Citation Nr: 1819129 Decision Date: 03/29/18 Archive Date: 04/05/18 DOCKET NO. 08-34 056 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for sleep apnea. 2. Entitlement to service connection for narcolepsy. 3. Entitlement to service connection for a prostate disorder. 4. Entitlement to service connection for high cholesterol. 5. Entitlement to service connection for hypertension. 6. Entitlement to service connection for a respiratory disorder manifested by shortness of breath. 7. Entitlement to service connection for a skin disorder of the back. 8. Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD). 9. Entitlement to an increased disability rating in excess of zero percent prior to October 26, 2009 and in excess of 10 percent effective October 26, 2009 for cataract of the right eye. 10. Entitlement to an increased disability rating in excess of 20 percent disabling prior to February 11, 2014 and in excess of 40 percent effective February 11, 2014 for diabetes mellitus type II. 11. Entitlement to an initial compensable rating for erectile dysfunction. 12. Entitlement to an initial rating in excess of 10 percent for dermatophytosis, tinea pedis, and onychomycosis. 13. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left lower extremity. 14. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right lower extremity. 15. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left upper extremity. 16. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right upper extremity. 17. Entitlement to an effective date earlier than October 26, 2009 for the award of service connection for diabetes mellitus type II and secondary complications including cataract of the right eye, erectile dysfunction, dermatophytosis, tinea pedis, and onychomycosis, and peripheral neuropathy of the bilateral upper and lower extremities. 18. Entitlement to an effective date earlier than October 26, 2009 for the award of service connection for cataract of the right eye, erectile dysfunction, dermatophytosis, tinea pedis, and onychomycosis, and peripheral neuropathy of the bilateral upper and lower extremities. 19. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Ralph J. Bratch, Attorney At Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. L. Krasinski, Counsel INTRODUCTION The Veteran had active service from January 1968 to September 1969, to include service in the Republic of Vietnam. These matters come to the Board of Veterans' Appeals (Board) on appeal from November 2006, December 2010, June 2013, and June 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In September 2012, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing at the RO. A transcript of that hearing is of record. In May 2013, the Board reopened the claim for service connection for PTSD and remanded the issue of entitlement to service connection for a psychiatric disorder, to include PTSD, on the merits, for further development. In July 2015, the Board remanded all of the issues on appeal for additional development including to afford the Veteran a VA psychiatric examination, issue a statement of the case for the sleep apnea and narcolepsy issues, and afford the veteran a Board hearing. The Agency of Original Jurisdiction (AOJ) substantially complied with the mandates of the Board remands. Stegall v. West, 11 Vet. App. 268, 271 (1998). In May 2017, the Veteran withdrew the request for a Board hearing. 38 C.F.R. § 20.704 (d) (2017). In December 2012 and February 2014, the Veteran submitted a waiver of AOJ consideration of new evidence pursuant to 38 C.F.R. § 20.1304 (2017). The issues of entitlement to service connection for hypertension and skin disorder of the back; higher initial ratings for the service-connected dermatophytosis, tinea pedis, and onychomycosis, peripheral neuropathy of the upper and lower extremities, cataract of the right eye, and diabetes mellitus type II; entitlement to an effective date earlier than October 26, 2009 for the award of service connection for diabetes mellitus type II, cataract of the right eye, erectile dysfunction, dermatophytosis, tinea pedis, and onychomycosis, and peripheral neuropathy of the bilateral upper and lower extremities; and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam during the Vietnam War era. 2. The Veteran's obstructive sleep apnea did not originate in service or until years thereafter, and is not otherwise etiologically related to an injury, disease, or other event in active service. 3. The Veteran does not have a current diagnosis of narcolepsy at any time during the period of the appeal. 4. The Veteran's prostate disorder did not originate in service or until years thereafter, and is not otherwise etiologically related to an injury, disease, or other event in active service. 5. The Veteran does not have a current diagnosis of prostate or lung cancer at any time during the period of the appeal. 6. Hypercholesterolemia or high cholesterol is not a disability for VA purposes. 7. The Veteran's respiratory disorder to include asthma and chronic obstructive pulmonary disease did not originate in service or until years thereafter, and is not otherwise etiologically related to an injury, disease, or other event in active service. 8. It is as likely as not that the Veteran's current psychiatric disorder variously characterized as depressive disorder and PTSD is related to active service. 9. The Veteran has erectile dysfunction, but no penile deformity or anatomical loss of any part of the penis. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. The criteria for service connection for narcolepsy are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 3. The criteria for service connection for a prostate disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 4. The criteria for service connection for hypercholesteremia or high cholesterol are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 5. The criteria for service connection for a respiratory disorder characterized as COPD and asthma have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 6. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for a psychiatric disorder variously characterized as PTSD and depressive disorder have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2017). 7. The criteria for a compensable rating for erectile dysfunction are not met. 38 U.S.C. §§ 1155, 5103A (West 2012); 38 C.F.R. §§ 3.102, 4.3, 4.115b, Diagnostic Codes 7520-7522 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. Duty to Notify and Duty to Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5103, 5103A (West 2012); 38 C.F.R. § 3.159 (2017). VA provided the Veteran with 38 U.S.C. § 5103 (a)-compliant notice in December 2004, January 2005, March 2006, April 2006, May 2006, June 2006, July 2010, August 2010, May 2011, January 2013, March 2014, August 2015, and November 2015. Therefore, additional notice is not required. VA has fulfilled its obligation to assist the Veteran in developing the claims. Neither he nor his attorney has identified any deficiency in VA's notice or assistance duties. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017); Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) ("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 duty to assist). 2. Legal Criteria: Service Connection Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 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). Service connection requires competent evidence showing, (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), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Under 38 C.F.R. § 3.310 (a), service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation to a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310 (2017); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Pursuant to § 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. at 448. Service connection for PTSD requires the following three elements: (1) a current medical diagnosis of PTSD (presumed to include the adequacy of the PTSD symptomatology and the sufficiency of a claimed in-service stressor in accordance with 38 C.F.R. § 4.125 (a)), (2) credible supporting evidence that the claimed in-service stressor(s) actually occurred, and (3) medical evidence of a causal relationship between current symptomatology and the specific claimed in-service stressor(s). See 38 C.F.R. § 3.304 (f) (2017). In adjudicating a claim for service connection for PTSD, the Board is required to evaluate evidence based on places, types, and circumstances of service, as shown by the veteran's military records and all pertinent medical and lay evidence. Hayes v. Brown, 5 Vet. App. 60, 66 (1993); see also 38 U.S.C. § 1154 (a) (West 2012); 38 C.F.R. § 3.304 (f). The evidence necessary to establish the occurrence of an in-service stressor for PTSD will vary depending on whether or not the veteran "engaged in combat with the enemy." Id. If VA determines that the veteran engaged in combat with the enemy and that the alleged stressor is related to combat, then the veteran's lay testimony or statements are accepted as conclusive evidence of the occurrence of the claimed stressor. 38 U.S.C. § 1154 (b) (West 2012); 38 C.F.R. § 3.304 (f). No further development or corroborative evidence is required, provided that the claimed stressor is "consistent with the circumstances, conditions, or hardships of the veteran's service." Id. If, however, VA determines that the veteran did not engage in combat with the enemy or that the alleged stressor is not related to combat, the veteran's lay testimony by itself is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain service records or other evidence to corroborate the veteran's testimony or statements. See Moreau v. Brown, 9 Vet. App. 389, 394 (1996). If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. "Fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304 (f). If a veteran did not engage in combat with the enemy, or the claimed stressors are not related to combat, and the stressor is not related to "fear of hostile military or terrorist activity," then the veteran's testimony alone is not sufficient to establish the occurrence of the claimed stressors and his testimony must be corroborated by credible supporting evidence. Cohen v. Brown, 10 Vet. App. 128 (1997); Moreau v. Brown, 9 Vet. App. 389 (1996); Dizoglio v. Brown, 9 Vet. App. 163 (1996). Furthermore, service department records must support, and not contradict, the claimant's testimony regarding non-combat stressors. Doran v. Brown, 6 Vet. App. 283 (1994). The question of whether a veteran was exposed to a stressor in service is a factual one, and VA adjudicators are not bound to accept uncorroborated accounts of stressors or medical opinions based upon such accounts. Wood v. Derwinski, 1 Vet. App. 190 (1991), aff'd on reconsideration, 1 Vet. App. 406 (1991). Hence, whether a stressor was of sufficient gravity to cause or support a diagnosis of PTSD is a question of fact for medical professionals and whether the evidence establishes the occurrence of stressors is a question of fact for adjudicators. With any claim for service connection (under any theory of entitlement), it is necessary for a current disability to be present. See Brammer v. Derwinski, 3 Vet. App. 223 (1992); see also McClain v. Nicholson, 21 Vet. App. 319 (2007) (service connection may be warranted if there was a disability present at any point during the claim period, even if it is not currently present); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (when the record contains a recent diagnosis of disability immediately prior to a veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Once the evidence has been assembled, it is the Board's responsibility to evaluate the evidence. 38 U.S.C. § 7104(a). The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. 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. § 7105; 38 C.F.R. §§ 3.102, 4.3. 3. Analysis: Service Connection for Sleep Apnea and Narcolepsy The Veteran contends that he has sleep apnea and narcolepsy that are related to active service. Based upon a review of all the lay and medical evidence, the Board finds the weight of the competent and credible evidence shows that the current sleep apnea is not related to injury, disease, or other event in active service. The record shows that obstructive sleep apnea was first detected upon sleep study in April 2013. Service treatment records show no treatment or diagnosis of sleep apnea. Examinations in February 1967 (enlistment) and September 1969 (separation) indicate that physical examination of the nose, sinus, mouth, throat, and lungs was normal. The Veteran separated from active service in September 1969. As noted, the first evidence of a diagnosis of sleep apnea is in April 2013, over 40 years after service separation. The Board notes that the passage of time between the Veteran's discharge and an initial diagnosis for the claimed disorder is one factor that weighs against the Veteran's claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Post service, the Veteran was afforded VA examinations in November 1985 and July 2010. The Veteran did not have complaints or diagnosis of sleep apnea. The record in this case is negative for any indication, other than the Veteran's own general assertion, that the sleep apnea is related to active service. The Veteran did not present any lay or medical evidence of symptoms or diagnosis of sleep apnea in active service or a nexus to active service. As a layperson, he is not competent to provide a medical opinion that relates the sleep apnea to active service. The Veteran is not shown to possess the type of medical expertise that would be necessary to opine whether the current sleep apnea is medically related to injury or disease or other event in active service or had its onset in active service. See Kahana v. Shinseki, 24 Vet. App. 428, 435 2011). The Veteran, as a lay person, is competent to describe observable symptoms. Although lay persons are competent to provide opinions on some medical issues, as to the specific issue in this case, an opinion as to whether the sleep apnea is medically related to active service falls outside the realm of common knowledge of a lay person. The Veteran has not provided any lay or medical evidence to support his general contentions that the sleep apnea may be associated to active service. The Board finds that the weight of the evidence does not demonstrate objective evidence of a current diagnosis of narcolepsy at any time during the appeal period. The service treatment records do not document treatment or diagnosis of narcolepsy. Post-service medical evidence including the VA treatment records does not show any objective evidence of narcolepsy. There are no objective findings of a diagnosis of narcolepsy. The Veteran has not submitted or identified competent evidence of a current diagnosis of narcolepsy. He has provided general assertions that he has narcolepsy because he falls asleep when driving but the medical evidence of record does not establish a diagnosis. The Board finds that the Veteran, as a layperson, is not competent to render a medical diagnosis, such as establishing that he has a current diagnosis of narcolepsy. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, an opinion as to a specific diagnosis falls outside the realm of common knowledge of a lay person. See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). It is not shown that the Veteran has medical expertise. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1110 (West 2012). In the absence of proof of present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The probative evidence of record demonstrates that the Veteran does not have a current diagnosis of a bilateral eye or vision disability and has not at any time during the pendency of this claim (i.e., since the filing of them). See McClain v. Nicholson, 21 Vet. App. 319, 312 (2007). A VA medical opinion and examination were not provided for the issue of service connection for sleep apnea and narcolepsy. The Federal Circuit Court of Appeals (Federal Circuit) has recognized that there is not a duty to provide an examination in every case. See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Rather, the Secretary's obligation under 38 U.S.C. § 5103A (d) to provide the Veteran with a medical examination or to obtain a medical opinion is not triggered unless there is an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability. See McLendon v. Nicholson, 20 Vet. App.79, 81 (2006). The record in this case is negative for any indication that the sleep apnea is associated to service. The record in this case is negative for any indication, other than the Veteran's own general assertion, that his sleep apnea is related to active service. The Veteran did not provide lay or medical evidence of sleep apnea in active service or symptoms or disease in active service. The service treatment records do not document sleep apnea or narcolepsy. There is no competent evidence of narcolepsy and the first evidence of a diagnosis of sleep apnea is 40 years after service. The Veteran's sole assertion that he wants service connection for sleep apnea is insufficient to trigger VA's duty to provide an examination with an opinion. There is no evidence of the claimed disabilities in active service or any indication of an association to service. The weight of the evidence shows that the Veteran does not currently have narcolepsy and he did not have sleep apnea or symptoms in active service and the disability first manifested decades after active service. There is sufficient competent evidence on file for the Board to make a decision on the claims. As such, VA's duty to provide an examination with an opinion is not triggered. See Waters, 601 F.3d 1274. The Board finds the weight of the competent and credible evidence shows that sleep apnea did not manifest in service, first manifested decades many years after active service and is not related to active service. The Board finds the weight of the competent and credible evidence shows that the Veteran does not have a current diagnosis of narcolepsy. Thus, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for sleep apnea and narcolepsy and the claims for service connection are denied. 4. Analysis: Service Connection for a Prostate Disorder The Veteran contends that he has a prostate disorder that is related to active service. Based upon a review of all the lay and medical evidence, the Board finds the weight of the competent and credible evidence shows that the current prostate disorder is not related to injury, disease, or other event in active service. The record shows that prostate symptoms were detected in 2005. VA treatment records show that the Veteran had benign prostatic hypertrophy (BPH) symptoms in September 2005. His prostate was moderately enlarged. He was prescribed a trial of terazosin. An August 2008 VA treatment record noted BPH and nocturia with urgency likely related to prostatitis. The July 2010 VA examination report indicates that examination of the prostate revealed that it was enlarged. An October 2010 VA problem list shows a diagnosis of prostatitis. A September 2015 VA active problem list notes hypertrophy (benign) of prostate. An October 2017 VA active problem list notes hypertrophy (benign) of prostate and prostatitis. Service treatment records show no treatment or diagnosis of a prostate disorder. Examinations in February 1967 (enlistment) and September 1969 (separation) indicate that physical examination of the genito-urinary system was normal. The Veteran separated from active service in September 1969. A September 1985 VA examination report idnicates that prostate exam was within normal limits. As noted, the first evidence of a diagnosis of prostate symptoms was in 2005, over 35 years after service separation. The Board notes that the passage of time between the Veteran's discharge and an initial diagnosis for the claimed disorder is one factor that weighs against the Veteran's claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The record in this case is negative for any indication, other than the Veteran's own general assertion, that the prostate disorder is related to active service. The Veteran did not present any lay or medical evidence of symptoms or diagnosis of a prostate disorder in active service or a nexus to active service. As a layperson, he is not competent to provide a medical opinion as to the etiology or onset of the prostate disorder. The Veteran is not shown to possess the type of medical expertise that would be necessary to opine whether the current prostate disorder is medically related to injury or disease or other event in active service or had its onset in active service. See Kahana v. Shinseki, 24 Vet. App. 428, 435 2011). The Veteran has not provided any lay or medical evidence to support his general contentions that the prostate disorder may be associated to active service. A VA medical opinion and examination were not provided for the issue of service connection for a prostate disorder. VA does not have a duty to provide an examination in every case. See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Rather, the Secretary's obligation under 38 U.S.C. § 5103A (d) to provide the Veteran with a medical examination or to obtain a medical opinion is not triggered unless there is an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability. See McLendon, 20 Vet. App.at 81. The record in this case is negative for any indication that the prostate disorder is associated to service. The record in this case is negative for any indication, other than the Veteran's own general assertion, that his prostate disorder is related to active service. The Veteran did not provide lay or medical evidence of this disorder in active service or symptoms or disease in active service. The service treatment records do not document a prostate disorder or symptoms. The first evidence of this disorder is 35 years after service. The Veteran's sole assertion that he wants service connection for a prostate disorder is insufficient to trigger VA's duty to provide an examination with an opinion. There is no evidence of the claimed disability in active service or any indication of an association to service. There is sufficient competent evidence on file for the Board to make a decision on the claim. As such, VA's duty to provide an examination with an opinion is not triggered. See Waters, 601 F.3d 1274. The Board recognizes that the Veteran served in the Republic of Vietnam during the Vietnam era and he is therefore presumed to have been exposed to herbicide agents and is eligible for presumptive service connection for prostate cancer. 38 U.S.C. § 1116 (f). However, presumptive service connection for prostate cancer pursuant to 38 C.F.R. § 3.307 (a) based upon herbicide exposure is not warranted in this case because the weight of the evidence does not establish a diagnosis of prostate cancer at any time during the appeal. The Board finds the weight of the competent and credible evidence shows that prostate disorder did not manifest in service, first manifested decades many years after active service and is not related to active service. The Board finds the weight of the competent and credible evidence shows that the Veteran does not have a current diagnosis of prostate cancer. Thus, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for a prostate disorder and the claim for service connection is denied. 5. Analysis: Service Connection for Hypercholesteremia The Veteran maintains that he has hypercholesterolemia, or high cholesterol, as a result of service. Post-service treatment records reveal treatment for hyperlipidemia. See the VA treatment records dated in July 2007, April 2010, and June 2012. The veteran was taking medication for the high cholesterol. See the October 2017 VA active outpatient medications list. This evidence notwithstanding, the Veteran does not meet the preliminary requirement for service connection, namely showing of a current "disability". By way of reference, "hyperlipidemia" is defined as "a general term for elevated concentrations of any or all of the lipids in the plasma, such as...hypercholesterolemia, and so on." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 903 (31st Ed. 2007). In turn, "hypercholesterolemia" is defined as "excessive cholesterol in the blood." Id., at 899. In other words, hypercholesterolemia (i.e., an elevated or high cholesterol level) is merely a laboratory finding, not a ratable disability for VA compensation purposes. The term "disability," as used for VA purposes, refers to impairment of earning capacity and Congress specifically limits entitlement to service connection for diseases or injuries that have resulted in a disability. See 38 U.S.C. § 1110; Allen v. Brown, 7 Vet. App. 439, 448. Simply stated, this is a test result, not a disability. In this case, there is no evidence showing that the Veteran's hypercholesterolemia has resulted in a disability. See Brammer, 3 Vet. App. 223; Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). The Court has held that where the law is dispositive of the claim, the claim should be denied because of lack of entitlement under the law. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Therefore, as there is no basis in the law to grant the Veteran's appeal, the claim for service connection for hypercholesterolemia must be denied. Under the circumstances, the Veteran has not met the regulatory requirements to establish service connection for hypercholesterolemia and service connection must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. Here, however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert; supra. 6. Analysis: Service Connection for a respiratory disorder manifested by shortness of breath. The Veteran contends that he has respiratory disorder manifested by shortness of breath that is related to active service. He asserts that this disorder is due to exposure to herbicides. See the November 2007 statement. Based upon a review of all the lay and medical evidence, the Board finds the weight of the competent and credible evidence shows that the current respiratory disorder diagnosed as chronic obstructive pulmonary disease (COPD) and asthma is not related to injury, disease, or other event in active service. The record shows that the Veteran reported having shortness of breath in 2007. A July 2007 VA treatment record indicates that the veteran presented with complaints of occasional difficulty breathing with some wheezing. It was noted that the veteran was a smoker and he smoked 1 pack of tobacco per day for 32 years. The assessment was COPD. The Veteran was counseled about the need to stop smoking and was started on Combivent. The July 2010 VA examination report indicates that the Veteran reported having shortness of breath for the past 4 years. He denied having asthma attacks. Chest x-ray revealed no significant abnormalities. The assessment was asthma. The subjective factors are shortness of breath. The objective factors are poor effort on PFTs with subsequent restrictive pattern. The VA examiner noted that the Veteran did not have any complications such as cor pulmonale, right ventricular hypertrophy, pulmonary hypertension, or chronic respiratory failure with carbon dioxide retention. An October 2010 VA problem list lists COPD. See also the VA treatment records dated in January 2011 and October 2017 (VA problem list which notes COPD). Service treatment records show no treatment or diagnosis of a respiratory disorder. Examinations in February 1967 (enlistment) and September 1969 (separation) indicate that physical examination of the lungs and chest was normal. The Veteran separated from active service in September 1969. A September 1985 VA examination report indicates that chest exam was within normal limits and the lungs were clear. As noted, the first evidence of shortness of breath symptoms was in 2007, over 35 years after service separation. The Board notes that the passage of time between the Veteran's discharge and an initial diagnosis for the claimed disorder is one factor that weighs against the Veteran's claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The record in this case is negative for any indication, other than the Veteran's own general assertion, that the respiratory disorder is related to active service. The Veteran did not present any lay or medical evidence of symptoms or diagnosis of a respiratory disorder in active service or a nexus to active service. As a layperson, he is not competent to provide a medical opinion as to the etiology or onset of the respiratory disorder. The Veteran is not shown to possess the type of medical expertise that would be necessary to opine whether the current respiratory disorder is medically related to injury or disease or other event in active service or had its onset in active service. See Kahana v. Shinseki, 24 Vet. App. 428, 435 2011). The Veteran has not provided any lay or medical evidence to support his general contentions that the respiratory disorder may be associated to active service. A VA medical opinion and examination were not provided for the issue of service connection for a respiratory disorder. VA does not have a duty to provide an examination in every case. See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Rather, the Secretary's obligation under 38 U.S.C. § 5103A (d) to provide the Veteran with a medical examination or to obtain a medical opinion is not triggered unless there is an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability. See McLendon, 20 Vet. App.at 81. The record in this case is negative for any indication that the respiratory disorder is associated to service. The record in this case is negative for any indication, other than the Veteran's own general assertion, that his respiratory disorder is related to active service. The Veteran did not provide lay or medical evidence of this disorder in active service or symptoms or disease in active service. The service treatment records do not document a respiratory disorder or symptoms. The first evidence of this disorder is 35 years after service. The Veteran's sole assertion that he wants service connection for a respiratory disorder is insufficient to trigger VA's duty to provide an examination with an opinion. There is no evidence of the claimed disability in active service or any indication of an association to service. There is sufficient competent evidence on file for the Board to make a decision on the claim. As such, VA's duty to provide an examination with an opinion is not triggered. See Waters, 601 F.3d 1274. The Board recognizes that the Veteran served in the Republic of Vietnam during the Vietnam era and he is therefore presumed to have been exposed to herbicide agents and is eligible for presumptive service connection for lung cancer. 38 U.S.C. § 1116 (f). However, presumptive service connection for lung cancer pursuant to 38 C.F.R. § 3.307 (a) based upon herbicide exposure is not warranted in this case because the weight of the evidence does not establish a diagnosis of lung cancer at any time during the appeal. The record in this case is negative for any indication, other than the Veteran's own general assertion, that his respiratory disorder is related to active service to include herbicide exposure. The Veteran did not provide lay or medical evidence of this disorder in active service or symptoms or disease in active service and he did not provide any evidence of an indication that the shortness of breath symptoms were due to herbicide exposure. The weight of the competent and credible evidence shows that respiratory disorder did not manifest in service, first manifested decades many years after active service and is not related to active service. The Board finds the weight of the competent and credible evidence shows that the Veteran does not have a current diagnosis of respiratory disorder. Thus, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for a respiratory disorder and the claim for service connection is denied. 7. Analysis: Service Connection for a Psychiatric Disorder and PTSD Resolving all reasonable doubt in the Veteran's favor, service connection for an acquired psychiatric disorder, variously diagnosed as PTSD and depressive disorder, is granted. The Board finds that the competent and credible evidence shows that the Veteran currently has a diagnosis of unspecified depressive disorder. The September 2015 VA psychiatric examination report indicates that the Veteran met the DSM-5 criteria for this diagnosis. Review of the medical evidence of record shows that depressive disorder has been diagnosed since 2004. See the October 2004 VA treatment record (Axis I diagnosis of depressive disorder) and the September 2015 VA psychiatric examination report (the September 2015 VA examiner stated that according to the available records, the Veteran was treated for PTSD symptoms and a depressed mood in 2005 with intermittent follow-up aftercare group therapy and medication management in 2006). Next, the Board finds that the evidence is at least in equipoise on the question of whether the current unspecified depressive disorder is related to active service. The September 2015 VA examiner stated that according to the available records, the Veteran was treated for PTSD symptoms and a depressed mood in 2005 with intermittent follow-up aftercare group therapy and medication management in 2006. The VA examiner stated that much of the notes indicate that the Veteran had symptoms of intrusive nightmares, avoidance behaviors, depressed mood/anxiety, hyper startle response, irritability, and chronic sleep issues. As the Veteran's treatment progressed his notes indicate these symptoms began to improve greatly and were responsive to medication. The VA examiner noted that the Veteran continued to employ coping strategies he learned during his treatment and from 2006 until the present he appears to have improved significantly to the point that his PTSD symptoms are sub-threshold for meeting the criteria for the disorder at this time. In his recent treatment notes, his reported nightmares occur very infrequently with medication and he has made tremendous strides in adapting to more social interaction. In the current examination, he appeared to be confused about whether it is depression or boredom he is experiencing. It was noted that the Veteran's treatment notes do not reflect that he is particularly depressed or anxious; they do not emphasize a diagnosis of mood problems. Rather, they continue to reflect his improvement and willingness to get better. The VA examiner stated that there is some indication that the Veteran's management of his diabetes is not simple and requires his active participation but there is no definitive correlation between managing his diabetes and any mood disorder. The VA examiner noted that in the current examination, the Veteran appeared to be torn between whether he is depressed or just bored. He did say that it makes him feel depressed to have to take all his pills and his insulin as well; however, it appears that those feelings are transient and do not appear to be significantly impacting his overall functioning. The Veteran was taking mirtazapine for depression. The VA examiner indicated that the preponderance of the evidence suggests that the Veteran has an unspecified depressive disorder that appears more likely related to his subthreshold PTSD symptoms rather than his diabetes mellitus. Therefore, it is the opinion of the VA examiner that the Veteran's unspecified depressive disorder was at least as likely as not incurred in or aggravated by his military service and is not proximately due to or caused by the Veteran's service connected diabetes mellitus or other service connected disability. There is medical evidence that weighs against the claim for service connection for a depressive disorder. The April 2014 VA psychiatric examination report indicates that the VA examiner opined that it was less likely than not that the current depressive disorder and anxiety disorder were related to active service. On balance, the record contains medical evidence that is both for and against the claim. Accordingly, resolving all reasonable doubt in the Veteran's favor, service connection for an acquired psychiatric disorder diagnosed as depressive disorder is granted. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). By way of history for the claim for service connection for PTSD, the record shows that an unappealed May 1997 rating decision continued a prior denial of service connection for PTSD on the basis that there was no verified stressor to support a diagnosis of PTSD related to the Veteran's service. This decision became final. The Veteran filed a claim to reopen service connection for PTSD in June 2004. Effective July 13, 2010, VA amended the regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required inservice stressor. Specifically, 38 C.F.R. § 3.304 (f) was amended to redesignate former paragraphs (f)(3) and (f)(4) as paragraphs (f)(4) and (f)(5), respectively, and by adding a new paragraph (f)(3) that reads: (f)(3) If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirm that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the veteran's symptoms are related to the claimed stressor in the absence of clear and convincing evidence to the contrary and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in service stressor. In May 2013, the Board reopened the claim for service connection for PTSD based upon additional lay evidence as to the claimed stressor events in active service. The Board remanded the claim for a VA examination by a VA psychiatrist or psychologist and asked the VA examiner to render a medical opinion as to whether the Veteran had a current diagnosis of PTSD in accordance with the DSM due to the fear of hostile military or terrorist activities. 38 C.F.R. § 3.304(f)(3) (2017). The Board finds that there is competent and credible evidence that the Veteran does not have a current diagnosis of PTSD in accordance with DSM-IV or 5. The April 2014 VA examination report indicates that the VA psychologist concluded that the Veteran did not have a diagnosis of PTSD in accordance with DSM-IV or 5. The VA examiner stated that the full criteria for a diagnosis of PTSD were not met and the Veteran specifically did not meet Criterion C (No persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness) or Criterion D (No persistent negative alterations in cognition or mood). The September 2015 VA examination report indicates that the VA examiner, a psychologist, concluded that the Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria. The VA examiner stated that according to the available records, the Veteran was treated for PTSD symptoms and a depressed mood in 2005 with intermittent follow-up aftercare group therapy and medication management in 2006. The VA examiner noted that, as the Veteran's treatment progressed, the treatment notes indicate these symptoms began to improve greatly and were responsive to medication. The VA examiner noted that the Veteran continued to employ coping strategies he learned during his treatment and from 2006 until the present he appears to have improved significantly to the point that his PTSD symptoms are sub-threshold for meeting the criteria for the disorder. The Board finds the April 2014 and September 2015 VA medical opinions to have great evidentiary weight as the opinions reflect a comprehensive and reasoned review of the entire evidentiary record. The VA examiners reviewed the claims folder and the Veteran's medical history, considered the Veteran's report of symptoms and onset of the claimed disorder, considered the results of the psychological testing, and examined the Veteran before rendering the medical opinions. The VA examiners cited to the facts that support the opinion. Factors for assessing the probative value of a medical opinion are the examiner's access to the claims file and the thoroughness and detail of the opinion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The medical opinions are based on sufficient facts and data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA examiners have the skill and expertise to analyze the medical evidence and render an opinion as to whether the Veteran meets the DSM IV or 5 criteria for a diagnosis of PTSD. See Black v. Brown, 10 Vet. App. 279, 284 (1997). However, the Board also finds that there is competent and credible evidence that the Veteran does have a current diagnosis of PTSD in accordance with DSM-IV or 5, the Veteran had a fear of hostile military or terrorist activity during active service, and a VA psychiatrist or psychologist confirmed that the claimed stressor was adequate to support a diagnosis of PTSD and that his symptoms are related to the claimed stressor. The Board recognizes that VA mental health treatment records show diagnosis PTSD in accordance with DSM and treatment of PTSD for several years. February 1994 and December 1996 VA psychiatric examination reports show a diagnosis of PTSD. An October 2004 VA mental health and behavioral since consult shows a diagnosis of PTSD. A May 2005 VA PTSD clinical team consult indicates that the Veteran was referred for evaluation of PTSD clinical team. The Veteran was administered a battery of psychological tests. His responses were consistent with a diagnosis of combat-related PTSD. The Veteran reported intrusive memories of his Vietnam experience and stated that he used a flamethrower in service; one experience was when an enemy rocket landed between his feet but did not go off. The diagnosis was severe and chronic PTSD. See also VA PTSD clinic team and VA mental health treatment records dated in May 2006, June 2007, January 2009, September 2011, March 2012, July 2013, February 2016 (DSM-IV diagnosis of PTSD), and December 2015 (DSM-5 diagnosis of PTSD). The previous diagnoses of PTSD made by VA psychiatrists and psychologists during the appeal period constitute a current disability for purposes of establishing service connection. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the requirement of a "current disability" is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal). On balance, the record contains medical evidence that is both for and against service connection for PTSD based upon fear of hostile military or terrorist activity. Accordingly, resolving all reasonable doubt in the Veteran's favor, service connection for an acquired psychiatric disorder, variously diagnosed as PTSD, is granted from July 13, 2010 (the effective date that VA amended the regulations governing service connection for PTSD by liberalizing 38 C.F.R. § 3.304 (f)(3). 38 U.S.C. § 5107 (b); Gilbert; supra. In conclusion, resolving all reasonable doubt in the Veteran's favor, service connection for an acquired psychiatric disorder, variously diagnosed as depressive disorder and PTSD, is granted. The Board acknowledges that service connection for depressive disorder and PTSD is warranted, as discussed above. The Federal Circuit has recognized that separately diagnosed psychiatric conditions can be service connected, but cannot not be separately rated unless they resulted in different manifestations. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). Here, the Board is granting entitlement to service connection for a psychiatric disorder variously diagnosed as depressive disorder and PTSD. The severity of the Veteran's service-connected psychiatric disorder will be evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130 (2017). In that regard, the Veteran will not be entitled to separate and additional ratings for depressive disorder and PTSD unless there is evidence that the symptoms can be distinguished, as manifestations of a disability under multiple diagnoses (i.e., pyramiding) is to be avoided under 38 C.F.R. § 4.14. That is, the Veteran cannot be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). 8. Legal Criteria: Disability Ratings Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The United States Court of Appeals for Veterans Claims (Court) has held that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" rating. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (the Court noted a distinction between claims stemming from an original rating versus increased rating). See also Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings). It is the defined and consistently applied policy of the VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of a veteran. See 38 C.F.R. § 4.3. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the veteran. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), it was observed that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 9. Analysis: Higher Initial Rating for Erectile Dysfunction The evidence of record shows that erectile dysfunction is a complication of diabetes. See the April 2017 VA examination which indicates that erectile dysfunction is related to the diabetes mellitus type II. A compensable disability rating is not warranted for this disability. 38 C.F.R. § 4.115b, Diagnostic Code 7522 (2017). Erectile dysfunction is rated by analogy, to "penis, deformity, with loss of erectile power," Diagnostic Code 7522. See 38 C.F.R. § 4.20 (2017). The rating schedule provides a 20 percent rating for deformity of the penis with loss of erectile power. This is a conjunctive set of criteria; both must be present to warrant compensation at the sole authorized level, 20 percent. In this case, the medical evidence does not indicate that the Veteran has a penile deformity. The veteran did not permit an exam of his penis in April 2017 or June 2011. The July 2010 VA examination report indicates that exam of the penis was normal. VA treatment records show that examination of the penis revealed no abnormalities. See for instance the May 2004 VA primary carte new patient evaluation. Where the criteria for a compensable rating under a diagnostic code are not met, as here, a noncompensable rating is awarded. 38 C.F.R. § 4.31 (2017). There is no basis for payment of compensation for erectile dysfunction under the rating schedule. The Board points out that special monthly compensation based on loss of use of a creative organ under 38 U.S.C. § 1114(k) has been awarded. Accordingly, the Board finds that the criteria for a compensable rating for erectile dysfunction are not met. The Board finds that the preponderance of the evidence is against the assignment of a compensable rating and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (West 2012); 38 C.F.R. § 3.102 (2017). ORDER Service connection for sleep apnea is denied. Service connection for narcolepsy is denied. Service connection for a prostate disorder is denied. Service connection for high cholesterol is denied. Service connection for a respiratory disorder to include asthma and COPD is denied. Service connection for a psychiatric disorder characterized as a depressive disorder and PTSD is granted. A higher initial compensable rating for erectile dysfunction is denied. REMAND VA's duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A (d) (West 2012). VA is required to conduct an accurate and descriptive medical examination based on the complete medical record. 38 C.F.R. §§ 4.1, 4.2; Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The Court has held that once VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also 38 C.F.R. § 3.159 (c)(4) (2017). Regarding the issues of entitlement to higher initial ratings for peripheral neuropathy of the upper and lower extremities, the Board finds that further examination is necessary in order to obtain medical evidence as to the functional impairment of each upper and lower extremity due to the neuropathy. The Veteran was afforded VA examinations in July 2010 and June 2011 but the VA examiners did not provide an assessment as to the severity of the peripheral neuropathy of each extremity in terms of mild, moderate or severe. See 38 C.F.R. § 4.124a (2017). As the VA examinations did not provide all of the information necessary to properly rate the Veteran's service-connected peripheral neuropathy the upper and lower extremities, the Board finds the exams to be inadequate. Accordingly, a new VA examination should be provided. Regarding the claim for service connection for a skin rash of the back, the Board finds that an additional medical opinion is necessary. The Veteran was afforded a VA examination in July 2010. The VA examiner opined that the Veteran's skin disorder diagnosed as dermatophytosis, tinea pedis, and onychomycosis were at least as likely as not a complication of diabetes because there was as strong association with diabetes mellitus and this condition. However, the VA examiner did not provide a medical opinion as to whether the skin rash on the back was secondary to the service-connected diabetes mellitus Type II. The July 2010 VA examination report indicates that physical examination only found evidence of a skin disorder on the feet and toenails. The Veteran reported having a skin rash on the back. An April 2010 VA treatment record indicates that the Veteran had complaints of itching on back for 3 months. Physical examination revealed an erythematous papular rash to the back. The assessment was dermatitis likely atopic. A June 2011 VA examination report indicates that on exam, there were no signs of a skin disease. The Board finds that a remand for a supplemental VA examination or opinion is warranted to clarify the diagnosis and etiology of the claimed skin disorder of the back and the VA examiner should opine whether the skin rash on the back was at least as likely as not caused by or permanently aggravated by the service-connected diabetes mellitus type II. The VA examiner should also opine whether the skin rash on the back is at least as likely as not part of the service-connected skin disorder characterized as dermatophytosis, tinea pedis, and onychomycosis. The Board finds that the Veteran's claim of entitlement to a higher rating for the service-connected dermatophytosis, tinea pedis, and onychomycosis is inextricably intertwined with the claim for service connection for a skin disorder on the back. Therefore, the adjudication of the higher rating claim must be deferred pending resolution of the service connection claim since whether or not the skin disorder of the back is part of the service-connected skin disorder possibly affects the rating assigned to the service-connected skin disorder under Diagnostic Code 7806. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). The Board further finds that a VA examination of the service-connected skin disorder is necessary to obtain medical evidence as to current severity of the service-connected skin disorder. The most recent VA examinations were conducted in July 2010 and the June 2011, and the June 2011 VA examination report indicates that there was no sign of skin disease. Thus, another examination is needed. Regarding the claim for service connection for hypertension, the Board finds that additional examination and medical opinion are necessary. There is medical evidence that the service-connected diabetes mellitus type II at least as likely as not (at least 50 percent probability) permanently aggravated (meaning that any worsening of the condition is not due to natural progress) the hypertension. See the April 2017 VA examination report. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310 (b). VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level." Id. In reaching the determination as to aggravation of a nonservice-connected disability, consideration is required as to the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition), in comparison to the current level of severity of the nonservice-connected disease or injury. The evaluations of baseline and current levels of severity are to be based upon application of the corresponding criteria under the VA rating schedule for evaluating that particular nonservice-connected disorder. Thus, another VA examination is necessary as to the evaluations of baseline and current levels of severity of the hypertension. The AOJ should conduct a search for any outstanding VA treatment records from the VA Healthcare System showing treatment of the service-connected neuropathy of the upper and lower extremities, skin disorder, diabetes mellitus type II, cataract of the right eye, the claimed hypertension, and the claimed skin disorder of the back from October 2017. VA has a duty to seek these records. 38 U.S.C. § 5103A (b)(1). The Board finds that the issues of entitlement to an effective date earlier than October 26, 2009, for the award of service connection for diabetes mellitus type II, cataract of the right eye, erectile dysfunction, dermatophytosis, tinea pedis, and onychomycosis, and peripheral neuropathy of the bilateral upper and lower extremities, and entitlement to higher initial ratings for diabetes mellitus type II and cataract of the right eye must be remanded. Review of the record shows that an earlier effective date of August 20, 2007 is possible for the award of service connection for diabetes mellitus type II. The Veteran submitted an informal claim for service connection for diabetes mellitus and this claim was received at the RO on August 20, 2007. The Board finds that the August 20, 2007 statement from the Veteran meets the requirements for an informal claim and the statement indicates an intent to apply for benefits for diabetes mellitus under the laws administered by VA. This statement identifies the benefit sought. 38 C.F.R. § 3.155 (a). However, additional development is necessary as to the issue of whether there was a diagnosis of diabetes mellitus type II at the time of this claim. Review of the VA treatment record shows that the Veteran may have had diabetes mellitus since January 2009 but it was not known. The Veteran asserts that he has had diabetes mellitus at the time of the claim. Thus, additional development and a medical opinion is necessary to make a medical determination as to whether the Veteran had a diagnosis of diabetes mellitus type II at the time of the August 20, 2007 claim. The effective date for the award of service connection is date of receipt of the claim or date the entitlement arose, whichever is later. See 38 C.F.R. § 3.400 (b)(2) (2017). The Board finds that the issues of entitlement to an effective date earlier than October 26, 2009, for the award of service connection for cataract of the right eye, erectile dysfunction, dermatophytosis, tinea pedis, and onychomycosis, and peripheral neuropathy of the bilateral upper and lower extremities, and entitlement to higher initial ratings for diabetes mellitus type II and cataract of the right eye must be remanded pending resolution of the effective date claim for the award of service connection for diabetes mellitus type II. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). Finally, the Board finds that the Veteran's claim of entitlement to TDIU is inextricably intertwined with the claims for service connection, higher initial ratings, and earlier effective dates that are discussed in the remand. Therefore, the adjudication of the TDIU claim must be deferred pending resolution of these claims. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and ask him to identify and/or submit all medical treatment and/or medical evidence of a diagnosis of diabetes mellitus type II in August 2007 or earlier. If the Veteran adequately identifies the health care providers and provides the completed authorizations, request legible copies of all pertinent clinical records that have not been previously obtained, and incorporate them into his claims file. 2. Obtain the copies of all clinical records from the VA Healthcare System referable to treatment rendered the Veteran for the service-connected peripheral neuropathy of the upper and lower extremities, skin disorder, diabetes mellitus type II, cataract of the right eye, and the claimed hypertension since October 2017. 3. Schedule the Veteran for a VA examination to evaluate the current nature and severity of the service-connected neuropathy of the left and right upper and lower extremities. The examiner should undertake any evaluation and/or testing including EMG and nerve conduction studies if deemed necessary. The VA examiner should report all current neurologic manifestations and must specifically state whether any neurologic manifestations found results in complete or incomplete paralysis of any nerve. The specific nerves involved must be identified. If incomplete paralysis is found, the examiner must state whether the incomplete paralysis and resulting functional impairment is best characterized as mild, moderate, moderately severe, or severe. The VA examiner should clearly outline the rationale for any opinion expressed. If any requested medical opinion cannot be given, the VA examiner should state the reason why. 4. Schedule the Veteran for a VA dermatology examination in order to determine the severity of the service-connected dermatophytosis, tinea pedis, and onychomycosis, and to obtain medical evidence as to the etiology of the skin disorder of the back. a). The VA examiner should report all skin disorder diagnoses pertinet to the back. The VA examiner should provide a medical opinion as to whether it is at least as likely as not that any current skin disorder of the back either began during or is related to injury or disease or other event of active service, to include as a result of exposure to herbicides. The VA examiner should provide a medical opinion as to whether it is at least as likely as not that any current skin disorder of the back is caused by, or permanently aggravated by, or is part of the service-connected dermatophytosis, tinea pedis, and onychomycosis? b). Regarding the service-connected dermatophytosis, tinea pedis, and onychomycosis, the VA examiner should report the measurement of the percentage of the entire body and the exposed areas affected by each of the service-connected skin disorders. The VA examiner should report whether systemic therapy such as corticosteroids or other immunosuppressive drugs is required; and if so, the total duration required over the past 12 months. If such examination cannot be conducted during a period of flare-up of the skin disorders, the examiner should record a detailed clinical history referable to the manifestations. The Veteran's VA claims folder should be made available to the examiner for review in connection with the examination. Any indicated testing should be performed. The VA examiner should clearly outline the rationale for any opinion expressed. If any requested medical opinion cannot be given, the VA examiner should state the reason why. 5. Obtain an addendum opinion, or full VA examination if deemed necessary by an appropriate VA examiner, to assess the current nature and etiology of the Veteran's hypertension. The examiner should review the claims file and specifically consider the April 2017 VA medical opinion that the service-connected diabetes mellitus type II at least as likely as not (at least 50 percent probability) permanently aggravated (meaning that any worsening of the condition is not due to natural progress) the hypertension. The VA examiner should provide an opinion as to the baseline level of severity of the hypertension (prior to the onset of aggravation by service-connected diabetes mellitus type II), in comparison to the current level of severity of the hypertension. To establish that baseline level of severity of the hypertension, the VA examiner should consider the medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the hypertension. The VA examiner should clearly outline the rationale for any opinion expressed. If any requested medical opinion cannot be given, the VA examiner should state the reason why. 6. Obtain an addendum opinion, or full VA examination if deemed necessary, by an appropriate VA examiner as to the date of onset of the diabetes mellitus type II. The examiner should review the claims file and specifically render an opinion as to whether the service-connected diabetes mellitus type II was manifested in August 2007 or earlier. The VA examiner should clearly outline the rationale for any opinion expressed. If any requested medical opinion cannot be given, the VA examiner should state the reason why. 7. After completing the requested action, readjudicate the issues of entitlement to service connection for hypertension and skin disorder of the back; higher initial ratings for the service-connected dermatophytosis, tinea pedis, and onychomycosis, peripheral neuropathy of the upper and lower extremities, cataract of the right eye, and diabetes mellitus type II; entitlement to an effective date earlier than October 26, 2009 for the award of service connection for cataract of the right eye, erectile dysfunction, dermatophytosis, tinea pedis, and onychomycosis, and peripheral neuropathy of the bilateral upper and lower extremities; and TDIU in light of all of the evidence of record. If any benefit sought on appeal remains denied, furnish a fully responsive Supplemental Statement of the Case to the Veteran and his representative and afford them a reasonable opportunity for response. The Veteran has the right to submit additional evidence and argument on the matters that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2012). ______________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs