Citation Nr: 19144930 Decision Date: 06/11/19 Archive Date: 06/10/19 DOCKET NO. 17-49 916 DATE: June 11, 2019 ORDER The request to reopen the claim for service connection for hypertension is granted. Entitlement to service connection for hypertension is granted. Entitlement to service connection for sleep apnea is granted. Entitlement to service connection for a headache disability is denied. Entitlement to service connection for tinnitus is granted. Entitlement to a rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a bilateral leg disability is remanded. Entitlement to service connection for hemorrhoids is remanded. Entitlement to service connection for a prostate disability is remanded. Entitlement to a rating in excess of 10 percent for hepatitis A is remanded Entitlement to a total disability rating due to unemployability (TDIU) is remanded. FINDINGS OF FACT 1. A January 2013 rating decision denied service connection for hypertension on the basis that there was no nexus to service. The Veteran was informed of the decision and did not appeal nor was new and material evidence submitted within a year of the decision. Therefore, the decision is final. 2. Since the January 2013 denial, the Veteran submitted a November 2017 statement contending that hypertension was due to in-service exposure to herbicide agents and in its 2018 Update the National Academy of Sciences (NAS) indicated that there is “sufficient” evidence of an association between hypertension and herbicide agent exposure. This evidence is relevant and probative and cures a prior evidentiary defect; namely, the lack of a nexus to service as it indicates that hypertension may be due to presumed in-service exposure to herbicide agents. 3. The Veteran had physical presence in the Republic of Vietnam during the Vietnam Era. 4. Resolving doubt in the Veteran’s favor, hypertension is due to in-service herbicide agent exposure. 5. The competent evidence indicates that the Veteran’s service-connected PTSD aided in the development of and permanently aggravated his sleep apnea. 6. The preponderance of the competent evidence shows that the Veteran’s headache disability was not present in service or until many years thereafter and is not related to service or to an incident of service origin. 7. Resolving all doubt in the Veteran’s favor, the Veteran’s tinnitus is attributable to active service. 8. During the period on appeal, the Veteran’s PTSD has been characterized by depressive periods lasting several days at a time, anxiety, chronic sleep impairment, nightmares and dreams of combat, passive thoughts of death and suicidal ideation without intent or plan, panic attacks weekly or less often, isolative behavior and hypervigilance. CONCLUSIONS OF LAW 1. The January 2013 rating decision is final as to the denial of service connection for hypertension. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2018). 2. Evidence received since the January 2013 rating decision is new and material, and the claim for service connection for hypertension is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2018). 3. The criteria for service connection for hypertension have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 4. The criteria for service connection for sleep apnea, secondary to PTSD, have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2018). 5. The criteria for service connection for a headache disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 6. The criteria for service connection for tinnitus have been met. 38 U.S.C. § 1131 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 7. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1967 to January 1970. This matter came before the Board of Veterans Appeals (Board) on appeal from November 2014 and March 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The September 2017 Formal Appeal included the issue of service connection for left foot plantar callouses. However, a March 2018 letter from the Veteran’s attorney, while noting the pending appeal, asked that the issue be expanded and a review performed for any and all left and right foot conditions. A November 2018 rating decision granted service connection for bilateral flat feet, and the assigned rating explicitly encompassed callosities. As service connection for a left foot condition has been granted and has been rated with consideration of callosities, the Board finds that this is a full grant of the benefit sought on appeal and the issue of service connection for left foot plantar callouses (claimed as a left foot condition) is not before the Board. For the reasons stated above, the request to reopen the claim for service connection for hypertension has been granted. The Board will proceed with the adjudication of the issue in the decision below. Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). Secondary service connection may be granted for disability that is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310. The evidence must show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). 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. § 5107 (West, 2004); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For benefits to be denied, “the preponderance of the evidence must be against the claim.” Id. at 54. 1. Entitlement to service connection for hypertension is granted. The Veteran contends that his hypertension is related to active service. Granting the benefit of the doubt to the Veteran, the Board concludes that hypertension is at least as likely as not due to the Veteran’s presumed herbicide agent exposure in Vietnam and that service connection is therefore warranted. The Veteran had service in the Republic of Vietnam; herbicide exposure is therefore presumed. 38 U.S.C. § 1116 (f); 38 C.F.R. § 3.307(a)(6)(iii). The Veteran has been diagnosed with hypertension. Hypertension is not included on the list of diseases presumed to have been incurred in service in Vietnam. 38 U.S.C. § 1116(a); 38 C.F.R. §§ 3.307(a)(6), 3.309(e). However, the Veteran may still be entitled to service connection on a direct basis if the evidence establishes that hypertension is related to herbicide agent exposure. In this regard, the Board notes that in its 2018 Update the National Academy of Sciences (NAS) indicated that there is “sufficient” evidence of an association between hypertension and herbicide agent exposure. The NAS therefore upgraded hypertension from its prior classification in the “limited or suggestive” evidence category to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. See National Academy of Science, Veterans and Agent Orange: Update 11 (2018), http://nationalacademies.org/hmd/ reports/2018/veterans-and-agent-orange-update-2018.aspx. An April 2018 VA examination diagnosed hypertension but found that it was not due to service as the Veteran’s blood pressure was normal at separation and there was no evidence of hypertension on active duty. However, the opinion did not address the question of exposure to herbicide agents and the Board therefore accords it no probative weight. There is no other competent evidence of record addressing the relationship between the Veteran’s hypertension and herbicide agent exposure. Therefore, resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for hypertension is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, 3.303. 2. Entitlement to service connection for sleep apnea is granted. The Veteran contends that his sleep apnea is due to his service-connected PTSD or to in-service herbicide agent exposure. The Board concludes that secondary service connection is warranted. VA treatment records show a current diagnosis of obstructive sleep apnea. A March 2016 private opinion from Dr. H.S. found that the Veteran’s service-connected PTSD and medication for that disability likely aided in the development of and permanently aggravated his sleep apnea. Dr. H.S. cited research showing that PTSD is commonly associated with sleep apnea as well as a study showing an arousal-based mechanism initiated by PTSD that promotes the development of sleep apnea. He further noted studies showing that with CPAP treatment the symptoms of PTSD and sleep apnea both decreased, which he opined indicates co-morbidity. Dr. H.S. also noted the Veteran’s reports of difficulty using CPAP as it made him feel claustrophobic and trapped. Finally, Dr. H.S. noted that the Veteran takes Sertraline to treat his PTSD and cited a study showing that medications of this type cause decreased sleep efficiency, working against treatment for sleep apnea. Therefore, Dr. H.S. concluded that PTSD likely aided in the development of and permanently aggravated the Veteran’s sleep apnea. The Board finds that the March 2016 private opinion is adequate for appellate review. There is no evidence that the examiner was not competent or credible, and as the report is based on the Veteran’s statements, in-person examination and the examiners’ observations, the Board finds it entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302–05 (2008). As noted above, secondary service connection is warranted when the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). The March 2016 private opinion supports a finding of secondary service connection under 38 C.F.R. § 3.310(a). The opinion stands uncontradicted by any other competent evidence of record. Service connection is therefore warranted. 38 C.F.R. § 3.310. 3. Entitlement to service connection for a headache disability is denied. The Veteran contends that he is entitled to service connection for a headache disability. After a review of the competent evidence of record, the Board concludes that the Veteran’s headache disability is not related to service and service connection is therefore not warranted. Service treatment records are silent for complaints, treatment or diagnosis of a headache disability. The December 1969 separation medical history indicated no history of frequent or severe headaches and the December 1969 separation examination is silent for headaches. February 1998 private treatment records indicate that the Veteran visited the emergency room with a severe headache and was diagnosed with headache, NOS and medicated for pain. May 2005 VA treatment records note the Veteran’s report of migraine headaches twice a year. The Veteran submitted a July 2014 application claiming compensation benefits for headaches but did not make any specific assertions regarding the onset of his headaches or the relationship between his disability and his active service. The Board finds that the competent evidence of record does not support the conclusion that the Veteran’s headache disability began in service or was otherwise due to service. Service treatment records are silent for headaches or any reports of symptoms or treatment for headaches. The Veteran was discharged from service in January 1970, and the evidence does not show complaints of headaches symptoms or that he otherwise sought treatment for headaches until February 1998, over 28 years later. The Veteran also did not present any lay evidence regarding the onset of his headaches. There is simply no competent evidence of record that establishes an earlier onset of headaches. The record is also negative for any evidence, other than the Veteran’s generalized assertion that he is entitled to service connection, of a relationship between his service and the later headache disability of migraine. The Veteran did make any specific assertion regarding the relationship of his headache disability to active service. He also did not present any lay or medical evidence of symptoms or diagnosis of headaches prior to 1998 or any evidence of a relationship between his headache disability and his service. While the Veteran contends that his headache disability is related to service, as a layperson, he does not possess the medical expertise required to provide a nexus opinion. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board acknowledges that a VA examination was not obtained for this issue but finds that an examination is not required to make a final adjudication. Although the Veteran contends service connection is warranted for a headache disability, there is no indication (or specific assertion) that a headache disability was manifested in, or is otherwise directly related to, the Veteran’s service. As noted above, STRs are silent for any complaints of a headache disability and private and VA treatment records are silent for complaints of a headache disability until 1998. The Board therefore finds that the preponderance of the evidence indicates that the Veteran’s headache disability was not caused by or incurred in service. Service connection is therefore not warranted. 38 C.F.R. § 3.303. 4. Entitlement to service connection for tinnitus is granted. The Veteran contends that he is entitled to service connection for tinnitus. Resolving benefit of the doubt in favor of the Veteran, the Board concludes that service connection is warranted. The Veteran’s records show that he was a combat Veteran. VA treatment records have noted the Veteran’s complaints of tinnitus. A May 2005 symptoms review was positive for tinnitus. At the July 2012 primary care appointment, an ear nose and throat examination was positive for tinnitus. A September 2014 VA audiological examination noted the Veteran’s reports of noise exposure from gunfire in service but found that the Veteran did not report recurrent tinnitus. The examiner then stated that “there was no complaint of tinnitus today.” The Board notes that the fact that the Veteran did not report tinnitus on a particular day does not preclude the possibility of recurrent, or periodic, tinnitus, and the examiner did not address the VA treatment records noting reports of tinnitus. The Board therefore finds that the examination is inadequate and accords it no probative weight. A February 2018 VA audiological examination found that the Veteran did not report recurrent tinnitus. The examiner did not provide an etiological opinion. The examiner conceded exposure to hazardous noise exposure, noting the Veteran’s reports of gunfire during combat. The examiner noted that the Veteran denied severe ear infections or surgeries or pre-service noise exposure and that the Veteran’s post-service occupational record was in pest control, at Revlon and in property management and that he did not report recreational noise exposure. The Board finds that the February 2018 VA examination is adequate for appellate review and entitled to significant probative weight as it is based on the Veteran’s statements, in-person examinations and the examiners’ observations. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302–05 (2008). The Board acknowledges that the February 2018 VA examiner did not find recurrent tinnitus. However, VA treatment records document the Veteran’s reports of ongoing tinnitus. In the case of a wholly lay-observable disability such as tinnitus, the Veteran is competent to report both its onset date and its persistency since that date. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, his reports of tinnitus are entitled to significant probative weight. Therefore, the preponderance of the competent evidence of record indicates that Veteran has a current disability of recurrent tinnitus. The Board also notes that the Veteran has conceded in-service hazardous noise exposure and that there is no indication in the record of ear infections or surgeries or post-service occupational or recreational hazardous noise exposure. There is simply no basis upon which to dissociate the Veteran’s tinnitus from his in-service hazardous noise exposure. Therefore, resolving all doubt in the Veteran’s favor, the Board finds that the competent evidence of record indicates that the Veteran’s tinnitus was caused by in-service hazardous noise exposure and that service connection is therefore warranted. 38 C.F.R. §§ 3.102, 3.303. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Individual disabilities are assigned separate diagnostic codes. See U.S.C. §1155; 38 C.F.R. § 4.1. When there is a question as to which of two evaluations applies, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for the rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 39 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to a rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is denied. The Veteran contends that he is entitled to a higher rating for his PTSD. The Board concludes that a rating above 70 percent is not warranted. For the entire period on appeal, the Veteran has been rated under DC 9411 for PTSD, which is evaluated under the General Rating Formula for Mental Disorders. Under the DC, the criteria for a 70 percent rating are occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. The criteria for a 100 percent rating are 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 of others; intermittent 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. 38 C.F.R. § 4.130, DC 9411. Ratings are assigned according to the manifestation of particular symptoms, but the use of the term “such as” in the General Rating Formula demonstrates that the symptoms after the phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). See also Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (explaining that the symptoms that could give rise to a given rating are those in like kind, i.e., of similar duration, severity, and frequency, to those provided in the non-exhaustive lists). VA treatment records document treatment for PTSD. July 2014 records noted nightmares and that the Veteran had trouble on July 4th due to memories of war. The Veteran denied suicidal or homicidal ideation or intent and also denied auditory or visual hallucinations and paranoid ideations. He denied depressive symptoms. The provider found that he was alert and oriented, with fair grooming and hygiene, normal speech, appropriate affect and linear and goal-directed thoughts. October 2014 records indicate that the Veteran had run out of medication and reported worsening depression. He reported poor sleep and anhedonia. He reported passive suicidal ideation but denied active ideation with plan or intent. The provider found that he was alert and oriented, with fair grooming and hygiene, normal speech, logical and goal-directed thoughts and no auditory or visual hallucinations. March 2015 records noted that the Veteran denied suicidal or homicidal ideation. He reported poor sleep and anhedonia, hypervigilance, intrusive thoughts and irritability. He denied auditory or visual hallucinations. The provider found that he was alert and oriented and well groomed, with normal speech, normal memory and concentration, a full range of affect and linear and goal directed thoughts. April 2015 records noted that the Veteran was feeling less anxious and irritable and that his sleep was improving. He reported that he had 5 fish tanks that he took care of and that it relaxed him and kept him busy. He still reported symptoms of hypervigilance, intrusive thoughts, avoidance, nightmares and flashbacks, but he reported improvement with medication. He denied suicidal or homicidal ideation and intent as well as auditory or visual hallucinations and paranoid ideations. The provider noted that the Veteran appeared calm, relaxed, stable and without distress. The provider found that the Veteran was fairly groomed, with normal speech, appropriate affect and logical and goal-directed thoughts. February 2016 records noted that the Veteran had restarted his medications a week prior and felt much better. He reported that he spent days reading, taking care of his fish, attending veteran’s groups and going to church. He denied anhedonia, worthlessness and hopelessness and “adamantly” denied suicidal or homicidal ideation. He also denied auditory or visual hallucinations. The provider also noted that no delusions or paranoia were elicited. The provider found that the Veteran was alert and oriented, with fair grooming and hygiene, fair eye contact, regular rate and rhythm of speech, appropriate affect and coherent thoughts. April 2017 records noted that the Veteran was doing better since restarting his medications and reported good mood and that he was sleeping well. He denied passive death wishes and suicidal thoughts. October 2018 records noted the Veteran’s up and down mood and depression lasting for days. The Veteran reported that taking care of his fish tanks no longer improved his mood, but that he had joined several choirs and started guitar lessons. The Veteran also reported waking at night. The provider found that the Veteran was dressed neatly and had good eye contact, regular speech, a normal range of affect congruent with mood and that his thoughts were logical and goal-directed. The Veteran denied passive death wishes and suicidal thoughts, plans or intent. He also denied homicidal ideation and the provider found no evidence of psychosis. The provider noted that the Veteran was at baseline and that his mood symptoms were stable. A September 2014 VA examination found that the Veteran had occupational and social impairment with reduced reliability and productivity. The examiner noted that the Veteran had a poor relationship with his family, had problems maintaining friendships and endorsed social withdrawal. The examiner also noted a deterioration of self-care, neglecting household work, and poor hygiene. The examiner found symptoms of depression, anxiety, panic attacks weekly or less often, chronic sleep impairment, and impairment of short and long-term memory such as retention of only highly learned material and forgetting to complete tasks. The examiner also found suicidal ideation. The examiner noted that the Veteran was dressed in casual but neat attire, made good eye contact and appeared anxious and depressed. A February 2015 VA examination found symptoms of depression, anxiety, near-continuous panic and depression, mild memory loss, neglect of personal appearance and hygiene and intermittent ability to perform the activities of daily living. The examiner noted the Veteran’s reports that he needed to be alone in to avoid conflict and to avoid feeling overwhelmed. The examiner found that the Veteran was well groomed, with a full range of affect congruent with his mood. He noted that the Veteran was tearful at times. The examiner found no auditory or visual hallucinations and no paranoid ideation. The Veteran endorsed chronic passive suicidal ideation without intent or plan. An April 2018 VA examination noted sleep symptoms associated with the Veteran’s PTSD. The examiner noted that the Veteran got 5 to 6 hours of sleep per night and had nightmares and dreams of combat 2 to 3 times per week. On mental status examination, the examiner found no impairment of thought processes or communication. The Veteran’s eye contact was noted to be good. The examiner found no suicidal or homicidal thoughts, ideation, plans or intent. The examiner found that the Veteran had the ability to maintain minimal personal hygiene and other basic activities of daily living and was oriented to person, place and time. At the outset, the Board finds that the VA examination is adequate for appellate review. There is no evidence that the examiner was not competent or credible, and as the report is based on the Veteran’s statements, in-person examination and the examiners’ observations, the Board finds it is entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302–05 (2008). The Board finds that the preponderance of the evidence is against an evaluation in excess of 70 percent for the period on appeal. The medical evidence of record does not support the conclusion that the Veteran’s overall disability picture more nearly approximates the frequency, severity, or duration of psychiatric symptoms required for a 100 percent disability evaluation based on total occupational and social impairment. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. That is, the competent evidence of record does not show that the Veteran experiences symptoms of or equivalent to gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place or memory loss for names of close relatives, own occupation or own name. The Board finds that the evidence of record indicates that the Veteran’s PTSD has been characterized by passive suicidal ideation, depression lasting days at a time, chronic sleep impairment, nightmares and dreams of combat, panic attacks weekly or less often and impairment of short and long-term memory. All of these symptoms are contemplated by the 70 percent rating already assigned. In finding that the Veteran’s current 70 percent rating is justified, the Board contemplates the Mauerhan decision and does not identify the symptoms as a mere exhaustive list, but rather as indicative of the overall complaints associated with the condition throughout the period on appeal. While the Veteran has a history of passive suicidal ideation, the evidence consistently indicates that the Veteran had suicidal ideation but no plan or intent. Indeed, while VA providers and examiners noted passive suicidal ideation and thoughts of death, the Veteran consistently denied any plans or intent during the period on appeal. There is also no evidence of homicidal ideation, intent or plan. The Board therefore finds that the evidence does not indicate that the Veteran has persistent danger of hurting himself or others. The Board also finds that the evidence does not indicate that the Veteran is unable to maintain minimal personal hygiene. The Board notes that September 2014 VA examiner noted a decrease in hygiene and self-care and the February 2015 VA examiner found neglect of personal hygiene and intermittent inability to perform the activities of daily living, however the majority of the evidence indicates that the Veteran was able to perform basic hygiene and activities of daily living throughout the period on appeal. The VA treatment records throughout the period on appeal consistently indicate that the Veteran’s grooming and hygiene were fair or better and that he was consistently noted to be neatly dressed. Even the February 2015 examiner, despite finding neglect of personal hygiene, found that the Veteran was well groomed. VA treatment records also frequently note that the Veteran cared not only for his own personal hygiene but maintained 5 fish tanks during the period. Finally, the April 2018 VA examiner specifically found that the Veteran was able to maintain minimal personal hygiene and perform other activities of daily living. The Board therefore finds that the preponderance of the evidence does not support the conclusion that the Veteran is unable to maintain minimal personal hygiene or perform basic activities of daily living. The Board also finds that the record does not contain evidence of other symptoms of a severity contemplated by a 100 percent rating. There is no indication in the record that the Veteran had memory impairment of a severity approximating memory loss for names of close, relatives or his own name and occupation. While the September 2014 VA examiner found impairment of short and long-term memory, the severity indicated was of forgetting to complete tasks but retaining highly learned material, not of forgetting his own name. In addition, the February 2015 VA examiner found only mild memory impairment and March 2015 VA treatment records note normal memory and concentration. There is also no indication that the Veteran has gross impairment in thought processes, delusions or hallucinations or disorientation to time or place. VA treatment records consistently noted that the Veteran was alert and oriented, that his thoughts were logical and goal-directed and that he denied hallucinations and paranoid ideation. His speech was also consistently found to be normal throughout the period on appeal. The Board therefore finds that the evidence of record supports the conclusion that the Veteran’s PTSD does not cause total social and occupational impairment. The Board has considered the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the Veteran’s disability in his favor. The Board finds that the Veteran’s overall picture more nearly approximates that of a 70 percent disability rating, and his symptoms do not more nearly reflect the frequency, severity, and duration of symptoms associated with the 100 percent rating. A rating in excess of 70 percent is therefore not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a back disability is remanded. 2. Entitlement to service connection for a bilateral leg disability is remanded. VA examinations have not yet been provided for these disabilities. Board’s review of private and VA medical records indicates that the Veteran has low back and bilateral leg pain. May 1995 private treatment records noted back pain for two days with pressure on the low back and thighs. June 2013 VA treatment records noted complaints of bilateral leg pain and that the Veteran was unable to walk for long distances. The Board notes the Federal Circuit’s holding in Saunders v. Wilkie, which stated that even in the absence of a presently-diagnosed condition, pain can cause functional impairment, and that in that situation, “pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability.” Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). September 2013 VA physical therapy records note bilateral pes planus and that the Veteran ambulated using a cane and exhibited a mild antalgic left lower extremity. As the Veteran has been service connected for bilateral flat feet and the evidence indicates that gait disturbances are associated with that disability, the Board finds that remand for an opinion regarding secondary service connection is required. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 3. Entitlement to service connection for hemorrhoids is remanded. An April 2018 VA examination diagnosed a history of hemorrhoids without chronic evidence of ongoing hemorrhoids or symptoms. The examiner noted the Veteran’s reports of surgery 4 years after service but stated that the Veteran had no symptoms since that surgery. The examiner noted March 2017 findings of small “incidental non-bleeding hemorrhoids.” The examiner then stated that at the examination, the Veteran did not report current or chronic hemorrhoid symptoms and there were no visible hemorrhoids upon examination. The examiner then stated that hemorrhoids can come and go and concluded that without chronic symptoms and no evidence of hemorrhoids upon examination, it was less likely that the Veteran had a diagnosis of chronic hemorrhoids due to his in-service thrombosed hemorrhoid. Upon review, the Board finds that the record does not contain the March 2017 findings referenced by the April 2018 examiner. March 2017 VA urology records not that there were no external hemorrhoids upon examination but are silent regarding internal hemorrhoids. March 2014 VA treatment records note that small internal hemorrhoids were found during a procedure to remove colon polyps, but the records do not characterize the hemorrhoids either as non-bleeding or incidental. As the April 2018 opinion did not clearly address the March 2014 findings of internal hemorrhoids, remand for a new examination to consider the Veteran’s complete medical history is required. The Board also finds that it is unclear why the findings of internal hemorrhoids noted by the April 2018 examination were “incidental” and did not constitute chronic hemorrhoid symptoms. The significance of the findings of internal hemorrhoids should therefore also be clarified upon remand. 4. Entitlement to service connection for a prostate disability is remanded. An April 2018 VA examination noted a diagnosis of benign prostatic hypertrophy with benign elevation in PSA. The examiner opined that the prostate disability was not likely incurred in or caused by service. However, the examiner did not address the Veteran’s contention that this prostate disability is due to his presumed herbicide agent exposure. Remand for a new examination is therefore required. 5. Entitlement to a rating in excess of 10 percent for hepatitis A is remanded. Nearly 5 years has elapsed since the last VA examination in September 2014. A new examination is therefore required so that the Board can properly assess the current severity of the Veteran’s disability. 6. Entitlement to a total disability rating due to unemployability (TDIU) is remanded. The Board notes that service connection for hypertension and sleep apnea has been granted herein. The issue of entitlement to TDIU must therefore be deferred pending the assignment of disability ratings and because it is inextricably intertwined with the remanded service connection and the issue of an increased rating for hepatitis A. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when the adjudication of one issue could have “significant impact” on the other issue). The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current back and bilateral leg disabilities. The examiner should review the file and provide a complete rationale for all opinions expressed. For any current back or bilateral leg disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to service or to the Veteran’s service-connected bilateral pes planus. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of his symptoms. 2. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current hemorrhoid disability. The examiner should review the file and provide a complete rationale for all opinions expressed. The examiner should provide the following opinions: (a.) Has the Veteran had a hemorrhoid disability at any point during the period on appeal? The opinion should address the March 2014 VA treatment records noting findings of small internal hemorrhoids. If those findings do not constitute evidence of a hemorrhoid disability, the examiner should explain why. The opinion should also address the Veteran’s lay statements regarding his symptoms. (b.) If the examiner finds that the Veteran had a hemorrhoid disability during the period on appeal, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of his symptoms. 3. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current prostate disability. The examiner should review the file and provide a complete rationale for all opinions expressed. For any current prostate disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service, to include his presumed in-service exposure to herbicide agents. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of his symptoms. 4. Schedule the Veteran for an appropriate VA examination to determine the current level of severity of his hepatitis A. The examiner should review the file and provide a complete rationale for all opinions expressed. The examiner should also provide an opinion regarding the functional impact of the Veteran’s hepatitis A upon his ability to work. CONTINUED ON NEXT PAGE 5. If upon completion of the above action the appeal remains denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Arnold, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.