Citation Nr: 20002298 Decision Date: 01/10/20 Archive Date: 01/10/20 DOCKET NO. 18-55 586 DATE: January 10, 2020 ORDER As new and material evidence sufficient to reopen the previously denied claim for service connection for bipolar disorder with depression has been received, the application to reopen is granted. As new and material evidence sufficient to reopen the previously denied claim for service connection for left ear hearing loss has been received, the application to reopen is granted. Entitlement to service connection for bipolar disorder with depression is denied. Entitlement to an effective date earlier than July 15, 2014 for the grant of service connection for PTSD is denied. Entitlement to an initial disability rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted for the entire period on appeal. Entitlement to a disability rating of 40 percent, but no higher, for glaucoma is granted for the entire period on appeal. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. REMANDED Entitlement to service connection for left ear hearing loss is remanded. Entitlement to an evaluation in excess of 60 percent for chronic bronchitis is remanded. FINDINGS OF FACT 1. In an October 2012 rating decision, the RO denied the Veteran’s claim for service connection for the purpose of establishing eligibility to treatment on the basis that bipolar disorder with depression was not incurred in or caused by military service; the Veteran did not appeal this decision or submit new evidence within one year of the denial. 2. Evidence submitted subsequent to the October 2012 rating decision bears directly and substantially upon the specific matter under consideration, is not cumulative or redundant, and in connection with evidence previously assembled raises a reasonable possibility of substantiating the claim of entitlement to service connection for bipolar disorder with depression. 3. In a January 2008 rating decision, the RO denied the Veteran’s claim for service connection for hearing loss on the basis that his hearing loss was unrelated to military service; the Veteran did not appeal this decision or submit new evidence within one year of the denial. 4. In an October 2012 rating decision, the RO denied reopening of the Veteran’s claim of entitlement to service connection for hearing loss. The Veteran did not appeal this decision or submit new evidence within one year of the denial. 5. Evidence submitted subsequent to the October 2012 rating decision bears directly and substantially upon the specific matter under consideration, is not cumulative or redundant, and in connection with evidence previously assembled raises a reasonable possibility of substantiating the claim of entitlement to service connection for left ear hearing loss. 6. The preponderance of the evidence fails to establish that the Veteran has or had bipolar disorder with depression at any time during the pendency of the appeal. 7. On January 23, 1998, the RO notified the Veteran that service connection for PTSD was denied, as the evidence failed to show a diagnosis of PTSD. The Veteran did not file a notice of disagreement or submit new and material evidence within the applicable appeal period, and as such, the January 1998 rating decision became final. 8. On July 15, 2014, the Veteran filed an application to reopen his claim of entitlement to service connection for PTSD. In a December 2014 rating decision, the RO granted service connection for PTSD, and assigned a 50 percent disability rating effective from July 15, 2014. 9. There is no evidence of record, dated between January 23, 1998 and July 15, 2014, that could be reasonably construed as a claim, formal or informal, to reopen the prior denial of service connection for PTSD. 10. Throughout the appellate period, the Veteran’s PTSD has been manifested by occupational and social impairment, with deficiencies in most areas. 11. Throughout the appellate period, the Veteran’s PTSD has not been productive of total occupational and total social impairment. 12. Throughout the appellate period, the Veteran’s glaucoma has not been productive of muscle dysfunction. 13. Throughout the appellate period, the Veteran’s glaucoma has been productive of visual acuity of, at worst, 20/50 bilaterally. 14. Throughout the appellate period, the Veteran’s glaucoma has been productive of average concentric contraction of, at worst, 41 degrees in the right eye, and 38 degrees in the left eye. 15. The Veteran is precluded from gaining or maintaining substantially gainful employment due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The October 2012 rating decision denying service connection for bipolar disorder with depression is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104(a), 20.1103 (2019). 2. New and material evidence sufficient to reopen the Veteran’s claim of entitlement to service connection for bipolar disorder with depression has been submitted; the claim is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2019). 3. The January 2008 and October 2012 rating decisions denying service connection for hearing loss are final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104(a), 20.1103 (2019). 4. New and material evidence sufficient to reopen the Veteran’s claim of entitlement to service connection for left ear hearing loss has been submitted; the claim is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2019). 5. The criteria for service connection for bipolar disorder with depression have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2019). 6. The January 1998 rating decision denying service connection for PTSD is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1104 (2019). 7. The criteria for an effective date earlier than July 15, 2014 for the grant of service connection for PTSD have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2019). 8. Throughout the appellate period, the criteria for a 70 percent initial evaluation for PTSD have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2019). 9. Throughout the appellate period, the criteria for a 40 percent evaluation for glaucoma have been met. 38 U.S.C. § 1155 (2012); 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.79, Diagnostic Codes 6013, 6066, 6080 (2019). 10. Resolving all doubt in the Veteran’s favor, the criteria for entitlement to a TDIU have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from April 1981 to October 1994. During his period of service, he earned the Air Force Achievement Medal, Joint Meritorious Unit Award, Air Force Outstanding Unit Award with Valor Device with one Oak Leaf Cluster, Air Force Good Conduct Medal with two Oak Leaf Clusters, National Defense Service Medal with one Bronze Star, Southwest Asia Medal with Oak Leaf Cluster, Air Force Overseas Short Tour Ribbon, Air Force Overseas Long Tour Ribbon with two Oak Leaf Clusters, Air Force Longevity Service Award Ribbon with two Oak Leaf Clusters, Noncommissioned Officer Professional Military Education graduate Ribbon with one Oak Leaf Cluster, Air Force Training Ribbon, and Kuwait Liberation Medal. As an initial matter, the Veteran filed a formal claim for a TDIU in June 2008, which was denied by the RO in a March 2009 rating decision. As he did not appeal the decision, it thereby became final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2019). A TDIU claim has been raised by the record as part of the Veteran’s instant claims of entitlement to increased ratings for PTSD and glaucoma. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, there is evidence that the Veteran’s service-connected disabilities have impacted his employability. The Court has made clear in a series of memorandum decisions its view that even where a formal claim for a TDIU has been adjudicated and not appealed, the issue of entitlement to a TDIU raised as part and parcel of a higher initial or increased rating claim exists independent of the formal TDIU claim and must be separately adjudicated. The Court has also held that the Board has jurisdiction over the issue of entitlement to a TDIU if raised by the evidence of record as part of a claim for a higher initial or increased rating, as is the case here. See id. The Board will therefore adjudicate the issue of entitlement to a TDIU based on the current evidence before it and has expanded the appeal to include this issue. Additionally, the Board notes that in a December 2018 rating decision, the RO restored the 60 percent evaluation for chronic bronchitis, effective from March 29, 2007; granted entitlement to right ear hearing loss, assigning a noncompensable rating from July 15, 2014; and denied entitlement to service connection for left ear hearing loss. In January 2019, the Veteran submitted a timely Notice of Disagreement (NOD) with the effective date and evaluation of chronic bronchitis and right ear hearing loss, as well as the denial of service connection for left ear hearing loss. See 38 C.F.R. § 20.201 (2019). VA’s Veterans Appeals Control and Locator System (VACOLS) indicates that the RO has already acknowledged the NOD and that the RO is continuing to work on that matter. See e.g., August 2019 Decision Review Officer (DRO) letter to Veteran. As the RO has acknowledged receipt of the NOD and VACOLS indicates that further action is pending at the RO, this situation is distinguishable from Manlincon v. West, 12 Vet. App. 238 (1999), where a NOD had not been recognized. As the record reflects pending additional action on the NOD, the Board will not address the issues of entitlement to an earlier effective date and increased evaluation for right ear hearing loss and earlier effective date for chronic bronchitis at this time. The issues of entitlement to service connection for left ear hearing loss and entitlement to an increased evaluation for chronic bronchitis remain part of the instant appeal. New and Material Evidence Where service connection for a disability has been denied in a final decision, a subsequent claim for service connection for that disability may be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. New evidence means evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). According to the United States Court of Appeals for Veterans Claims (Court), the pertinent VA law requires that in order to reopen a previously and finally disallowed claim, there must be new and material evidence presented or secured since the time that the claim was finally disallowed on any basis. See Evans v. Brown, 9 Vet. App. 273 (1996). When determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, raise a reasonable possibility of substantiating the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). The newly presented evidence need not be probative of all the elements required to award the claim, just probative of each element (or at least one element) that was a specified basis for the last disallowance of the claim. See Evans, 9 Vet. App. at 283; see also Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998) (noting that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant’s injury or disability, even where it would not be enough to convince the Board to grant the claim). The credibility of the newly submitted evidence is presumed for purposes of reopening the claim. See Justus v. Principi, 3 Vet. App. 510 (1992). 1. New and material evidence sufficient to reopen claim for service connection for bipolar disorder with depression The Veteran’s claim for service connection for bipolar disorder with depression was initially denied in an October 2012 rating decision. The RO determined that bipolar disorder with depression was not incurred in or caused by military service. The Veteran did not appeal this decision or submit new evidence within one year of the denial. The October 2012 decision thereby became final. See 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. In a December 2014 rating decision, the RO denied reopening of the Veteran’s claim for service connection, reasoning no new and material evidence was submitted to substantiate the claim of entitlement to service connection for bipolar disorder with depression. The Veteran filed a timely notice of disagreement (NOD) with that decision in November 2015. In a December 2018 statement of the case (SOC), the RO reopened but ultimately denied the claim of service connection for bipolar disorder with depression. Despite this, the Board has the responsibility of adjudicating the issue of whether new and material evidence has been submitted in the first instance. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Subsequent to the October 2012 rating decision, new and material evidence has been received that relates to unestablished facts that are necessary to substantiate the Veteran’s claim for service connection for bipolar disorder with depression, to include VA and private PTSD examination reports. This evidence satisfies the low threshold requirement for new and material evidence and the claim is reopened. See Shade v. Shinseki, 24 Vet. App. 110 (2010). 2. New and material evidence sufficient to reopen claim for service connection for left ear hearing loss The Veteran’s claim for service connection for hearing loss was initially denied in a January 2008 rating decision. The RO determined that there was no evidence that the Veteran’s hearing loss manifested to a compensable degree during the one-year presumptive period following separation from service. The Veteran did not appeal this decision or submit new evidence within one year of the denial. The January 2008 decision thereby became final. See 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. Subsequently, an October 2012 rating decision denied reopening of the Veteran’s claim for service connection, reasoning no new and material evidence was submitted to substantiate the claim of entitlement to service connection for hearing loss. The Veteran did not appeal this decision or submit new evidence within one year of the denial. The October 2012 rating decision, therefore, is final. See 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. In a December 2014 rating decision, the RO denied reopening of the Veteran’s claim for service connection, reasoning no new and material evidence was submitted to substantiate the claim of entitlement to service connection for hearing loss. The Veteran filed a timely notice of disagreement (NOD) with that decision in November 2015. A December 2018 Decision Review Officer (DRO) rating decision subsequently granted service connection for right ear hearing loss but continued the denial of entitlement to service connection for left ear hearing loss. Since the October 2012 rating decision, new and material evidence has been received that relates to unestablished facts that are necessary to substantiate the Veteran’s claim for service connection for left ear hearing loss, to include a November 2018 VA hearing loss examination report. This evidence satisfies the low threshold requirement for new and material evidence and the claim is reopened. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Service Connection 3. Entitlement to service connection for bipolar disorder with depression Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In order to prevail on a claim of service connection, generally, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a Veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. The Veteran contends that he is entitled to service connection for bipolar disorder with depression. A review of the medical evidence of record fails to establish that the Veteran has been diagnosed with bipolar disorder with depression at any time during the appellate period or proximate thereto. Notably, the Veteran appeared for a VA PTSD examination in November 2014. The examiner noted a diagnosis of PTSD and indicated that the Veteran did not have more than one diagnosed mental disorder. Further, private PTSD disability benefits questionnaire (DBQ) was associated with the Veteran’s claims file in December 2018. The examiner diagnosed PTSD and indicated that the Veteran did not have more than one diagnosed mental disorder. In light of the foregoing, the most probative evidence of record is against the finding of a diagnosis of bipolar disorder with depression. See Brammer, supra; McClain, supra; Romanowsky, supra. Without such evidence, service connection for bipolar disorder with depression cannot be granted. See Shedden, supra. Accordingly, the Board finds that the claim of entitlement to service connection for bipolar disorder with depression must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection, that doctrine is not applicable. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2018); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Earlier Effective Date Except as otherwise provided, the effective date of an award of service connection, to include on a secondary basis, will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2019). A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by VA. 38 U.S.C. § 5101(a) (2012); 38 C.F.R. § 3.151(a) (2019). The term “claim” or “application” means a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p) (2018). 4. Entitlement to an earlier effective date for the grant of service connection for PTSD The Veteran seeks to establish an effective date earlier than July 15, 2014 for the award of service connection for PTSD. He has not provided any argument as to why he believes earlier effective date is warranted or what effective date he believes should be assigned. By a January 1998 rating decision, the Veteran was denied service connection for PTSD. The Veteran was informed of the decision and his appellate rights in a January 1998 letter. The Veteran did not file a notice of disagreement and no additional evidence pertinent to the issue was physically or constructively associated with the claims folder within one year of that decision. Thus, the January 1998 rating decision became final. 38 U.S.C. § 7105 (2002); 38 C.F.R. § 20.1103 (2019). An application to reopen his claim of entitlement to service connection for PTSD was received by VA on July 15, 2014. By a December 2014 rating decision, the RO granted service connection for PTSD, and assigned a 50 percent disability rating effective July 15, 2014, the date in which the Veteran’s request to reopen the claim was received. Nevertheless, in November 2015, the Veteran filed a notice of disagreement and perfected an appeal as to the assigned effective date. Upon a review of the record, the Board finds the appropriate effective date for the grant of service connection for PTSD is July 15, 2014, the date the Veteran’s request to reopen the claim of entitlement to service connection for PTSD was received. Generally, when granting entitlement to service connection for a disability in response to an application to reopen a claim that has previously been denied, VA cannot assign an effective date earlier than the date of receipt of the application to reopen. See 38 U.S.C. § 5110(a); see also 38 C.F.R. § 3.400(r) (effective date of reopened claim is date of receipt of claim or date entitlement arose, whichever is later); Comer v. Peake, 552 F.3d 1362, 1370 (Fed. Cir. 2009) (“The earliest effective date for an award based on a veteran’s request to reopen a final decision based on new and material evidence is generally the date that the application to reopen was filed”). As discussed above, the January 1998 rating decision is considered final, as the Veteran did not file a notice of disagreement and no additional evidence pertinent to the issue of entitlement to service connection for PTSD was physically or constructively associated with the claims folder within one year of that decision. Further, there is no correspondence during the period between the January 1998 and July 15, 2014 claim that may be construed as a request to reopen the claim for service connection for PTSD. The only other avenue to establishing an effective date as of the first claim in 1998 is to allege clear and unmistakable error (CUE) in that earlier (January 1998) rating decision, which must be specifically pled. See Fugo v. Brown, 6 Vet. App. 40, 43 (1993). However, the Veteran has not alleged CUE in the January 1998 rating decision, nor has such issue been reasonably raised by the record. Consequently, the claim for an effective date prior to July 15, 2014 must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim of entitlement to an effective date earlier than July 15, 2014 for the grant of service connection for PTSD, that doctrine is not applicable. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2019); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Increased Ratings Disability ratings are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Veteran’s entire history is reviewed when assigning disability ratings. See generally 38 C.F.R. § 4.1. If there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based upon the facts found. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). But where service connection has already been established, and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). 5. Entitlement to a higher rating for PTSD The Veteran contends that he is entitled to a rating in excess of 50 percent for his service-connected PTSD. PTSD is evaluated under a general rating formula for mental disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted where there is 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The use of the term “such as” in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating, in addition to permitting consideration of other symptoms particular to each veteran and disorder, and the effect of those symptoms on his/her social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit stated that “a Veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” It was further noted that “§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas.” The Veteran appeared for a VA PTSD examination in November 2014. The examiner indicated that the Veteran’s level of occupational and social impairment could be best summarized as occupational and social impairment with reduced reliability and productivity. The Veteran stated that he had been prescribed medication for the management of his disability in the past but was out of medication. He reported experiencing flashbacks. The Veteran also reported an arrest for driving under the influence (DUI), as well as a history of alcohol and cocaine usage. The examiner noted symptoms of depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect, disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting. At the time of examination, the examiner indicated that the Veteran was poorly dressed and groomed and described his speech as rambling and tangential. A private PTSD DBQ was associated with the Veteran’s claims file in December 2018. The examiner indicated that the Veteran’s level of occupational and social impairment could be best summarized as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported being socially isolated and withdrawn. He admitted self-medicating with alcohol and marijuana in the past, with continued occasional alcohol usage. He reported participation in VA inpatient treatment programs. The examiner noted symptoms of depressed mood; anxiety; suspiciousness; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect, disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective work and social relationships; impaired impulse control, such as unprovoked irritability with periods of violence; persistent delusions or hallucinations; neglect of personal appearance and hygiene; and intermittent ability to perform activities of daily living including maintenance of minimal personal hygiene. In addition to the medical evidence, the Veteran’s significant other provided a written statement regarding the Veteran’s PTSD symptoms. This lay evidence is consistent with the medical evidence of record. In considering the evidence of record and resolving all reasonable doubt in the favor of the Veteran, the Board concludes that the Veteran is entitled to a 70 percent evaluation for his service-connected PTSD throughout the appeals period. The medical and lay evidence supports a finding of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The medical evidence supports and finding that the Veteran’s symptomatology has remained consistent throughout the appeals period. The Veteran has consistently reported symptoms that include alcohol and drug usage; depressed mood; anxiety; suspiciousness; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect, disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective work and social relationships; impaired impulse control, such as unprovoked irritability with periods of violence; persistent delusions or hallucinations; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene. Thus, the Board will afford the Veteran the full benefit-of-the-doubt and find that the totality of the evidence favors the assignment of a 70 percent rating for the period on appeal. Although an increased rating of 70 percent is warranted, the evidence of record does not reflect symptoms that would meet the criteria for a 100 percent rating for any period of time during the pendency of the claim. Although the presence or absence of certain symptoms is not dispositive to the issue of the proper disability rating, the presence or absence of symptoms is useful in determining the severity of the condition. There is no evidence of gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. The treatment records and multiple VA examination reports were not indicative of occupational and social impairment that approximate the criteria for a 100 percent. Rather, while the evidence of record demonstrates significant impairment in occupational and social functioning, it does not show total occupational and social impairment to warrant an increased rating of 100 percent. The Veteran has maintained a significant relationship for over 20 years. He has also reported that he rides along to do grocery shopping and assists in the kitchen with cooking. As such, the Veteran’s overall disability picture for PTSD is more closely approximated by a 70 percent rating. The Board notes that the December 2018 examiner documented that the Veteran experiences intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene, as well as persistent delusions or hallucinations; however, the evidence overall does not demonstrate these symptoms were of the severity, frequency, or duration to warrant a finding of total social and occupational impairment. This record is the only time such symptoms appear in the evidentiary record over the long course of the appeal. Further, the Veteran’s other remaining symptoms are either contemplated by or more consistent with a 70 percent disability rating. Additionally, there is no indication in the medical evidence of record that the Veteran’s symptomatology warranted other than the currently assigned 70 percent disability rating throughout the appeal period. Assignment of staged ratings is not warranted. See Hart, supra. Based on the foregoing, the Board finds that the Veteran’s symptoms do not more nearly approximate both total social and total occupational impairment as required to warrant a 100 percent rating for the appellate period. Mauerhan, supra, Vazquez-Claudio, supra. The criteria for the next higher rating of 100 percent have not been met or approximated during this period on appeal. See 38 C.F.R. § 4.130, Diagnostic Code 9411. For all the foregoing reasons, the Board finds that a 70 percent initial rating, but no higher, is appropriate for the entire period on appeal. In reaching this conclusion, the Board has applied the benefit-of-the-doubt doctrine. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2019); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). 6. Entitlement to a higher rating for glaucoma The Veteran is currently assigned a 10 percent rating for his service-connected glaucoma. He contends that a higher rating is warranted. The Veteran’s glaucoma is currently evaluated under DC 6013, applicable to open-angle glaucoma. See 38 C.F.R. §§ 4.79. During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Both the former and revised criteria indicate that a minimum 10 percent rating was warranted if continuous medication was required. Under the former criteria, DC 6013 instructed to evaluate pursuant to visual impairment due to open-angle glaucoma. Under the revised criteria, DC 6013 instructs to evaluate pursuant to the General Rating Formula for Diseases of the Eye. The Board notes that the General Rating Formula for Diseases of the Eye instructs to evaluate a condition based on visual impairment or its rating criteria for incapacitating episodes. Thus, the primary difference between the former and revised criteria is consideration of incapacitating episodes. With regard to visual impairment, the amendments made no substantive changes to how visual acuity is rated. With regard to visual field and muscle function examinations, the use of a Goldmann chart is no longer required. There are otherwise no substantive changes to how those types of visual impairment are rated. Incapacitating Episodes A 10 percent rating is warranted with documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months. A 20 percent rating is warranted with documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months. A 40 percent rating is warranted with documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months. A 60 percent rating is warranted with documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months. For the purposes of evaluation under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. See 38 C.F.R. § 4.79, Note (1). Examples of treatment may include but are not limited to: Systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. See 38 C.F.R. § 4.79, Note (2). Here, the Veteran does not contend, and the evidence does not suggest that his service-connected glaucoma has been productive of incapacitating episodes as defined by the rating criteria. Specifically, the VA examinations of record do not indicate that the Veteran’s glaucoma has been productive of incapacitating episodes. Accordingly, a higher rating is not warranted on the basis of incapacitating episodes. Visual Impairment Visual impairment is rated based on the consideration of three factors: (1) impairment of visual acuity (excluding developmental errors of refraction); (2) visual field; and (3) muscle function. 38 C.F.R. § 4.75(a). Examinations of visual impairment must be conducted by a licensed optometrist or ophthalmologist, and the examiner must identify the disease, injury, or other pathologic process for any visual impairment found. 38 C.F.R. § 4.75(b). Examinations of visual fields or muscle function will be conducted only when there is a medical indication of disease or injury that may be associated with visual field defect or impaired muscle function. Id. A. Muscle Function In this case, Veteran does not contend, and the evidence does not suggest that his service-connected glaucoma has been productive of impairment of muscle function. In fact, VA examinations of record do not indicate that the Veteran’s glaucoma has been productive of impairment of muscle function. Accordingly, a higher rating is not warranted on the basis of impairment of muscle function. B. Visual Acuity As to impairment of visual acuity, evaluations are based on corrected distance vision with central fixation. 38 C.F.R. § 4.76(b)(1). The measurements for each eye are applied to the table for Impairment of Central Visual Acuity. Generally, the table is divided into steps corresponding to different levels of visual acuity for one eye, and each step is further divided into subsections of visual acuity for the other eye, with corresponding ratings. The rater will first locate the step that matches the visual acuity of the poorer eye. Within that step, the rater will then locate the subsection that matches the visual acuity of the better eye, which will produce the corresponding rating. Where a reported visual acuity is between two sequentially listed visual acuities, the visual acuity which permits the higher evaluation will be used. 38 C.F.R. § 4.76(c). In this case, the Veteran appeared for a VA eye conditions examination in November 2014. The Veteran’s best corrected distance visual acuity was 20/40 or better bilaterally. The Veteran most recently appeared for a VA eye conditions examination in November 2018. The Veteran’s best corrected distance visual acuity was 20/50 bilaterally. Diagnostic Code 6066 provides ratings where vision in one eye (the poorer eye) is 10/200 or better. Where the visual acuity in both eyes is 20/50, a 10 percent rating is warranted. Applying these measurements to the table for Impairment of Central Visual Acuity, visual acuity is consistent with a 10 percent rating for the period on appeal. Examinations of record show impairment of visual acuity of, at worst, 20/50 bilaterally, which warrants a 10 percent rating during the period on appeal. See 38 C.F.R. § 4.79, Diagnostic Code 6066. Accordingly, a higher rating is not warranted on the basis of impairment of visual acuity. C. Visual Fields Evaluation of visual field is based on the remaining field of vision in each eye. The examiner must record the remaining visual field of at least 16 meridians 22½ degrees apart for each eye, even though only the visual field at eight principal meridians 45 degrees apart will be used for rating purposes. 38 C.F.R. § 4.77. The table of Ratings for Impairment of Visual Fields provides ratings for visual field loss. The first half of the table provides ratings based on loss of an entire half of field of vision in an eye. The second half of the table provides ratings based on the average concentric contraction of the visual field of each eye. Under 38 C.F.R. § 4.76a, Table III, the normal visual field extent at the 8 principal meridians totals 500 degrees. The normal field for the 8 principal meridians is as follows: 85 degrees temporally; 85 degrees down temporally; 65 degrees down; 50 degrees down nasally; 60 degrees nasally; 55 degrees up nasally; 45 degrees up; and 55 degrees up temporally. The extent of visual field contraction in each eye is determined by recording the extent of the remaining visual fields in each of the eight 45-degree principal meridians. The number of degrees lost is determined at each meridian by subtracting the remaining degrees from the normal visual fields given in 38 C.F.R. § 4.76a, Table III. To calculate average concentric contraction, the rater should add the remaining visual field (in degrees) at each of eight principal meridians 45 degrees apart and divide the sum by eight. 38 C.F.R. § 4.77(b). Homonymous hemianopsia is rated 30 percent. Loss of temporal half of visual field warrants a 30 percent rating if it is bilateral and a 10 percent rating if it is unilateral. Alternatively, this equates to 20/70 vision in each affected eye. Loss of nasal half of visual field warrants a 10 percent rating, whether or not the effect is bilateral or unilateral. Alternatively, this equates to 20/50 vision in each affected eye. Loss of inferior half of visual field warrants a 30 percent rating if it is bilateral and a 10 percent rating if it is unilateral. Alternatively, this equates to 20/70 vision in each affected eye. Loss of superior half of visual field warrants a 10 percent rating, whether or not the effect is bilateral or unilateral. Alternatively, this equates to 20/50 vision in each affected eye. Ratings are also provided for concentric contraction of visual field. Where there is a remaining field of 46 to 60 degrees, a 10 percent rating is warranted for either bilateral or unilateral involvement. Alternatively, this equates to 20/50 vision in each affected eye. Where there is a remaining field of 31 to 45 degrees, a 30 percent rating is warranted for bilateral involvement and a 10 percent rating is warranted for unilateral involvement. Alternatively, this equates to 20/70 vision in each eye. Where there is a remaining field of 16 to 30 degrees, a 50 percent rating is warranted for bilateral involvement and a 10 percent rating is warranted for unilateral involvement. Alternatively, this equates to 20/100 vision in each affected eye. Where there is a remaining field of 6 to 15 degrees, a 70 percent rating is warranted for bilateral involvement and a 20 percent rating is warranted for unilateral involvement. Alternatively, this equates to 20/200 vision in each affected eye. Where there is a remaining field of 5 degrees, a 100 percent rating is warranted for bilateral involvement and a 30 percent rating is warranted for unilateral involvement. Alternatively, this equates to 5/200 vision in each affected eye. The Veteran appeared for a VA eye conditions examination in November 2014. The examiner noted that the Veteran had a visual field defect or a condition that may result in a visual field defect. The examiner determined that the Veteran did have a loss of visual field and a contraction of a visual field was noted. Visual field testing was performed using Goldmann’s equivalent III/4e target; however, the examiner explained that the results were unreliable due to the Veteran’s attention span and/or fixation losses during testing. The examiner determined that the Veteran did not have a scotoma and did not have legal (statutory) blindness based on visual field loss. The Veteran most recently appeared for a VA eye conditions examination in November 2018. The examiner indicated that the Veteran did not have a visual field defect or a condition that may result in a visual field defect. Visual field testing was performed using Goldmann’s equivalent III/4e target. Goldmann visual field testing results, in degrees, for the right eye were as approximately as follows: 55 temporally; 55 down temporally; 40 down; 35 down nasally; 45 nasally; 35 up nasally; 20 up; and 40 up temporally. The total remaining visual field for the left eye is 325. The right eye shows an average contraction to 40.625 degrees. Goldmann visual field testing results, in degrees, for the left eye were as approximately as follows: 60 temporally; 55 down temporally; 45 down; 35 down nasally; 40 nasally; 25 up nasally; 15 up; and 30 up temporally. The total remaining visual field for the left eye is 305. The left eye shows an average contraction to 38.125 degrees. Applying these foregoing measurements to the table of Ratings for Impairment of Visual Fields, the Veteran’s visual field defects are consistent with a 30 percent rating for the period on appeal. Average concentric contraction measured, at worst, 41 degrees in the right eye and 38 degrees in the left eye, which warrants a 30 rating. See 38 C.F.R. § 4.79, Diagnostic Code 6080. The Board notes that throughout the pendency of the appeal, a 0 percent rating for decreased visual acuity is warranted, as well as a 30 percent rating for visual field defects. To determine the evaluation for visual impairment where, as here, both decreased visual acuity and visual field defect are present in one or both eyes, the visual acuity and visual field defect (expressed as a level of visual acuity) are to be separately evaluated and then combined under the provisions of § 4.25. See 38 C.F.R. § 4.77(c). When combined, as directed by the rating schedule, the total evaluation for the Veteran’s visual impairment warrants an overall evaluation of 40 percent. Thus, affording the Veteran the full benefit of the doubt, the Board finds that the totality of the evidence favors the assignment of a 40 percent rating, but no higher, for glaucoma throughout the appeal period. Although an increased rating of 40 percent is warranted, the evidence of record does not reflect symptoms that would meet the criteria for a higher rating for any period of time during the pendency of the claim. A higher rating for the Veteran’s glaucoma is not warranted without a showing of worsened visual acuity, greater visual field loss or some impairment of muscle function. Without such evidence, an evaluation in excess of 40 percent cannot be granted. Additionally, there is no indication in the medical evidence of record that the Veteran’s symptomatology warranted other than the now assigned 40 percent disability rating throughout the appeal period. Assignment of staged ratings is not warranted. See Fenderson, supra. Accordingly, the Board finds that the Veteran’s glaucoma warrants a 40 percent rating throughout the appeals periods, but that the claim of entitlement to a disability rating in excess of 40 percent must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim of entitlement to an increased rating, beyond that assigned herein, that doctrine is not applicable. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2018); see also Ortiz, supra. 7. Entitlement to a TDIU Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Where these percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the veteran is unable to secure and follow a substantially gainful occupation by reason of service- connected disabilities. 38 C.F.R. § 4.16(b). The central inquiry is, “whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran’s education, special training, and previous work experience, but not to his age or to the impairment cause by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In order for a Veteran to prevail in his claim for TDIU, the record must reflect circumstances, apart from non-service-connected conditions, that place him in a different position than other Veterans who meet the basic schedular criteria. The sole fact that a Veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question is whether the Veteran, in light of his service-connected disorders, is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Van Hoose, 4 Vet. App. at 361. Here, the Veteran is service-connected for PTSD, now rated 70 percent disabling; chronic bronchitis, rated 60 percent disabling; glaucoma, now rated 40 percent disabling; residuals of laceration, posterior left leg, status-post surgical reattachment of peroneal nerve, with neuropathy, rated 10 percent disabling; scar, sutured laceration, right scalp, rated 10 percent disabling; scar, sutured laceration over right eye, rated 10 percent disabling; scar, sutured laceration, dorsum of right wrist, rated 10 percent disabling; tinnitus, rated 10 percent disabling; pseudofolliculitis barbae, rated 0 percent disabling; and right ear hearing loss, rated 0 percent disabling. Hence, the Veteran meets the schedular criteria for TDIU rating per 38 C.F.R. § 4.16(a). However, the evidence must still show that the Veteran is unable to pursue a substantially gainful occupation due to his service-connected disabilities in order to be entitled to a TDIU. The evidence of record indicates that the Veteran obtained a General Education Diploma (GED), though there is no evidence of additional specialized education or training. The record reflects that the Veteran was last employed in January 2008 for Columbia VAMC as a housekeeper. The Veteran appeared for a VA eye conditions examination in November 2014. The examiner indicated that Veteran’s eye condition did not impact his ability to work. The Veteran also appeared for a VA PTSD examination in November 2014. The Veteran reported that he was not currently working. He indicated that his last period of employment was at VA in 2007. He reported that his was fired for not showing up to work on time and not showing up for work at a time he thought he was off. The Veteran appeared for a VA respiratory conditions examination in February 2015. The examiner indicated that Veteran’s respiratory condition impacted his ability to work, as the Veteran reported that the condition limited his ability to do physical labor. The Veteran appeared for a VA hearing loss and tinnitus examination in November 2018. The examiner indicated that Veteran’s hearing loss impacted his ability to work, as the Veteran reported difficulty understanding conversations in a group setting. He also reported difficulty locating where sounds are coming from. His tinnitus also made it harder to hear at times. The Veteran appeared for another VA eye conditions examination in November 2018. The examiner indicated that Veteran’s eye condition did not impact his ability to work. A private PTSD examination report was associated with the Veteran’s claims file in December 2018. Dr. H. H.-G. indicated that the Veteran could not sustain the stress from a competitive work environment or be expected to engage in gainful activity due to PTSD. The Veteran reported not getting enough restful sleep and feeling fatigued daily. He also reported difficulty remembering events, requests, and forgetting details or sequencing. He has difficulty maintaining and sustaining a steady mood. He also feels nervous and worried and struggles with ongoing anxiety issues. The reviewer stated that the Veteran’s poor interpersonal skills and workplace trust issues would cause an increase in paranoia and affect appropriate work interaction. The Veteran also had physical signs of depression that interfered with daily work, such as extreme fatigue, hypersomnia, appetite issues, weight fluctuation, and emotional outbursts. In light of the significant occupational restrictions and limitations, specifically those laid out by Dr. H. H.-G., the Board is satisfied that the evidence of record shows that the Veteran’s service-connected disabilities would render him unemployable in either a physical or sedentary environment. See Geib v. Shinseki, 733 F.3d 1350 (2013) (held that determination of whether a Veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the RO). The Veteran’s last period of gainful employment ended in 2008. There is no evidence of any type of special training. The Veteran’s work history of record has consisted of employment as a cook, deliveryman, and housekeeper. Even if the Veteran had special training or advanced education, the medical and lay evidence of record documents significant symptoms that would impair employment, such as depression; anxiety; forgetfulness; paranoia; fatigue; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; and inability to establish and maintain effective work and social relationships. In considering all of the Veteran’s service-connected disabilities and affording him the benefit of the doubt, the Board finds that there is sufficient evidence that the Veteran is unemployable due solely to his service-connected disabilities. The criteria for a TDIU have been met. 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS FOR REMAND 8. Entitlement to service connection for left ear hearing loss The Veteran contends that his left ear hearing loss is causally related to service. The Veteran most recently appeared for a VA hearing loss examination in November 2018. The examiner opined that the Veteran’s left ear hearing loss was less likely than not a result of military noise exposure. In so finding, the examiner indicated that the Veteran’s left ear hearing thresholds were within normal limits at the time of enlistment in March 1981 and upon separation in January 1994, without a significant shift or permanent decrease during service. The examiner explained that if hearing thresholds are normal or there is no evidence of permanent threshold changes during military service, there is no direct evidence of a link between the current hearing loss and in-service events. The examiner further explained that the Veteran reported post-service occupational noise exposure. As such, he opined that the Veteran’s intense occupational noise exposure was likely related to his current left ear hearing loss. Unfortunately, the Board finds the November 2018 VA hearing loss examination to be inadequate for adjudication purposes. The examiner appeared to base the negative opinion on an absence of hearing loss findings or complaints at enlistment and at discharge from service. The Board notes that service connection for hearing loss is not precluded where hearing was within normal limits on audiometric testing at separation from service. See Hensley v. Brown, 5 Vet. App. 155, 160 (1993). Thus, the Board finds that a remand is necessary to provide the Veteran with a new VA examination to determine the nature and etiology of his left ear hearing loss. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 9. Entitlement to a higher rating for chronic bronchitis The Veteran is seeking a higher evaluation for his service-connected chronic bronchitis. The most recent VA respiratory conditions examination of record was conducted in February 2015. Notably, the November 2018 statement of the case (SOC) and December 2018 rating decision reference a July 28, 2018 VA examination. However, this report is not of record, which indicates that there may be outstanding pertinent VA medical records. Upon remand, an attempt must be made to obtain the November 2018 examination report. See 38 U.S.C. § 5103A(c) (2012); Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency and must be obtained if pertinent). Alternatively, if a VA respiratory conditions examination was not conducted in July 2018 or a copy of the examination report is not available, the Veteran must be afforded a new VA examination to ascertain the current severity of his service-connected chronic bronchitis, as it has been more than four years since his last examination. Green v. Derwinski, 1 Vet. App. 121 (1991); Caffrey v. Brown, 6 Vet. App. 377 (1994); 38 C.F.R. § 3.326(a) (2019). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with the appropriate examiner to address the nature and etiology of his left ear hearing loss. The examiner must review pertinent documents in the Veteran’s claims file in conjunction with the examination. This must be noted in the examination report. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. (a.) The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that a current left ear hearing loss disability was incurred in service or are otherwise medically related to service, to include noise exposure therein. The examiner is advised that in-service noise exposure has been established. The examiner is further reminded that normal hearing at separation is not, in and of itself, sufficient rationale to conclude that any current hearing loss is not related to in-service noise exposure. 2. Obtain the July 28, 2018 VA examination report and associate it with the record. 3. If, and only if, VA respiratory conditions examination was not conducted in July 2018 or a copy of the examination report is not available, schedule the Veteran for VA examination with the appropriate examiner to determine the current severity and manifestations of the Veteran’s service-connected chronic bronchitis. The claims folder must be made available to the examiner for review in connection with the examinations. The examination report must reflect that such a review was conducted. All necessary testing must be performed. (a.) The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Joseph, 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.