Citation Nr: 19112862 Decision Date: 02/21/19 Archive Date: 02/21/19 DOCKET NO. 15-30 310 DATE: February 21, 2019 ISSUES 1. Evaluation of migraine headaches, currently evaluated as 50 percent disabling, to include consideration of an extraschedular rating. 2. Entitlement to service connection for sleep apnea. 3. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), exclusive of depressive disorder, as secondary to migraine headaches. 4. Entitlement to a total disability rating based on individual unemployability (TDIU). ORDER Evaluation of migraine headaches, currently evaluated as 50 percent disabling, to include consideration of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) is denied. REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder, exclusive of depressive disorder, as secondary to migraine headaches is remanded. Entitlement to a TDIU is remanded. FINDINGS OF FACT 1. Migraine headaches are manifested by no more than very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 2. The preponderance of the evidence of record does not show that the Veteran’s disability picture for migraine headaches is unusual or exceptional. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 50 percent for migraine headaches have not been met. 38 U.S.C. §§ 5103, 5103A, 5107, 5110(a) (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.124a, 4.27, 4.3, 4.7, 4.10; Diagnostic Code 8100 (2018). 2. An evaluation in excess of 50 percent for migraine headaches on an extraschedular basis is not warranted. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321(b)(1), 4.124a; Diagnostic Code 8100 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1990 to November 1996. This matter is before the Board of Veterans Appeals (Board) on appeal from August 2013 and March 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. By way of background, a November 2017 Board decision in part denied service connection for sleep apnea. An August 7, 2018 Order from the United States Court of Appeals for Veterans Claims (CAVC) granted an August 1, 2018 Joint Motion for Remand (JMR) related to the issue of entitlement to service connection for sleep apnea. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§3.102, 3.156(a), 3.159, 3.326(a) (2018). In the various Notices of Disagreement (NODs) and VA Form 9s, the Veteran through his attorney advanced several general contentions regarding errors in the adjudication and development of the Veteran’s claims. These are discussed further in the Remand section below. With respect to the claim for an extraschedular rating for migraine headaches, the Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Evaluation of migraine headaches, currently evaluated as 50 percent disabling, to include consideration of an extraschedular rating The Board incorporates its discussion from the sections above by reference. Migraine headaches are currently rated at 50 percent disabling. Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, a uniform evaluation is still warranted for this disability. Under Diagnostic Code 8100, a 0 percent rating is assigned for less frequent attacks than for a 10 percent rating; a 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one in two months over the last several months; a 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months; and a maximum 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks, productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The rating criteria do not define “prostrating” nor has the Court. Fenderson, supra, (reciting Diagnostic Code 8100 verbatim but not specifically addressing the definition of a prostrating attack). By way of reference, in Dorland’s Illustrated Medical Dictionary 1554 (31st Ed. 2007), “prostration” is defined as “extreme exhaustion or powerlessness.” Under Diagnostic Code 8100, the term “economic inadaptability” is not synonymous with an “inability to work.” Pierce v. Principi, 18 Vet. App. 440 (2004). The use of the conjunctive “and” in a statutory provision means that all of the conditions listed in the provision must be met. Melson v. Derwinski, 1 Vet. App. 334 (1991); Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive “or” requirement must be met in order for a higher rating to be assigned). The Veteran contends that he is entitled to a higher rating for migraine headaches, to include on an extraschedular basis. He avers that sleep apnea and migraine headaches have caused his inability to work. Migraine headaches are currently rated as 50 percent disabling under Diagnostic Code 8100. Under Diagnostic Code 8100, 50 percent is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. This rating is at the schedular maximum. AB v. Brown, 6 Vet. App. 35, 39 (1993). In light of the above, as the highest rating has been awarded, the Board concludes that the Veteran is not entitled to a higher schedular rating. There are no other diagnostic codes that are applicable for rating the Veteran’s migraine headaches. Therefore, a schedular rating in excess of 50 percent for migraine headaches is not warranted. Next, the Veteran through his attorney contends that he is entitled to an extraschedular rating for migraine headaches. Ordinarily, the VA schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to VA regulations, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321 (b)(1) (2018). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). “The determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § 3.321 (b) is a three-step inquiry... The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate.” Thun v. Peake, 22 Vet. App. 111, 115 (2008). “Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant’s service-connected disability with the established criteria found in the rating schedule for that disability...[I]f the criteria reasonably describe the claimant’s disability level and symptomatology, then the claimant’s disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required.” Thun at 115. “However, in the second step of the inquiry, if the schedular evaluation does not contemplate the claimant’s level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant’s exceptional disability picture exhibits other related factors such as those provided by the regulation as ‘governing norms.’” 38 C.F.R. § 3.321 (b)(1) (related factors include “marked interference with employment” and “frequent periods of hospitalization”). Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant’s disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant’s disability picture requires the assignment of an extraschedular rating.” Thun, supra. In this case, the Veteran has been assigned the 50 percent rating for his disability, which contemplates, “Very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability.” The Veteran’s symptomatology is contemplated by the rating criteria. Diagnostic Code 8100 indicates migraines should be rated according to the frequency of prostrating attacks. Prostration incorporates the additional symptomatology reported by the Veteran that is associated with migraines, to include sensitivity to light and sound, changes in vision, vertigo, nausea, and vomiting. By way of background, a February 10, 2012 private treatment record from Edward Medical Group shows that the Veteran presented with complaints of intermittent episodes of right frontal headache, described as throbbing, non-radiating. They lasted for about ten minutes, and were happening daily for one week. The associated symptoms included new onset headache and photophobia, but no nausea, vomiting, no phonophobia, no aura, no scotoma, no numbness, no tingling, no weakness, no fever, no chills, no scalp tenderness, no vertigo, no ataxia, no dysarthria, no diplopia, and no vision loss. Next, a June 18, 2012 Pulmonary Consult Reply with Addendum received on October 22, 2014 from the Hines VA Medical Center (VAMC) shows a notation of headaches in the AM. Later, a May 30, 2014 decision from the Social Security Administration (SSA) shows that the Veteran has been deemed disabled under the Social Security Act since June 30, 2012, the Veteran’s alleged date of onset of disability. The severe impairments noted include plantar fasciitis; s/p bilateral cheilectomy; recurrent foot neuromas, s/p excision surgeries; degenerative disc disease of the cervical spine, s/p fusion; s/p lumbar spinal cord stimulation implant; obstructive sleep apnea; and depression. Neither headaches nor migraines are listed. The Board observes that headaches began in service. The October 30, 2014 VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability shows that his service connected disabilities preventing him from securing or following any substantially gainful occupation are listed as “neck, back, sleep apnea.” Headaches are not listed. Received on December 1, 2014, a private treatment record dated September 2, 2014 shows, “severe headaches started last 7-10 days, on right side, becoming more regular, has sensitivity to light. Pain is a (sic) now a 7.” The Veteran was afforded a February 9, 2015 VA Headaches examination. The Veteran reported that he has a history of headaches lasting three hours, but can last two days, occurring about daily, bilaterally, and throbbing. He took Imitrex. Symptoms included sensitivity to sound and changes in vision. Head pain lasted more than two days, on both sides of the head. The Veteran had characteristic prostrating attacks occurring once every month, and productive of severe economic inadaptability. Later, the VA examination shows that prostrating type headaches occur daily and impact his ability to work. A March 2015 rating decision granted service connection for headaches with a 50 percent evaluation effective November 5, 2013, the date of the Veteran’s claim. In the Veteran’s October 2015 Notice of Disagreement (NOD), he avers, “I have submitted [a] DBQ with sleep apnea and headaches that show I am unable to work also my SSDI shows approval for sleep apnea.” A July 13, 2016 private treatment record from Chicago Dizziness and Hearing received by VA in June 2017 shows that the Veteran gets several types of headaches. The most bothersome consist of a severe, sharp, throbbing, bilateral frontotemporal and parietal pain associated with photophobia, sonophobia, osmophobia, and motion intolerance. The headaches can be ameliorated by retreating to a dark quiet room, by sleep, and sometimes by medication. These headaches began around 1992 and are sometimes exacerbated by sleep deprivation and by weather changes. An October 19, 2016 Letter from Chicago Dizziness and Hearing shows that the Veteran described no change in dizziness, despite aggressive physical therapy for Benign Paroxysmal Positional Vertigo (BPPV). It shows that the Veteran has tried numerous therapies for migraines. The Veteran was currently on a generous dose of Topamax. He previously tried Botox injections. The Veteran reported that during the July 13, 2016 visit, he had been on “numerous” other medications, but could not recall the names. The clinician wrote, “At this point, I think it would be medically reasonable to pursue additional care for headaches under the supervision of a headache specialist…” A June 5, 2017 private treatment record from the Edward Medical Group shows that the Veteran reported a headache. He has them 15 times per month despite medication. He uses Midrin. The Veteran no longer uses Frova because the “red pill works.” VA received a June 30, 2017 Evidentiary Submission and Argument in Further Support of Veterans Claims Waiver of RO Consideration document. It contains argument that the evidence is at least in equipoise supporting a 100 percent extraschedular rating as the Veteran is unable to secure gainful employment due to the severity of his headaches. An August 2, 2017 VA Mental Health Attending Note shows that the Veteran was admitted in Edwards for headache. He was discharged after eight hours. It shows that an implanted device was helping some, but not the headaches. A VA Neurology Attending Note from September 10, 2018 shows that the Veteran reported a chief complaint of chronic migraine headaches. He was getting them for 20 days out of the month, starting as a headache and leading to nausea, vomiting, and vertigo. The Veteran was very sensitive to light and sounds. The Veteran was currently treating this with Botox and Aimovig monthly. He had previously tried other medications. In the October 5, 2018 VA Form 9, the Veteran and his attorney advanced general contentions preserving all errors for appeal. However, they did not point to any specific errors, including in the duty to assist, to support this request. The Board observes, “The duty to assist is not always a one-way street. If a veteran wants help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence.” Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Additional VA and private treatment records are substantially the same. Having considered all of the evidence, the Board finds that entitlement to an extraschedular rating for migraine headaches is not warranted at any time during the pendency of this claim. Altogether, the 50 percent rating adequately contemplates the severity and frequency of the Veteran’s headaches and reasonably describes the Veteran’s disability level and symptomatology. The Board finds that these symptoms are squarely contemplated by the present 50 percent rating. The current rating contemplates very frequent, completely prostrating and prolonged attacks. Moreover, speculation regarding the inability to work as a direct result of headache events does not surpass the level of severe economic inadaptability. The Board is not suggesting that the Veteran does not suffer from a significant degree of impairment as a result of his headache events, however, that is already contemplated by the rating schedule. In other words, some degree of occupational impairment is inherent in the assigned schedular ratings. As such, it is not necessary to further discuss whether he exhibited other related factors such as those provided by the regulation as “governing norms” (including marked interference with employment and frequent periods of hospitalization). The Board has also considered ongoing VA and private treatment records. They show ongoing treatment with various medications for headaches. They also show other factors. Additionally, we have considered the findings at the February 5, 2015 VA examination. The VA examination shows that Veteran had characteristic prostrating attacks occurring once every month, and productive of severe economic inadaptability. Later, the VA examination shows that prostrating type headaches occur daily and impact his ability to work. They can last from three hours to up to two days. The Board has considered this. The Board has also considered the Veteran’s own lay reporting of the impact on his employment. The Veteran is competent to report his headache symptoms and their frequency. The October 2015 NOD shows that sleep apnea impacts his ability to work. This is consistent with his prior reporting on the VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, which does not list headaches as a cause of his disability. The Board observes that the Veteran and his attorney have had several years to supplement the record to clarify any inconsistencies and/or to further elaborate upon any impact specifically from headaches as they relate to the Veteran’s disability picture. In light of the foregoing, the Board finds that the Veteran’s service-connected migraine headaches are not manifested by an exceptional or unusual disability picture that renders impractical the application of the regular schedular standards. To the extent the Veteran contends that he is unemployable, the Board notes other factors, as considered by the May 30, 2014 SSA Administrative Law Judge (ALJ). The severity of the Veteran’s migraine headaches with very frequent completely prostrating and prolonged attacks, productive of severe economic inadaptability already is completed by the current 50 percent rating. Referral to the Under Secretary for Benefits or the Director of the Compensation and Pension Service need not be considered. 38 C.F.R. § 3.321 (b)(1). Therefore, we find that entitlement to an evaluation in excess of 50 percent for migraine headaches is not warranted, including not warranted on an extraschedular basis. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching this conclusion, the Board finds that the preponderance of the evidence is against the claim. As such, the benefit of the doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea is remanded. The Board incorporates its discussion from the sections above by reference. A remand is necessary for additional development. By way of background, the Veteran reported at an October 1999 private medical consultation that he had been experiencing snoring and possible events of apnea for approximately one year. Shortly thereafter, he underwent a sleep study and was diagnosed with severe obstructive sleep apnea. The Veteran was afforded a July 2013 VA examination. The VA examiner stated that the Veteran, “was diagnosed with OSA since he was in the military” when noting Appellant’s medical history, and then also stated “dx in the service” when describing Veteran’s sleep apnea at the end of the report. The VA examination shows a date of onset of 1996. There is no nexus opinion in this VA examination. In an undated, typewritten letter received on November 30, 2014, addressed to VA Compensation and Pension, the Veteran’s spouse stated that she met the Veteran while he was stationed in Germany in 1995, and that in the first couple of weeks of dating him she noticed that Veteran snored very loud and stopped breathing at night. The Veteran’s spouse also stated that Veteran would always wake up with a sore throat and headaches and that these were due to Veteran’s sleep problem. In May 2016, the Veteran through his attorney submitted a December 2016 private Disability Benefits Questionnaire (DBQ) from Dr. R. C. It shows a diagnostic impression of sleep apnea, with a date of onset of 2001. A February 2017 Chronic Fatigue Syndrome DBQ completed by Dr. R. C. shows a diagnostic impression of sleep apnea. The Veteran was afforded a November 7, 2017 VA contract examination. The VA examiner identified sleep apnea. The VA examiner rendered a negative nexus opinion. However, the VA examiner noted, “There is no evidence of claimed condition during service dates. Veteran did not seek treatment for condition until 2014.” The August 1, 2018 JMR shows in part, “The Board, therefore, must reexamine the evidence of record, seek any other evidence the Board feels is necessary, and issue a timely, well-supported decision in this case.” Here, the VA examinations are incomplete for lack of a nexus opinion, fully considering the Veteran’s spouse’s lay statement, and consistency with addressing the evidence of possible onset of sleep apnea prior to 2014. With respect to the specific onset date, this inconsistency in the record should be resolved. The Board has considered the arguments advanced by the Veteran through his attorney in the August 1, 2018 JMR. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (noting that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Therefore, and in light of the Veteran’s contentions, the Board finds that a remand for supplemental VA examination with medical opinion is warranted. In addition, the entire claims file should be made available to the VA examiner for review. On remand, pursuant to the JMR, the Veteran and his attorney may also submit any additional evidence or lay statements. 2. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder, exclusive of depressive disorder, as secondary to migraine headaches is remanded. The Board incorporates its discussion from the sections above by reference. The Veteran submitted a typewritten stressor statement dated August 5, 2015. He reported an automobile accident on January 19, 1995 in Nuremberg, Germany. He reported that he had neck and back pain, and that he suffers from PTSD. He has flashbacks. He wrote that he has “major setbacks” to include being dismissed from the military. The Board observes that the Veteran submitted a January 5, 2016 38 U.S.C. § 5103 Notice Response. He indicated, “I have enclosed all the remaining information or evidence that will support my claim, or I have no other information or evidence to give VA to support my claim. Please decide my claim as soon as possible.” A March 2016 Review Post Traumatic Stress Disorder Disability Benefits Questionnaire from J. S.; M.C., L.C.P.C. identified PTSD. It shows, “Many of the mental health diagnoses share similar traits which make it hard to distinguish what contributes to overall impairment; Ie: depression, routine mental status change, crippling depression, anger/rage, interpersonal ineffectiveness, isolation/social withdrawal, chronic pain, decreased need for sleep, impulsivity, suicidal ideations, and lack of consistency/follow through, chronic migraines.” The Veteran was also afforded a March 2016 VA psychiatric examination with medical opinion. The VA examiner rendered a diagnosis of depressive disorder due to another medical condition with depressive features. After review of the evidence of record, the VA examiner concluded that the Veteran did not meet the diagnostic criteria for post-traumatic stress disorder. The rationale provided was that the Veteran’s post-traumatic disorder symptoms were triggered after his last motor vehicle accident in 2008. The VA examiner further noted that the Veteran’s VA treatment records did not support a diagnosis of post-traumatic stress disorder. Next, a September 2018 rating decision granted service connection for depressive disorder due to another mental condition, with depressive features (previously denied as depression) and assigned a 50 percent evaluation effective November 5, 2013. Shortly thereafter, in a VA Form 9 dated October 5, 2018, the Veteran through his attorney asserted in part, “The Appellant herby takes exception to and preserves for appeal all errors the VA regional office may have made or the Board may hereafter make in deciding this appeal. This includes errors in failing to adjudicate issues or claims reasonably raised by the record, even though not specifically mentioned by the Appellant. This also includes all legal errors, errors in fact-finding, failure to follow Manual M21-1 and Manual M21-1MR, failure to discharge the duty to assist, and other due process errors…The Appellant’s claim includes all theories reasonably raised by the evidence of record. This appeal specifically refers to, but is not limited to, VARO’s failure to grant service connection for PTSD secondary to chronic pain from service-connected headaches. It is noted that the RO in the Statement of the Case did not consider counsel’s June 23, 2017 argument that PTSD is secondary to [the Veteran’s] chronic pain which includes his chronic pain from service-connected headaches.” The Board observes that the current record does not contain independent or objective documentation that corroborates or verifies the Veteran’s reported January 19, 1995 claimed in-service stressor (i.e. automobile accident) and subsequent diagnosis. This is significant inasmuch as the Veteran’s alleged stressor is non-combat in nature. For this Veteran, service connection for PTSD may not be granted in the absence of a verified stressor. If there is no combat experience, there must be independent evidence to corroborate the Veteran’s statements as to the occurrence of a claimed stressor. Doran v. Brown, 6 Vet. App. 283, 288-89 (1994). A Veteran’s testimony, by itself, cannot, as a matter of law, establish the occurrence of a non-combat stressor. Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of a claimed in-service stressor. Cohen v. Brown, 10 Vet. App. 128, 142 (1997); Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996). On remand, the Veteran will once again be afforded the opportunity to assist VA in fully developing his claim. Consequently, a new notification letter should be provided to the Veteran which details requirements pertaining to his claim to service connection for PTSD based on non-combat stressors. This includes completion of a VA Form 21-0781 Statement in Support of Claim for Service Connection for PTSD. If the Veteran fails to respond, the claim will be adjudicated based upon the evidence of record. Next, with regard to the claim of service connection for PTSD: A finding of service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), a link, established by medical evidence between current symptoms and an in-service stressor, and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Consequently, a remand is necessary to obtain a stressor statement and then a supplemental VA examination that addresses with the Veteran’s contentions in the October 5, 2018 VA Form 9. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 3. Entitlement to a TDIU is remanded. The Board incorporates its discussion from the sections above by reference. In a VA Form 9 dated October 5, 2018, the Veteran through his attorney asserts in part, “The Appellant herby takes exception to and preserves for appeal all errors the VA regional office may have made or the Board may hereafter make in deciding this appeal. This includes errors in failing to adjudicate issues or claims reasonably raised by the record, even though not specifically mentioned by the Appellant. This also includes all legal errors, errors in fact-finding, failure to follow Manual M21-1 and Manual M21-1MR, failure to discharge the duty to assist, and other due process errors…This appeal specifically refers to, but is not limited to, VARO’s failure to grant entitlement to TDIU on an extraschedular basis.” Regarding the claim for a TDIU, consideration of entitlement to TDIU is dependent upon the effect of service-connected disabilities on a Veteran’s ability to obtain or retain substantially gainful employment. The matter of TDIU is therefore inextricably intertwined with the currently open claims for service connection. Harris v. Derwinski, 1 Vet. App. 180 (1991). Remand of the inextricably intertwined TDIU claim is therefore required as well. The matters are REMANDED for the following action: 1. If the Veteran identifies other evidence, obtain updated copies of the Veteran’s VA treatment records and any private treatment records, and associate them with the Veteran’s claims folder. 2. Please schedule the Veteran for a VA examination to determine the nature and etiology of any sleep apnea. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service. The VA examiner should specifically comment on the Veteran’s spouse’s reports of snoring and breathing cessation in service. See November 30, 2014 Lay Statement. The examiner should provide a rationale for all opinions expressed. 3. Issue to the Veteran a new notification letter which details evidentiary requirements in claims to service connection for PTSD based on in-service non-combat stressors, and request that he submit a new stressor statement on a VA Form 21-0781 Statement in Support of Claim for Service Connection for PTSD providing additional details regarding his claimed in-service stressors. If no additional evidence is received from the Veteran or his attorney, the case will be adjudicated based upon the evidence of record. After the development noted above has been completed, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his claimed acquired psychiatric disorder, to include PTSD, exclusive of depressive disorder. (This examination must be conducted by a VA psychiatrist or psychologist). The claims file and a copy of this remand must be made available to the examiner in conjunction with the requested examination, and the examiner should indicate that the claims file was reviewed. All necessary tests should be conducted, and the Veteran’s complaints should be recorded in full. The VA examiner should answer the following: (i) What are the Veteran’s current psychiatric disorders? In particular, has the Veteran had PTSD at any time during the appeal period (i.e., since July 2015)? (ii) Is it at least as likely as not (a probability of 50 percent or greater) that a diagnosed non-PTSD psychiatric disorder – exclusive of depressive disorder – began in service, was caused by service, or is otherwise related to active military service? (iii) Is it at least as likely as not (a probability of 50 percent or greater) that a diagnosed non-PTSD psychiatric disorder – exclusive of depressive disorder – is proximately due to, the result of, or aggravated by the Veteran’s service-connected disabilities, including migraine headaches. Attention is directed to the October 5, 2018 VA Form 9 showing this theory of entitlement. (iv) If PTSD is diagnosed, the examiner should opine on whether either of the Veteran’s claimed in-service stressors (car accident) has been verified (corroborated) by independent evidence, whether a verified in-service stressor is adequate to support a diagnosis of PTSD, and whether the current PTSD symptoms relate to the stressor(s). In addressing these questions, please discuss the Veteran’s lay assertions of record, to include any stressor statements submitted into evidence (e.g., August 5, 2015 typewritten statement). Lastly, the VA examiner should also comment on the Veteran’s ability to function in an occupational environment, and describe the functional impairment caused solely by the service-connected disability or disabilities. The VA examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The VA examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 4. Review the evidence obtained above to ensure that the remand directives have been accomplished. If the questions posed are not answered or sufficiently answered, return the case to the examiner for completion of the inquiry. (Continued on the next page.) After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his attorney an appropriate supplemental statement of the case (SSOC). Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Bodi, Associate Counsel