Citation Nr: 19106915 Decision Date: 01/29/19 Archive Date: 01/29/19 DOCKET NO. 16-53 984 DATE: January 29, 2019 ORDER Service connection for a low back disability is denied. Service connection for chronic sinusitis is granted. Service connection for hemorrhoids is denied. Service connection for right sciatic radicular pain associated with low back pain is denied. An evaluation in excess of 10 percent for bilateral tinnitus is denied. An evaluation of 50 percent for posttraumatic stress disorder is granted. Entitlement to a total disability rating based upon individual unemployability is denied. REMANDED Service connection for sleep apnea is remanded. The propriety of the severance of service connection for left ear hearing loss is remanded. A compensable evaluation for right ear hearing loss is remanded. A compensable evaluation for left ear hearing loss is remanded. FINDINGS OF FACT 1. A low back disability was not manifest in service or within the one-year presumptive period following service. A low back disability is not attributable to service. 2. Chronic sinusitis began during active service. 3. The preponderance of the evidence of record is against finding that the Veteran has had hemorrhoids at any time during or approximate to the pendency of the claim. 4. A right sciatic radicular pain disability is not caused or permanently worsened by a service-connected disease or injury. 5. The Veteran’s tinnitus has been assigned a 10 percent evaluation throughout the appeal period, which is the maximum rating authorized for tinnitus under Diagnostic Code 6260, for either a unilateral or bilateral condition. 6. PTSD was productive of occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disorder including arthritis are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for chronic sinusitis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for hemorrhoids have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. Disability due to right sciatic radicular pain is not proximately due to or the result of a service connected disease or injury. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 5. The criteria for an evaluation in excess of 10 percent for bilateral tinnitus have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.87, Diagnostic Code 6260. 6. The criteria for an evaluation of 50 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1969 to October 1989. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from June 2015, July 2015, August 2015, September 2016, and August 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims held that a total disability rating based on individual unemployability (TDIU) claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. In this case, a TDIU was asserted by the Veteran. Accordingly, the TDIU claim is before the Board as a component of his claim for an increased evaluation. Id. VA’s Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA’s duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The duty to notify in this case was satisfied by a form entitled “Notice to Veteran of Evidence Necessary to Substantiate a Claim for Veterans Disability Compensation and Related Compensation Benefits.” The Veteran certified receipt of such notice in his December 2014 and July 2015 claims submitted under the Fully Developed Claim program. 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2016); Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). He received additional notice via a letter in August 2018. The claims were last adjudicated in October 2016 and November 2016. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c), (d). This “duty to assist” contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In that regard, the Veteran’s service treatment records, VA treatment records, indicated private treatment records, and lay statements have been associated with the record. Throughout the appeal and in his claim forms, the Veteran did not identify treatment he may have undergone. A November 2018 medical authorization he supplied did not identify any treatment provider, so it could not be utilized. VA afforded the Veteran examinations in May 2015 and October 2016 for his low back, radicular pain, sinusitis, and hemorrhoids claims. The VA examiner reviewed the evidence of record, considered the Veteran’s history and statements, and rendered a medical opinion based upon the facts of the case and the examiner’s knowledge of medical principles. Therefore, the Board finds that the Veteran has been provided an adequate medical examination in conjunction with each of his claim. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). VA provided the Veteran May 2015 and July 2015 VA examinations in relation to his tinnitus and PTSD increased rating claims. The examiners described the disabilities in sufficient detail to enable a fully informed rating of the disabilities. Therefore, the Board finds that the Veteran has been provided adequate medical examinations in conjunction with his claims. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev’d on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection 1. Service connection for a low back disability. In the October 2016 VA examination, the Veteran was diagnosed with degenerative joint disease of the lumbar spine. At the time, the Veteran reported suffering a hard landing during service in 1971 with subsequent low back pain which resolved with a recurrence in the 1980’s. The Veteran reported that since then he has been self-treating with Tylenol. He reported being followed by a primary care practitioner, however, he had no formal treatment. Certain chronic diseases will be presumed related to service if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303, 3.307, 3.309. The question for the Board is whether the Veteran has a chronic disease that was noted as chronic in service or that manifested to a compensable degree in service or within the applicable presumptive period, or whether continuity of symptomatology has existed since service. The Board concludes that, while the Veteran has degenerative joint disease (arthritis) of the lumbar spine which is a chronic disease under 38 C.F.R. § 3.309(a), it was not shown as chronic in service or within a presumptive period, it did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. VA and private opinions do not indicate a date for diagnosis of degenerative joint disease, but the first reference to it is in a private medical opinion from December 2014. A service treatment record from June 1980, shows treatment for low back pain for one month, which was diagnosed as a muscle strain. Several medical examinations thereafter, including the separation examination, indicate a normal spine. The Veteran denied low back pain at the report of medical history at separation. Significantly, at his October 2016 VA examination he reported that his pain had resolved after his in service incident and did not return until years later. The foregoing indicates the low back disorder was not shown as manifestations of arthritis in-service. The December 2014 private doctor does not indicate that these symptoms were manifestations of arthritis. Instead, the examiner indicates only the presence of chronic back pain. The Veteran is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of arthritis. The issue is medically complex, as it requires medical testing such as X-ray or MRI to view the internal functioning of anatomical systems. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran in this case does not have the experience, skills, or medical training to make such a complex determination. Thus, there is insufficient credible and probative evidence to establish that the reported back pain was a manifestation of arthritis. Similarly, there is insufficient evidence to show that the arthritis disease process manifested to a compensable degree within one year of separation from service. At the time of separation, the credible and probative evidence indicates that there was no disability. Back pain that may have begun the day after service does not equate to a manifestation to a compensable degree. The Veteran’s and the private doctor’s reports of back pain are not specific enough to establish that the back pain that may have occurred during the year after separation was a manifestation of arthritis. For this, there is simply insufficient evidence. With respect to continuity of symptomatology, although the Veteran and a December 2014 private doctor both report that low back pain persisted since service, the Board finds the specific denials and the normal physical examinations in service medical records to be significantly more credible and of higher probative value than the later statements because the service medical records were recorded at the time of the period in question. On the other hand, the Veteran’s and the private doctor’s reports were made based on the recollections about events over two decades in the past. Based on the foregoing, none of the criteria for a chronic disease presumption of service connection has been met. Nonetheless, service connection for a low back disorder may still be granted on a direct basis. For direct service connection, the question before the Board is whether the Veteran’s low back disability manifest in service or is related to service. Here, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s low back disorder and an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. In addition to the negative evidence reviewed above, the October 2016 VA examiner opined that the Veteran’s low back disability is not at least as likely as not related to an in-service injury, event, or disease. The rationale was the normal findings on the periodic and retirement physical examination, the Veteran’s denial of recurrent back pain in the report of medical history at separation, and a lack of pattern of chronicity after the June 1980 treatment for a pulled back muscle. The evidence in favor of the claim includes the December 2014 private doctor’s opinion that the Veteran’s disability was chronic, persistent low back pain from onset while in service in Germany and persists to the present. Evidence in favor of the claim also consists of the Veteran’s lay statements that he had recurrent back pain in service and that is persisted until the present. The Board finds that the December 2014 private doctor’s opinion and the Veteran’s lay statements are less credible than the October 2016 VA examiner’s opinion. The VA examiner’s opinion is consistent with the service treatment records, whereas the private doctor’s opinion is contradicted by service treatment records to the important extent that the Veteran’s back pain in service was not recurrent and was not present at the time of separation from service or for many years prior to separation, as shown by the reports of medical history. As discussed above, the Board places greater weight upon the service treatment records than it does on the Veteran’s statements in support of the claim and the private doctor’s opinion. While the Veteran believes his low back disability is related to an in-service injury, event, or disease, he is not competent to provide a nexus opinion in this case. This issue is medically complex, as it requires specialized medical education and knowledge of internal biology and anatomy, and experience distinguishing the appropriate differential diagnosis from common symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. 2. Service connection for chronic sinusitis. The Veteran asserts that he has chronic sinusitis that began during service and continued since service. The Board concludes that, when giving the Veteran the benefit of the doubt, the Veteran has a current sinusitis disability that began during service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The evidence is in equipoise as to whether the Veteran has a current chronic sinusitis disability. The May 2015 VA examiner found that there is no objective evidence of a chronic sinusitis disability. The December 2014 private doctor diagnosed the Veteran with chronic sinusitis, and referenced the diagnosis was rendered via translumination and direct examination. Giving the Veteran the benefit of the doubt, he has a current disability. As to nexus, the December 2014 private doctor found that sinusitis was shown in service and has persisted to the present. The doctor noted the treatment for sinusitis at several duty stations during his service. The Board notes that this observation is consistent with service treatment records. Service treatment records show numerous instances of treatment for an upper respiratory infection and a few instances of treatment for sinusitis. The Veteran endorsed a history of sinusitis on the retirement report of medical history, although the clinical evaluation was normal. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s sinusitis arose during service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for chronic sinusitis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Service connection for hemorrhoids. The Veteran seeks service connection for hemorrhoids which he asserts began during service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current hemorrhoids diagnosis, and has not had hemorrhoids during the appeal period, although evidence shows that the Veteran underwent a hemorrhoidectomy in service. The most probative evidence in this regard is the medical examination provided at retirement. The report of medical examination at that time states “anus, rectum and prostate normal to digital exam. Stool negative for occult blood.” This shows that, although the evidence is clear that the Veteran had hemorrhoids in service, after a February 1988 surgery for their removal, they were no longer present. This conclusion is supported by the May 2015 VA examiner’s finding of a normal rectal and anal area upon examination, and that “the illness treated during active military service resolved without residual.” Additionally, at that examination, the Veteran reported having a normal colonoscopy in 2007 or 2008. The December 2014 private doctor reported that the Veteran’s symptomatology of bleeding, pain and itching persisted from service to the present. This, however, is inconsistent with the finding on the retirement examination and contrary to the Veteran’s report in the VA examination. Moreover, the private doctor did not note that an actual examination of the anus was conducted, whereas the May 2015 VA examination report affirmatively noted that an examination of the rectal/anal area was conducted with normal results. For those reasons, the Board gives little probative weight to the private doctor’s report, especially in comparison with the VA examination report and the service treatment records. The Veteran believes he has a current hemorrhoids disability that is related to an in-service injury, event, or disease. However, he has not described his symptoms specifically enough or consistently enough to allow them to carry credibility. Indeed, he claims service connection for hemorrhoids, but also, inconsistently reported that his colonoscopy was normal. Consequently, the Board gives more probative weight to the VA examiner’s findings. 4. Service connection for right sciatic radicular pain associated with low back pain. The Veteran seeks service connection for right sciatic radicular pain, asserting that it is due to his low back disorder. As a matter of law, the Board may not grant the disorder on this basis. Service connection on a secondary basis may be granted for a disability that is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). Here, the disability that the Veteran claims causes his radicular pain is the low back disability. As the low back is not a service-connected disability, service connection for the radicular pain is not warranted. Although service connection may be granted on a direct basis, in this case the evidence does not show, and the Veteran does not contend, that his right radicular pain began during service or is related to service in some way other than because of the low back disorder. Increased Rating Disability ratings are determined by applying the criteria established in VA’s Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.20 (2017). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the claimant. 38 C.F.R. § 4.3 (2017). Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). 5. An evaluation in excess of 10 percent for bilateral tinnitus. The Veteran seeks an evaluation in excess of 10 percent for bilateral tinnitus. The Veteran’s tinnitus is evaluated as 10 percent disabling under Diagnostic Code 6260. Diagnostic Code 6260 limits a veteran to a single 10 percent maximum rating for tinnitus, regardless whether the tinnitus is unilateral or bilateral. 38 C.F.R. § 4.87. The Veteran’s service-connected tinnitus has been assigned the maximum schedular rating available for tinnitus of 10 percent under 38 C.F.R. §4.87, Diagnostic Code 6260. There is no legal basis upon which to award separate schedular evaluations for tinnitus in each ear. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The Board finds no other basis to award a higher evaluation, therefore, the appeal must be denied. 6. An evaluation in excess of 30 percent for posttraumatic stress disorder. The Veteran seeks a 70 percent or 100 percent evaluation for his posttraumatic stress disorder (PTSD). The Veteran has been assigned a 30 percent rating for his PTSD pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. All psychiatric disorders are evaluated under the General Rating Formula for Mental Disorders, which provides for a noncompensable evaluation when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent rating is warranted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). 50 percent rating is warranted for 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; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or 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; and the inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for 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; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Use of the term “such symptoms as” in § 4.130 indicates that the list of symptoms that follows is non-exhaustive, meaning that VA is not required to find the presence of all, most, or even some of the enumerated symptoms to assign a particular evaluation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013); see Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the U. S. Court of Appeals for Veterans Claims (Court) held that, given that the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the Global Assessment of Functioning (GAF) scale and that VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating when the appeal was certified after August 4, 2014. A December 2014 private psychological evaluation was submitted in evidence. The evaluation showed the Veteran experiences recurrent intrusive thoughts approximately two to three times per month. Recurrent nightmares were reported, and estimated to recur “maybe once every two to three months.” Night sweats, cognitive responses to loud sounds, and exposure to news accounts trigger recall of trauma. The Veteran reported intensive efforts to avoid his traumatic experiences, and feelings of detachment or estrangement from others. The Veteran reported marked problems with insomnia, including difficulties falling asleep, intermittent waking, and “terminal waking.” The Veteran also reported irritability. The examiner reported that concentration problems were markedly apparent during the interview. Hypervigilance in the form of walking his perimeter was described. The Veteran’s wife reported he is paranoid, tending to avoid leaving home without a gun. Additional reported symptoms included a “pretty crappy” mood most of the day, nearly every day, described by the examiner as significant depressive symptoms. He attributed this to his job loss and perception that he should be doing something productive. Significant experiences of fatigue and loss of energy were reported. Cognitive difficulties were also reported, as well as diminished ability to think and indecisiveness. Suicidality and homicidality were not present. The mental status examination showed below normal attention and concentration. Memory was normal. Intelligence and fund of information was within the average range. Judgment and insight were normal. MMPI-2 test results showed the Veteran with a substantial level of distress. The examiner reported that social- and work-related functional impairments were noted, while cognitive difficulties were observed but were only slightly apparent on the results of the Montreal Cognitive Assessment. The examiner found that difficulties with impulse control were quite evident and likely to substantially negatively impact the Veteran’s employability. The Veteran was afforded a July 2015 VA PTSD examination. The examiner concluded that the Veteran’s occupation and social impairment was due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. Social history showed the Veteran married to his second wife since 1999, but that they live separately in the same house and have limited contact with one another. The Veteran has an adopted son and two biological sons from his first marriage, which lasted about 15 years. He reportedly maintains contact with his sons. The Veteran reported he maintains an active social life. He recently visited his relatives out of state, enjoys shooting with friends, and is an active member of a ham radio club locally. Following the Veteran’s military retirement in 1989, he was employed in several higher-level supervisory positions in government settings doing generator maintenance until 2012. He has not worked since that time and has had no success job hunting. The Veteran reported that he is active now with some exercise and yard work. He denied any difficulty in completing his activities of daily living. Reported symptoms were depressed mood, anxiety, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, and disturbances of motivation and mood. Irritability, avoidance of stimuli, and recurrent intrusive memories were also present. The examiner observed the Veteran to be appropriately dressed for the evaluation and to behave in a cooperative way. Eye contact was consistent, and the Veteran's speech was understandable. He provided information in a detailed and organized manner. No significant deficits in his memory were noted. The Veteran maintained adequate emotional control throughout the assessment process. No psychotic symptoms were displayed. The examiner further noted the presence of distractibility. Upon review of the record, the Board finds that a 50 percent evaluation is warranted. This evaluation is based heavily upon the private examiner’s report that the Veteran has significant depressive symptoms, impaired cognitive capabilities, and impaired impulse control. All other symptoms reported such as sleep impairment and intrusive thoughts are also considered in this assessment. A higher evaluation is not warranted because, although there is seriousness with certain symptoms, such as depression and impaired impulse control, in the private evaluation, the VA examiner’s report indicates a much less serious level of impairment. When reconciling the two reports into a consistent disability picture, the Board finds the symptoms are not serious enough to warrant a higher evaluation. Moreover, the Veteran is not deficient in most areas. The reports indicate he maintains hobbies with friends, visits relatives, has had long-term marriages, although not ideal ones, and has motivation to work and be productive. Thus, his symptoms do not rise to the level of deficiencies with family relations. He also maintains intact judgment and thinking. Objective cognitive testing shows slight impairments in cognition, and the Board finds objective testing to be persuasive. Intrusive thoughts occur infrequently. The Board finds that a slight impairment in cognition is not serious enough to be considered a deficiency in thinking. For these same reasons, the Veteran does not have total occupational and social impairment. 7. Entitlement to a total disability evaluation based upon individual unemployability. The Veteran seeks a total disability rating based upon individual unemployability (TDIU). Total disability is considered to exist when there is any impairment in mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1). A total disability rating for compensation purposes may be assigned on the basis of individual unemployability, that is, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). If there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Individual unemployability must be determined without regard to any non-service connected disabilities or the veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.19 (2017); Van Hoose v. Brown, 4 Vet. App. 361 (1993). Eligible employment is not limited to the Veteran’s chosen field. The Veteran’s service-connected disabilities, as of this decision, are: chronic sinusitis with an evaluation to be assigned; PTSD evaluated at 50 percent disabling from December 11, 2014; right knee degenerative joint disease evaluated at 10 percent from December 11, 2014, 100 percent from January 20, 2015, and 30 percent from March 1, 2016; tinnitus evaluated at 10 percent from December 11, 2014; and right ear hearing loss and left ear hearing loss evaluated as noncompensable. With the increase from this decision in the PTSD evaluation, the Veteran’s combined evaluation will be at least 70 percent, with a single disability rated at least 40 percent. Thus, he qualifies for a schedular review. Nonetheless, the Board finds the Veteran is not unable to secure and maintain substantially gainful employment due to service-connected disabilities. The Veteran reported on his Application for Increased Compensation Based on Unemployability that he last worked full time in January 2009, his highest salary was $67,995.00, and that he had four years of college. An employment information form submitted by his former employer indicated the Veteran worked as an administrative professional and left the position for a promotion opportunity for career development. He worked at this employer for nearly twenty years. The December 2014 private psychological assessment showed he worked for 19 years at Patrick Air Force Base, performing electrical power generator work, supervisory work, communications management work, and other engineering work. The Veteran was not hired on the new contract. From January 2009 until August 2012, the Veteran worked for the Orlando Utilities Commission, but was dismissed from his job for performance reasons, for which he claims he did not have adequate training. The private assessment indicates the Veteran received an Associate degree in Electric Power Technology, a Bachelor’s degree in Organizational Management and a Master’s degree in Computer Resources and Information Management. Thus, the Veteran has significant skilled work experience and significant education, allowing for many possible occupations. As to the impairments from service-connected disabilities, the Veteran underwent a total knee replacement in January 2015. The main impairment he reported was pain, which arises when walking after a period of rest and will persist when walking for a period of time. He reported he is able to sit for no more than 15 to 20 minutes, to stand for no more than 15 to 20 minutes, and to walk for no more than 15 to twenty minutes. The range of motion testing showed pain did not result in functional loss. Strength and stability were intact. Although the Veteran reported he is limited to sitting for 15 to 20 minutes, his range of motion testing, and self-reports of pain on walking (rather than sitting) contradict this limitation. In the July 2015 VA PTSD examination, he reported being active with some exercise and yard work. Thus, the Board finds that the Veteran is not functionally limited from a job where he is primarily preforming tasks seated with some infrequent and short distance walking and infrequent and time limited standing. Turning to PTSD’s effect on his employability, the psychological assessments show some distractibility, mild cognitive impairment, reduced concentration, irritability, depressed mood and lowered motivation, fatigue, and loss of energy. Difficulties with impulse control were found likely to substantially negatively impact the Veteran’s employability. However, memory was normal, intelligence and fund of information was within the average range, and judgment and insight were normal. As noted above, the Board concluded that the Veteran’s occupational and social impairment resulted in reduced reliability and productivity. The Board finds that the Veteran’s residual functional capacity would enable him to obtain employment in occupations which are primarily seated, are routine and therefore do not require much concentration, and do not require significant interaction with others. Such occupations could include clerical or administrative work, production assembly line work, security monitoring, a parking garage attendant, a cashier position where sitting is possible, etc. The Veteran’s high-level supervisory experience shows he is likely capable of meeting the minimal training requirements of such or similar unskilled occupations. The remaining service connected disabilities do not marginally impact the Veteran’s occupational functioning. Sinusitis is unlikely to affect the Veteran’s employment as it was disputed that he even has a current sinusitis disability. Based on the evidence of record, the Board cannot find that the Veteran is unable to secure and maintain substantially gainful employment in any field. REASONS FOR REMAND 1. The issue of service connection for sleep apnea is remanded. The Board cannot make a fully-informed decision on the issue of service connection for sleep apnea as secondary to service-connected PTSD becaues the September 2016 VA examination has an inadequately explained rationale. Specifically, the examiner stated the the Veteran has a number of causes of his sleep apnea that were “very clearly delineated in the Cape Canaveral Hospital notations from some time ago.” It is not apparent to the Board what those delinations in the Cape Canaveral Hospital notations are. The Board cannot assess the credibility of the examiner’s opinion without this information. Secondly, the examiner did not render an opinion as to whether PTSD aggravated sleep apnea. The examiner stated that “comments about true aggravation cannot be applied, due to a number of medical and mental health comorbidities he has, even though it was reported that treatment for the sleep apnea was providing improvement in symptoms.” The examiner seems to be concluding that he cannot render an opinion without resort to speculation. The Court has provided guidance as to when VA can accept an examiner’s statement that an opinion cannot be provided without resort to speculation. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). Specifically, the Court held that simply concluding that the etiology of a disability could not be resolved without speculation without providing any explanation why was inadequate. Id. In Jones, the Court noted it was unclear whether the examiners were unable to provide a definitive medical comment on etiology because the limits of medical knowledge had been exhausted or, instead, for example, because they needed further information to assist in making this determination (e.g., additional records and/or diagnostic studies) or other procurable and assembled data. The Court in Jones acknowledged there are instances where a definitive opinion cannot be provided because required information is missing or can no longer be obtained or because current medical knowledge yields multiple possible etiologies with none more likely than not the cause of the claimed disability. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (noting the Board need not obtain further medical evidence where the medical evidence “indicates that determining the cause is speculative”). The Court explained that “it must be clear on the record that the inability to opine on questions of diagnosis and etiology is not the first impression of an uninformed examiner, but rather an assessment arrived at after all due diligence in seeking relevant medical information that may have bearing on the requested opinion.” Jones at 389-90. Here, it is not clear that there has been due diligence in seeking relevant medical information that has a bearing on the requested opinion. Accordingly, remand is warranted. 2. The propriety of severance of service connection of left ear hearing loss. Regarding the issue of the propriety of severance of service connection of left ear hearing loss, the Veteran submitted a timely notice of disagreement with an August 2017 rating decision, but a statement of the case has not yet been issued. A remand is required for the AOJ to issue a statement of the case. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). 3. The issues of a compensable evaluation for right ear hearing loss and a compensable evaluation for left ear hearing loss are remanded. A notation in a February 2018 VA treatment record indicates that there may be outstanding and relevant VA treatment records. Specifically, the treatment record indicates an audiogram was conducted, but that the results are stored in a separate module. The audigram results are not of record. A remand is required to allow VA to associate the audiogram with the claims file. The matter is REMANDED for the following action: 1. Associate with the claims file the VA audiogram conducted on February 26, 2018, which is not displayed in the CAPRI record of that date. 2. Direct the Veteran’s claims file to the examiner who conducted the September 2016 sleep apnea examination so a supplemental opinion may be provided. If that examiner is no longer available, direct the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination is only required if deemed necessary by the examiner. The examiner must provide opinions as follows: a. Whether the Veteran’s sleep apnea is at least as likely as not proximately due to the service-connected PTSD. b. Whether the Veteran’s sleep apnea is at least as likely as not aggravated beyond its natural progression by the service-connected PTSD. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. In that event, the examiner is encouraged to provide rationale that comports with Jones v. Shinseki, described above in this decision. 3. Send the Veteran a statement of the case that addresses the issue of the propriety of severance of service connection for left ear hearing loss. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration. (Continued on the next page)   4. If upon completion of the above action any benefit sought on appeal remains denied, the case should be returned to the Board after compliance with appellate procedure. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Rocktashel, Counsel