive disorder to a 50 percent, also effective May 20, 2010. The Veteran has not expressed satisfaction with the increased disability rating; this issue thus remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). The issues entitlement to service connection for hypertension, to include as secondary to service-connected PTSD; entitlement to an earlier effective date than May 20, 2010, for the grant of service connection for a low back disability; and entitlement to a TDIU 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 evidence is at least evenly balanced as to whether the symptoms and overall impairment caused by the Veteran's PTSD with major depressive disorder have, throughout the pendency of the claim, more nearly approximated occupational and social impairment, with deficiencies in most areas, but they have not more nearly approximated total social impairment. 2. Symptoms of the Veteran's erectile dysfunction do not more nearly approximate penile deformity. 3. The Veteran's right knee scar has not involved the head, face, or neck, is not deep, does not cause any limitation of motion or function, does not affect an area exceeding at least 6 square inches (39 square centimeters), and has not had any other disabling effects. 4. The Veteran's left wrist scar has not involved the head, face, or neck, is not deep, does not cause any limitation of motion or function, does not affect an area exceeding at least 6 square inches (39 square centimeters), and has not had any other disabling effects. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial rating of 70 percent, but no higher, for PTSD with major depressive disorder are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2017). 2. The criteria for an initial compensable rating for erectile dysfunction are not met. 38 U.S.C. § 1155 (2012), 38 C.F.R. §§ 3.321, 4.115b, 4.3-4.7, DC 7522 (2017). 3. The criteria for an initial compensable disability rating for the right knee scar are not met. 38 U.S.C.A. § 1155 (2012); 38 C.F.R. § 4.118, DC 7804 (2017). 4. The criteria for an initial compensable disability rating for the left wrist scar are not met. 38 U.S.C.A. § 1155 (2012); 38 C.F.R. § 4.118, DC 7804 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) Neither the Veteran nor his attorney has raised any issues with 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. Higher Initial Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Where the Rating Schedule does not provide a 0 percent or noncompensable rating for a particular diagnostic code, such a rating is to be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). 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. Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). A. PTSD with MDD The Veteran's PTSD with MDD is rated 50 percent disabling pursuant to 38 C.F.R. § 4.130, DC 9411. This disability is rated according to the General Rating Formula for Mental Disorders. Under this criteria, a 50 percent evaluation is for assignment 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; difficulty establishing effective work and social relationships. A 70 percent evaluation is contemplated for 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 work-like setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted when there is evidence of 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 and place; memory loss for names of close relatives, own occupation or name. The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating, in addition to permitting consideration of other symptoms particular to each veteran and disorder, and the effect of those symptoms on his/her social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. The Global Assessment of Functioning (GAF) scale reflects psychological, social, and occupational functioning of a hypothetical continuum of mental health illness. See Richard, 9 Vet. App. at 267 (citing the Diagnostic and Statistical Manual of December 2014. The date the Veteran's claim was certified to the Board was before August 4, 2014, which is the date the regulations replacing DSM-IV with DSM-5 are effective. See Schedule for Rating Disabilities-Mental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14308 (Mar. 19, 2015). Therefore, the GAF scores of record will be considered and weighed. Turning to the evidence of record, in a May 2010 statement, the Veteran's childhood friend reported that the Veteran has severe difficulties with maintaining social relationships. In October 2010 the Veteran was afforded an examination. He reported irritability; impaired impulse control; social isolation; chronic sleep impairment; and hypervigilance. He stated that he has three adult children with his first wife, who passed away. He is estranged from his children; he explained that he was not present in his children's life, as they were afraid of him. He remarried in 2005. He has a poor relationship with his wife; he indicated that they have almost divorced and separated. He denied any close friendships. However, he is social, as he has a large family and socially interacts with them. He indicated that he has lost several jobs due to his aggressive behavior. He denied suicidal ideations. The October 2010 VA examiner found that the Veteran was clean and causally groomed. His speech was unremarkable. His was oriented to time, place, and person. There was no evidence of inappropriate behavior. The examiner indicated that the Veteran exhibits obsessive ritualistic behavior, as he obsessively cleans his home. He has poor impulse control, which results in avoiding others and family gatherings. The examiner found that the Veteran has no difficulty with activities of daily living. His immediate memory is mildly impaired as he forgets important tasks. The examiner diagnosed PTSD and depression not otherwise specified (NOS) and assigned a GAF 55. The examiner concluded that the Veteran has difficulty in employment performance and family role functioning due to his PTSD. In a December 2012 letter, the Veteran's treatment provider for his PTSD indicated that the Veteran receive individual psychotherapy on a bi-weekly basis for his PTSD and disorder and depressive disorder In an April 2011 VA treatment record, the Veteran reported symptoms of impaired impulse control. He explained that he went to a crowded grocery store and attempted to initiate a physical altercation with another man who accidently brushed up against the Veteran. The Veteran also reported that his relationship with his daughter has improved. He stated that his daughter and grandson are coming to visit with the Veteran. The VA treatment provider diagnosed PTSD and mood disorder, NOS, and assigned a GAF score of 50. In letters dated in December 2012, the Veteran's VA treatment providers reported that the Veteran exhibits anxiety, irritability, insomnia, intrusive thoughts, flashbacks, and nightmare due to his PTSD. Additionally, the Veteran's treatment provider indicated that the Veteran's PTSD impairs his ability to get along and socialize with others and maintain gainful employment. In July 2016, the Veteran was afforded an examination. He reported depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The Veteran stated that he second wife passed away and he is currently single, as his girlfriend of four years left him. He oldest son is living with the Veteran. He stated that his son is messy and like to love alone. He stated that his other children live in a different state. The Veteran stated that his children remain in telephone contact. He indicated that he has one close friend. His leisure activities include listening to music and yard work. He denied any suicidal or homicidal ideation. He stated that he previously worked as an electrician and that he is he retried. The July 2016 examiner found that the Veteran was casually dressed, his affect was constricted. The examiner diagnosed PTSD and major depressive disorder. The examiner noted that the symptoms of these two disorders overlap and that it is not possible to differentiate what portion of symptoms are attributable to each diagnosis without resort to mere speculation. The examiner opined that the Veteran's PTSD results in in occupational and social impairment with reduced reliability and productivity. During an August 2017 VA treatment record, the Veteran reported that he has been in a relationship for one month and a half. He stated that he wants a companion. He has one friend that he socializes with. The evidence shows that in addition to the service-connected PTSD with major depressive disorder, the Veteran has been diagnosed with a mood disorder NOS. There has been no evidence differentiation between symptomatology associated with the Veteran's service-connected PTSD and the nonservice-connected disorder. To this end, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See Mittleider v. West, 11 Vet App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (holding that the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so). Accordingly, the Board will attribute all of the Veteran's psychiatric symptoms to his PTSD with major depressive disorder for the purposes of assessing the severity of that disability. Throughout the appeal period, the Veteran's PTSD with major depressive disorder has manifested by symptoms including irritability; impaired impulse control; social isolation; chronic sleep impairment; hypervigilance; inability to establish and maintain effective relationships; social isolation; and obsessive ritualistic behavior. Therefore, having considered these factors together and resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's PTSD with major depressive disorder symptoms are of such frequency, duration, and severity so as to result in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, warranting a 70 percent rating throughout the appeal period. See Vazquez-Claudio, 713 F.3d at 117. The Board finds that the Veteran does not meet the next higher rating, a 100 percent, as the PTSD with major depressive disorder symptoms do not more nearly approximate total social impairment. To this end, in a December 2012 letter, the Veteran's VA treatment provider indicated that the Veteran's PTSD impairs his ability to get along with others and maintain employment. Additionally, the Veteran has reported that previously worked as an electrician and that he is retired, but he did not indicate that his PTSD caused him to retire. Even assuming, however, that the symptoms and impairment more nearly approximated total occupational impairment, a preponderance of the evidence is against a finding that the symptoms and impairment more nearly approximate total social impairment. For instance, the evidence demonstrates that the Veteran is unable to establish and maintain effective relationship, as he has reported that he has an estranged relationship with his children and prefers social isolation. However, during VA treatment visits and VA examinations, the Veteran has reported that he remains in contact with his children. For example, he stated during the April 2011 VA treatment visit that his relationship with his daughter has improved. He stated that his daughter and grandson were coming to visit. Moreover, during the July 2016 examination, the Veteran stated that his older son currently lives with him. He also has indicated that he has one close friend that he socializes with. See VA examination report dated July 2016 and August 2017 VA treatment record. Thus, such social impairment more nearly approximates an inability to establish and maintain effective relationships, and not total social impairment as indicated in the 100 percent criteria. Further, the evidence has not revealed symptoms of such frequency, severity, and duration that they cause total social impairment. For example, there has been no evidence of symptoms such as gross impairment in thought process or communication, grossly inappropriate behavior, an intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Furthermore, during the appeal period, the Veteran's GAF scores ranged from 50 to 55. A GAF score of 41 to 50 reflects a serious level of impairment (e.g., suicidal ideation, severe obsessive rituals, frequent shoplifting), or serious impairment in social, occupational, or school functioning (e.g., occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., having few friends or having conflicts with peers or co-workers). A GAF score of 51 to 60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers. These scores reflect serious to moderate symptoms, which still do not indicate that the symptoms more nearly approximated total social impairment. As the preponderance of the evidence is against an initial rating higher than 70 percent, for PTSD with major depressive disorder, the benefit of the doubt doctrine is not otherwise for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. B. Erectile Dysfunction The Veteran's erectile dysfunction is rated as noncompensable under 38 C.F.R. § 4.115b, DC 7522, deformity of the penis. Under DC 7522, the only schedular evaluation available is a 20 percent rating for a deformity of the penis with loss of erectile power. Id. As "deformity" is not defined in the rating criteria, the term is given its ordinary meaning. In medical terminology, a "deformity" is a distortion of any part or general disfigurement of the body. Dorland's Illustrated Medical Dictionary 478 (32nd ed. 2012). A synonym for "deformity" is "misshapen." Webster's New College Dictionary 718 (3d ed. 2008). In this case, a noncompensable rating was assigned even though the schedule did not provide criteria for one because the requirements for the only compensable evaluation were not met. 38 C.F.R. § 4.31. DC 7522 also instructs the rater to review the claim for entitlement to special monthly compensation under 38 C.F.R. § 3.350. Here, the Veteran was granted special monthly compensation for loss of use of a creative organ, June 27, 2011, which is the same effective date as his noncompensable evaluation for erectile dysfunction. 38 U.S.C.A. § 1114(k); 38 C.F.R. § 3.350. The issue is whether the evidence more nearly approximates penile deformity to meet the compensable rating criteria. 38 C.F.R. § 4.115b, DC 7522. Turning to the evidence of record, in May 2012, the Veteran was afforded an examination. The examiner indicated that the Veteran did not have a voiding dysfunction or undergo an orchiectomy. Upon physical examination of the penis and testes, there were no abnormalities. The examiner indicated that the Veteran is able to achieve an erection sufficient for penetration and ejaculation with medication. The examiner diagnosed erectile dysfunction and benign prostate hypertrophy. In August 2016, the Veteran was afforded an examination. The Veteran reported that he seeks treatment from an urologist and that during a treatment visit in 2016, his urologist informed him that there were no abnormalities of genitalia except for the benign prostate enlargement. The August 2016 examiner indicated that the Veteran has a voiding dysfunction, due to the benign prostate hypertrophy. The voiding dysfunction does not cause urine leakage or require the wearing of absorbent material. The examiner found that the Veteran has increased urinary frequency due to the voiding dysfunction resulting in daytime voiding interval less than 1 hour and nighttime awakening to void 2 times. Upon physical examination of the penis, epididymis and testes, there were no abnormalities. The examiner diagnosed erectile dysfunction and benign prostate hypertrophy. The examiner opined that the Veteran's erectile dysfunction impacts his ability to work as he requires frequent visit to the restroom every one to two hours to empty his urinary balder. The Board finds that an initial compensable rating for erectile dysfunction is not warranted. The evidence shows that the Veteran has been diagnosed with erectile dysfunction and benign prostate hypertrophy. The VA examiners findings showed that the Veteran did not have a penile deformity. Physical examination of the penis, epididymis and testes were normal. Notably, neither the Veteran nor the examiners have described any physical deformity related to the Veteran's penis. Thus, the Board finds that the preponderance of the evidence establishes that the Veteran's erectile dysfunction is manifested by loss of erectile power without deformity of the penis. As noted above, other symptoms of the ED have been compensated by an award of the maximum level of SMC for loss of use of a creative organ. Therefore, the evidence does not reflect that the disability more nearly approximates the criteria for a 20 percent rating under Diagnostic Code 7522. For the reasons above, the criteria for a compensable rating for erectile dysfunction have not been met. As the preponderance of the evidence is against any higher rating, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. D. Scars The Veteran's right knee scar and left wrist scar are assigned, separately, noncompensable ratings under 38 C.F.R. § 4.118, DC 7805. The criteria for rating scars provide that burn scars or scars due to other causes, not of the head, face, or neck, that are deep and nonlinear are awarded a 10-percent rating when they have an area or areas of at least 6 square inches but less than 12 square inches. 38 C.F.R. § 4.118, DC 7801. Higher disability ratings are available with a greater area or areas of involvement. Burn scars or scars due to other causes not of the head, face, or neck, that are superficial and nonlinear are awarded a 10-percent rating only when they have an area or areas of 144 square inches or greater. 38 C.F.R. § 4.118, DC 7802. One or two scars that are unstable or painful are awarded a 10-percent rating. Three or four scars a 20-percent disability rating. Five or more scars that are unstable or painful warrant a 30-percent disability rating. 38 C.F.R. § 4.118, DC 7804. Turning to the evidence of record, in an October 2010 examination report, the examiner indicated that the Veteran had a left wrist scar that measured 2.0 centimeters long and 0.1 centimeter wide that was nontender and superficial. Additionally, he had a right knee scar that measured 3.0 centimeters long and 0.1 centimeters wide that was nontender and superficial. The examiner indicated that there was no skin break over the scars and the Veteran denied that his scars were painful. The examiner concluded that there were no effects on the Veteran's usual daily activities due to the scars. In August 2016, the Veteran was afforded an examination. Upon physical examination, the examiner indicated that the Veteran had a left wrist scar that measured 1.3 centimeters long and 0.1 centimeters wide. There was a right knee scar that measured 1.8 centimeters long and 0.2 centimeter wide. The examiner noted that the right knee and the left wrist scars were not unstable or painful. Additionally, the scars were not deep or non-linear. The Board finds a compensable rating for the right knee and left wrist scars not warranted. In this case, the Veteran's right knee and left wrist scars were less than 6 square inches (39 square centimeters), are not deep, nonlinear, or painful. The right knee and left wrist scars do not involve the head, face, or neck and there is no evidence that such scarring is deep, causes any limitation of motion or function, affects an area exceeding at least 6 square inches (39 square centimeters), or is unstable or painful. Hence, compensable ratings for the service-connected right knee and left wrist scars are not warranted at any time during the claim period. As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. III. Additional Considerations The Board has considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). For the following reasons, the Board finds that the symptoms of the Veteran's service-connected PTSD, erectile dysfunction, and scars of the right knee and left wrist are fully contemplated by the rating criteria. As to PTSD with MDD, the criteria in the general rating formula for mental disorders include both the symptoms listed as symptoms "such as" those listed, along with the overall impairment caused by these symptoms. This broad language in the criteria thus contemplates all of the symptoms even though they are not specifically listed. With respect to the erectile dysfunction, the Veteran's symptoms are productive of erectile difficulties. The degree of disability exhibited for erectile dysfunction is contemplated by the rating schedule, notably the assignment of special monthly compensation for loss of use of a creative organ. As to the scarring of the right knee and left wrist, the Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those listed in the criteria. The Board therefore need not consider whether the Veteran's PTSD, erectile dysfunction, and scars of the right knee and left wrist causes marked interference with employment for purposes of an extraschedular rating. ORDER Entitlement to an initial 70 percent initial rating, but no higher, for PTSD with MDD, is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial compensable rating for erectile dysfunction is denied. Entitlement to an initial compensable rating for a right knee scar is denied. Entitlement to an initial compensable rating for a left wrist scar is denied. REMAND The Veteran claims that his hypertension is related to his military service. Alternatively, he asserts that his hypertension is due to his service-connected PTSD. Pursuant to the May 2015 remand, a July 2016 VA opinion was obtained to determine whether the Veteran's hypertension is related to his military service or caused or aggravated by his service-connected PTSD. In the July 2016 VA opinion, the VA physician provided a negative nexus opinion as to direct and secondary service connection. Specifically, as to the secondary service connection opinion, the VA physician, generally, explained that there are several article that indicate that there is an "association" between hypertension and PTSD; however, an association does not correlate that PTSD caused or aggravated hypertension. The VA physician went further and stated that "there is currently no scientific evidence in the peer-reviewed medical literature that a diagnosis of PTSD is a risk factor for the development of [h]ypertension." Conversely, the VA physician then provided "[i]n fact PTSD was ASSOCIATED with an increased risk of hypertension in the National Comorbidity Survey and in an epidemiologic study of Vietnam veterans from Australia." And Veterans with mental health diagnoses had a significantly higher frequency of hypertension and other cardiovascular disease risk factors." To this end, the VA physician indicated that there is no medical evidence literature that supports that PTSD is a risk factor for hypertension; however, then the VA physician provided an article that demonstrates that PTSD increases the risk for hypertension. The Board finds that the VA physician's rationale is unclear and inconsistent. Furthermore, the VA physician provided a detailed explanation as to the differences between association, causation, and aggravation; however, the physician did not explain why in this case the Veteran's hypertension is not caused or aggravated by his PTSD. The Board notes that VA's own statements in connection with its rulemaking authority support an association between PTSD and hypertension. VA has found that a presumption of service connection is warranted for hypertensive vascular disease for prisoners of war (POWs). This presumption is based on several medical studies indicating that veterans who have a long-term history of PTSD have a high risk of developing cardiovascular disease and myocardial infarction; thus, since POWs have a relatively high rate of PTSD incurrence, they would presumably be at greater risk of cardiovascular disease to include hypertension. See Presumptions of Service Connection for Diseases Associated With Service Involving Detention or Internment as a Prisoner of War, 70 Fed. Reg. 37040 (June 28, 2005); Presumptions of Service Connection for Diseases Associated With Service Involving Detention or Internment as a Prisoner of War, 69 Fed. Reg. 60083 (Oct. 7, 2004). Therefore, the Board finds that a remand is necessary to obtain an opinion on this matter. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (noting that "a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two"). As indicated above, in May 2015, the Board granted service connection for a low back disability. In an April 2016 rating decision, the RO implemented the Board' May 2015 grant of service connection for a low back disability and assigned a 10 percent rating, effective May 20, 2010. In an April 2017 formal Notice of Disagreement (NOD), VA Form 21-0958, within a year of notification of the grant of service connection and assignment of an effective date, the Veteran timely disagreed with the effective date of the award for service connection for a back disability. To date, no statement of the case (SOC) has been furnished regarding entitlement to an earlier effective date than March 20, 2010, for the grant of service connection for a low back disability. Because the timely NOD placed the issues in appellate status, this matter must be remanded for the AOJ to issue a SOC. See 38 C.F.R. § 19.9(c) (2017), codifying Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). Lastly, during the pendency of the appeal, the evidence reflects that the Veteran has been unemployed. Furthermore, in a December 2012 letter, the Veteran's VA treatment provider indicated that the Veteran's PTSD impairs his ability to maintain employment. Thus, the issue of entitlement to a TDIU has thus been raised by the evidence of record. See Rice, 22 Vet. App. 447 at 453. This issue should be developed and adjudicated in the first instance by the AOJ, to include appropriate notification and a request for the Veteran to submit a formal application for a TDIU (VA Form 21-8940). Accordingly, the claims remaining on appeal are REMANDED for the following action: 1. Request that the Veteran submit a formal TDIU claim form (VA Form 21-8940), and ensure that he receives appropriate VCAA notice for a claim of entitlement to a TDIU. 2. Obtain any outstanding records of treatment that the Veteran may have received at any VA health care facility. All such available documents should be associated with the claims file. 3. Then, the claims folder should be referred to an appropriate VA physician for an opinion as to the etiology of the Veteran's hypertension. A copy of this remand must be made available to the physician for review in connection with the requested opinion. After a review of the claims file, the physician should provide an opinion whether it is it at least as likely as not (50 percent probability or greater) that hypertension had its onset during military service or is otherwise related to service. Additionally, the physician should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the service-connected PTSD with major depressive disorder either (a) caused or (b) aggravated his hypertension. If aggravated, specify the baseline of disability prior to aggravation, and the permanent, measurable increase in disability resulting from the aggravation. In rendering the above opinion, the VA physician must comment on VA material cited above (Presumptions of Service Connection for Diseases Associated With Service Involving Detention or Internment as a Prisoner of War, 70 Fed. Reg. 37040 (June 28, 2005); Presumptions of Service Connection for Diseases Associated With Service Involving Detention or Internment as a Prisoner of War, 69 Fed. Reg. 60083 (Oct. 7, 2004)) suggesting an association between PTSD and hypertension. The VA examiner must provide reasons for each opinion given. A complete rationale for all opinions is required. The psychiatrist should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). 4. Prepare a SOC in accordance with 38 C.F.R. § 19.29 (2017) regarding the issue of entitlement to an earlier effective date than March 20, 2010, for the grant of service connection for a low back disability. This is required unless the matter is resolved by granting the full benefits sought, or by the Veteran's withdrawal of the notice of disagreement. If, and only if, the Veteran files a timely substantive appeal should any of these issues be returned to the Board. 5. Thereafter, readjudicate the issues on appeal, to include entitlement to a TDIU. If the benefit sought on appeal remains denied, provide the Veteran and his attorney with a Supplemental Statement of the Case and afford them a reasonable opportunity to respond. Then return the case to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (2012). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252, only a decision of the Board is appealable to the Court. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b). Department of Veterans Affairs