Citation Nr: 20004837 Decision Date: 01/23/20 Archive Date: 01/21/20 DOCKET NO. 16-60 649 DATE: January 23, 2020 ORDER Entitlement to a 70 percent rating, but not higher, for posttraumatic stress disorder (PTSD) is granted, subject to the laws and regulations governing the award of monetary benefits. REMANDED The issue of entitlement to service connection for obstructive sleep apnea (OSA) is remanded. The issue of entitlement to service connection for gastroesophageal reflux disease (GERD), including as due to environmental hazards in the Persian Gulf Conflict, is remanded. The entitlement to a compensable evaluation for hearing loss of the right ear is remanded. The entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU rating) is remanded. FINDING OF FACT The evidence demonstrates that the Veteran’s symptoms of PTSD, standing alone and irrespective of nonservice-connected psychiatric disability, are productive of no more than symptoms causing occupational and social impairment with deficiencies in most areas and to not approximate total occupational and social impairment. CONCLUSION OF LAW The criteria for a 70 percent rating, but not higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.1-4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from February 1988 to January 1993 in the Army. His DD 214 shows that his military occupational specialty was a cannon crewmember, and that he served in Southwest Asis from January 1991 to June 1991. His military decorations include the Kuwait Liberation Medal, and the Southwest Asia Service Medal with 3 bronze Service Stars. It also shows that he was a high school graduate or equivalent. This matter comes before the Board of Veterans’ Appeals (Board) from rating decisions of a Department of Veterans Affairs (VA) Regional Office. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a September 2019 videoconference. A transcript thereof is on file. The Veteran is service-connected for: PTSD, rated 50 percent; and noncompensable evaluations are assigned for tinnitus; postoperative (PO) residuals of an inguinal hernia with surgical scar; residuals of an injury of the distal phalanx of the right 3rd finger; and hearing loss of the right ear. There is a combined disability evaluation of 60 percent. Background The Veteran was afforded a VA psychiatric examination on June 6, 2016, to evaluate his PTSD, at which time his VA e-folder was reviewed. The examiner noted that diagnoses which were relevant to understanding or management of mental health disorder were hyperlipidemia, tinnitus, hypothyroidism, degenerative disc disease, hypertension, osteoarthritis, and GERD. It was reported that the Veteran had only one mental disorder, which was PTSD. The examiner reported that the best summary of the Veteran’s level of occupational and social impairment was occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. It was noted that the Veteran lived with his wife of eight years. He reported experiencing irritability all the time and was easily angered. He also had a lot of nightmares. He stated he was not very close to his two sons, and that he might talk with them every six months. He did not have much contact with extended family members. He did not have any close friends outside of his family. He related having been really depressed for the last 4 or 5 years, and had been having anxiety attacks. He preferred to stay at home. He would have racing thoughts and would seat. Anxiety attacks occurred about every day, sometimes lasting 20 minutes and sometimes last an hour. It was usually stress which precipitated an anxiety attack. He stated that he did not have any particular recreational interests, and spent most of his time at home. The Veteran reported that he was currently unemployed, having last worked at a coal mine in May 2015, where he had worked for 21 years. He had stopped working because of a lot of problems with his neck, back, and knees. He reported that he had some interpersonal problems with people at work, but he but reported generally adequate reliability and productivity from a mental health perspective. He received individual counseling at the VA Medical Center in Beckley. He was currently prescribed Hydroxyzine, Praozsin, and Sertraline. Regarding current symptoms, the Veteran reported that he experienced trauma dreams "at least four or five times a week," and stated that he was awake for approximately 45 minutes to an hour after the dreams occurred. He reported experiencing intrusive, trauma-related thoughts "at least twice a day," and stated, "I just feel lost and helpless." He related that he did not watch violence on TV but also stated that he did not avoid any specific trauma-related cues otherwise. He reported that he experienced a depressed mood "every day," and reported tearfulness that occurs "every day." He indicated that he experienced feelings of worthlessness and hopelessness a lot. He denied suicidal ideation. He reported anxiety and irritability. He stated he had mild difficulty concentrating, and that he had a lot of short-term memory loss. He reported that his appetite had decreased, and that he usually did not eat a lot during the day. He had been arrested twice, once for an altercation with a neighbor and a second time for drinking, in 2003. The Veteran related using alcohol occasionally, to help his nerves but had not drank to the point of intoxication in a number of years, and denied any recent negative consequences of alcohol use. As to the criteria for a diagnosis of PTSD, the examiner reported that the Veteran had recurrent, involuntary, and intrusive distressing memories of traumatic event(s) and recurrent distressing dreams. He had intense or prolonged psychological distress at exposure to cues of past trauma. He avoided or attempted to avoid distressing memories, thought or feelings associated with past trauma as well as external reminders thereof. He had a persistently negative emotional state and markedly diminished interest or participation in significant activities. He had irritable behavior and angry outbursts, problems with concentration, and sleep disturbance. The PTSD symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance was not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. As to symptoms, the Veteran had a depressed mood; anxiety; panic attacks more than once a week; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; and difficulty in establishing and maintaining effective work and social relationships. Behaviorally, the Veteran was alert and fully oriented. His psychomotor activity was unremarkable. He was cooperative and friendly. His thought processes were unremarkable. As to thought content, this focused on re-experiencing traumatic events. He denied suicidal and homicidal ideation. His speech was within normal limits. He had no perceptual abnormalities. His mood was depressed. His affect was appropriate, and his insight and judgment were adequate. The examiner reported that the Veteran was capable of managing his financial affairs. The examiner, a psychologist, reported that psychological testing revealed a symptoms profile which was valid and consistent with: subjective depression, psychomotor retardation, physical limitations, somatic concerns, difficulty concentrating, negative rumination, low energy, and social avoidance. The Veteran underwent a VA psychiatric examination for evaluation of PTSD on April 28, 2017, to evaluate his PTSD, at which time his VA e-folder was reviewed. The examiner noted that diagnoses which were relevant to understanding or management of mental health disorder were hypertension, hyperlipidemia, chronic low back pain, and left knee pain. He walked with a cane. The examiner reported that the Veteran had two diagnosed psychiatric disorders, which were PTSD and an unspecified depressive disorder. The examiner reported that it was possible to differentiate which symptoms were attributable to each diagnosis. As to PTSD, the Veteran had PTSD relating to the Desert Storm. He was involved with heavy fighting with the 3rd armored division as a cannon crewmember. He had been to Saudi Arabia, Kuwait and Iraq. He was exposed to the SCUDS, sirens of chemical attack, bombings and firefights. He had had anxiety, intrusive thoughts, and dreams. He reported that he got tired and slept quite a bit, i.e., about 14 hours in 24 hours. He stated that medications helped him; otherwise, he would have had issues of hitting wife in his sleep, as before. He reported having anxiety and panic attacks, irritability and difficulty getting along with people, and social difficulties. He indicates his symptoms had increased since he retired. It was reported that the Veteran had an unspecified depressive disorder due to his PTSD, which related to problems with mood and energy, he did not feel like getting involved in hobbies, and had had a lack of motivation. He used to golf and fish in the past but had not done it since 2015. He had not entertained suicidal thoughts due to his religion. The examiner reported that the best summary of the Veteran’s level of occupational and social impairment was occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner reported that it was possible to differentiate what portion of the occupational and social impairment indicated above was caused by each mental disorder, with 2/3rds caused by PTSD and 1/3rd caused by the unspecified depressive disorder. It was reported that the Veteran had had two sons from his first marriage which was from 1988 to 2002 but none from his second marriage of one year, and none from his current third marriage. He used to fish and golf in the past but had not done that since 2015 due to lack of motivation. He did not have good relationship with his children because of their mother. He had a high school education but no college education. He had worked in hydraulics for 3 years and in coal mines for 21 years but quit in 2015 due to back, knee and PTSD related issues. He had applied for “SSD.” He was on VA prescribed medications, including “sertraline, hydroxyzine and trazodone.” He had not had any psychiatric hospitalizations. It was reported that he had no problems with alcohol or drugs. As to the criteria for a diagnosis of PTSD, the examiner reported that the Veteran had recurrent, involuntary, and intrusive distressing memories of traumatic event(s) and recurrent distressing dreams. He had marked physiological reactions to internal or external cues of past trauma. He avoided or attempted to avoid distressing memories, thought or feelings associated with past trauma as well as external reminders thereof. He had markedly diminished interest or participation in significant activities. He had feelings of detachment or estrangement from others. He had a persistent inability to experience positive emotions. He had marked alterations in arousal and reactivity associated with past trauma, including exaggerated startle response, concentration problems, and sleep disturbance. These symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance was not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. As to symptoms, the Veteran had a depressed mood; anxiety; panic attacks more than once a week; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; difficulty in establishing and maintaining effective work and social relationships; flattened affect, disturbance of mood and motivation; and difficulty adapting to stressful circumstance, including work or a work-like setting. Behaviorally, the Veteran was well oriented. His mood was dysthymic, and his affect was anxious and worried. He had no suicidal or homicidal thoughts. He had no delusions or hallucinations. He had age appropriate memory, insight and judgement. He was capable of managing his financial affairs. The examiner commented that continued to have issues with his PTSD affecting him in his social and occupational functioning in a negative manner. He had quit work in 2015 due to mental health and physical health issues. He indicated that his symptoms had subsequently increased. The current level of severity of his PTSD was moderate to severe. The effect of the Veteran's the disability on his ability to function in an occupational environment was moderate to severe due to the identified functional limitations of mood, anxiety, irritability, socialization issues, mood, concentration issues, and difficulty coping with stress. A report of a Disability Benefits Questionnaire – Initial PTSD, apparently conducted on January 14, 2018, at which time his VA e-folder was reviewed. The examiner reported that the Veteran had two psychiatric diagnoses, which were PTSD and schizoaffective disorder depressive type. It was reported that it was possible to differentiate what symptoms were attributable to each disorder, and that the schizoaffective disorder was manifested by hallucinations, delusions, and depression. His level of occupational and social impairment with regards to “all” psychiatric disorders was total occupational and social impairment. However, it was possible to differentiate what portion of occupational and social impairment was caused by each disorder, with PTSD causing 80 percent and the schizoaffective disorder depressive type causing 20 percent. He was capable of managing his financial affairs. Essentially no personal or clinical history was reported. The Veteran met the criteria for PTSD by virtue of having the following symptoms. He had intrusive symptoms of recurrent memories and dreams of past trauma; dissociative reactions, e.g., flashback; intense or prolonged distress on exposure to cues of past trauma, and marked physiological reactions to such exposures. As to avoidance of stimuli associated with past trauma, he avoided, or tried to avoid, external reminders and distressing memories, thoughts for feelings of past trauma. As to negative alterations in cognition and mood, he had an inability to remember important aspects of past trauma. He had persistent and exaggerated negative beliefs or expectations of himself or other; persistent distorted cognitions of the cause or consequences of past trauma; persistent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement; and persistent inability to experience positive emotions. As to marked alterations in arousal or reactivity, he had irritable behavior and angry outbursts; reckless or self-destructive behavior; hypervigilance; exaggerated startle response, problems with concentration; and sleep disturbance. On mental status evaluation, the Veteran had a depressed mood. He had anxiety and suspiciousness. He had panic attacks more than once a week. He had near-continuous panic or depression affecting the ability to function independently, appropriately and effectively. He had mild memory loss, e.g., forgetting names, directions or recent events. He had difficulty understanding complex commands. He had impaired abstract thinking. He had disturbances of motivation and mood. He had difficulty adapting to stressful circumstances, including work or a work-like setting. He had an inability to establish and maintain effective relationships. He had persistent delusions or hallucinations. The Veteran did not have memory loss for names of close relative, his occupation, or his own name. He did not have a flattened affect, or speech which was circumstantial, circumlocutory or stereotyped. His speech was not intermittently illogical, obscure or irrelevant. He did not have gross impairment in thought processes or communication. He did not have difficulty establishing and maintaining effective work and social relationships. He did not have suicidal ideation or obsessional rituals that interfered with routine activities. He did not have impaired impulse control, e.g., unprovoked irritability with periods of violence. He did not have spatial disorientation or grossly inappropriate behavior. He was not a persistent danger for hurting himself or others. He did not neglect his personal appearance or hygiene and he was not disorientated as to time or place. He did not have the intermittent inability to perform activities of daily living. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a September 2019 videoconference. As to the claim for an increased rating for PTSD, the Veteran’s attorney stated that the April 2017 VA psychiatric examination supported the assignment of a 70 percent disability rating. Page 3. It was stated that he was diligent in seeking VA treatment at the Beckley VA Medical Center. The Veteran testified that he received VA treatment for PTSD monthly and his saw a physician for renewal of his PTSD medications every three (3) months. Page 5. As to symptoms and impact of his PTSD, the Veteran testified that he had nightmares and was isolated. Page 5. He also had anxiety. Page 6. The Veteran testified that when in public he sometimes felt that people were watching him. Page 6. When he had anxiety, he broke out in a sweat. Page 9. His nightmares caused sleeping difficulties. Page 11. He went out in public once or twice a week. Page 11. He only received treatment for PTSD at the VA Medical Center in Beckley. Page 12. He was not sociable and did not get out very much. Page 13. He did not associate with friends that he used to have. Page 14. He had anger issues. Page 15. Rating Principles Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Veteran's PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411 which uses a general rating formula for the evaluation of mental disorders. Under 38 C.F.R. § 4.126 (a) and (b) consideration is given to the frequency, severity, and duration of psychiatric symptoms as well as the length and capacity for adjustment during periods of remission. While consideration is given to the extent of social impairment, a psychiatric rating will not be assigned solely on the basis of social impairment. Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). 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 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that 38 C.F.R. § 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 symptoms listed in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list, but rather 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). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) in Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013), however, noted the "symptom-driven nature" of the General Rating Formula, observed 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." Under Diagnostic Code 9411 a 50 percent disability rating is warranted for PTSD when the Veteran experiences 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating contemplates 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. “VA did not include in the criteria for a 70% evaluation the risk of actual self-harm. In fact, to the extent that risk of self-harm is expressly mentioned in § 4.130 at all, it is referenced in the criteria for a 100% evaluation as ‘persistent danger of hurting self, a symptom VA deemed to be typically associated with total occupational and social impairment. 38 C.F.R. § 4.130.” However, VA adjudicators are not “absolutely prohibited from considering [] risk of self-harm in assessing [a] level of occupational and social impairment” but there must be a differentiation between suicidal ideation, which is generally indicative of a 70% evaluation, and a risk of self-harm, the persistent danger of which is generally indicative of a 100% evaluation. Bankhead, slip op. at 12. A total schedular rating of 100 percent is warranted when the disorder results in 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 mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The Board must determine whether the weight of the evidence supports each claim or is in relative equipoise, with the appellant prevailing in either event. However, if the weight of the evidence is against the appellant’s claim, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.7; Gilbert v. Derwinski 1 Vet. App. 49 (1990). Analysis The 2017 VA examination shows that the Veteran complained of having anxiety attacks about every day. However, he had only mild memory loss, e.g., forgetting names, directions or recent events, his thought processes were unremarkable, his affect was appropriate, and he was alert and fully oriented. Significantly, the examiner found that the overall impairment was such as to cause only occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks and that he generally functioned satisfactorily. This is not indicative of entitlement to a higher rating. The April 2017 psychiatric examination found that the Veteran had PTSD and also had an unspecified depressive disorder. Although the examiner reported that symptoms, and thus impairment, of the two disorders could be differentiated, with 2/3rd of the impairment being due to PTSD, it was also stated that the unspecified depressive disorder as due to the service-connected PTSD. Thus, the symptoms and impairment due to both disorders must be considered for rating purposes. The 2017 examiner concluded that the two disorders caused occupational and social impairment with deficiencies in most areas, e.g., family relations, work, thinking or mood. This is consistent with the criteria for a 70 percent disability rating. As to this, the Veteran’s depressed mood is also consistent with a 70 percent rating, as is the Veteran’s estrangement from his children. The Board must note that the January 2018 examination indicated that the Veteran had two psychiatric disorders. Specifically, PTSD and a nonservice-connected schizoaffective disorder of depressive type. That examiner stated that it was possible to differentiate the symptoms attributable to but did not state that the schizoaffective disorder of depressive type was due to or caused by the service-connected PTSD. Further, it was stated that the symptoms of the schizoaffective disorder were hallucinations and delusions but, while the nature and form of the hallucinations and delusions were not described, these are not characteristic of PTSD. Thus, while that examiner concluded that the overall occupational and social impairment due to both disorders was total impairment it was further stated that the PTSD caused 80 percent, and the schizoaffective disorder caused 20 percent of the overall occupational and social impairment. Based on this, the Board must conclude that the Veteran’s PTSD alone is not production of total occupational and social impairment which would warrant a 100 percent schedular evaluation. As to this, the evidence does not demonstrate that the Veteran has had 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 mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Accordingly, after favorably resolving all doubt, the Board finds that since the Veteran’s April 28, 2017, VA psychiatric examination his PTSD has more closely approximated the scheduler criteria for no more than a 70 percent disability rating. REASONS FOR REMAND 1. The issue of entitlement to service connection for OSA is remanded. Here, the record shows that the Veteran was first diagnosed as having OSA in 2015, many years after service. At separation from active service in December 1992 he weighed 165 lbs. and denied trouble sleeping. Post-service clinical records show that the Veteran did gain some weight. Significantly, however, beginning many years after service he has been prescribed Synthroid for his thyroid disfunction. This indicates that the Veteran had hypothyroidism and the Board notes that weight gain can be a manifestation of hypothyroidism. At the 2019 Board videoconference the Veteran’s attorney stated that the Veteran was now treated for OSA by using a CPAP machine. It was alleged that his OSA was either secondary to his PTSD, or secondary to medication for PTSD, or that medication for PTSD caused obesity which in turn caused OSA. Pages 3 and 21. The Veteran testified that no one had ever told him that medications for his PTSD could cause sleep apnea. Page 19. He testified that he had been given a CPAP machine by VA and had used it since about November 2015. Page 19. Following the 2019 Board videoconference the Veteran’s attorney submitted an article from the Internet addressing a reported connection between PTSD and OSA. That article stated that there was a link between PTSD and sleep apnea. Research had found that Iraq and Afghanistan veterans evaluated for PTSD had a 69.2 percent higher risk for developing sleep apnea. It also stated that, typically, one of the biggest risk factors for sleep apnea was excessive weight, bur research was needed to determine exactly why PTSD was linked with sleep apnea. That article also contained a hyperlink to another article, i.e., https://www.sleepfoundation.org/articles/how-medications-can-affect-sleep which addressed how medications could affect sleep. Therein, it was stated that many prescription and over-the-counter (OTC) drugs could impact sleep. Some could cause insomnia, some could disrupt sleep, and some caused drowsiness. It was also stated that “[s]ome antidepressants and anti-anxiety medications can make you feel sluggish.” Thus, the Veteran should be afforded an examination to determine whether his OSA is due to his military service, including any reported exposure to toxins or smoke from burning oil wells, and whether his OSA (a) was caused or aggravated by his PTSD; (b) was caused or aggravated by any medication for PTSD; (c) whether medication for PTSD caused obesity which in turn caused OSA; (d) whether nonservice-connected thyroid dysfunction, including any hypothyroidism, caused or aggravated obesity which in turn caused OSA; and (e) whether any medication, i.e., Synthroid, for nonservice-connected thyroid dysfunction, including any hypothyroidism, caused or aggravated obesity which in turn caused OSA. 2. The issue of entitlement to service connection for GERD, including as due to environmental hazards in the Persian Gulf Conflict, is remanded. The Veteran was afforded a VA examination on January 17, 2018, for evaluation of his claimed GERD, at which time his VA e-folder was reviewed. It was reported that the Veteran had been diagnosed as having a hiatal hernia in 2013. The Veteran reported that he had developed acid reflux, i.e., heart burn and indigestion, for last 5 years and it had been getting worse. He mentioned that he had an esophago duodenoscopy (EGD) at Beckley VA Medical Center in 2915 and it documented a hiatal hernia. He had been taking Omeprazole 20mg twice daily and it helped. The examiner reported that the Veteran had the following signs and symptoms of GERD: persistently recurrent epigastric distress; infrequent episodes of epigastric distress; dysphagia; pyrosis; reflux; regurgitation; and substernal chest pain. He did not have an esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. It was reported that a December 2015 upper endoscopy had revealed a hiatal hernia with duodenitis. In response to the query of whether the Veteran had have a diagnosis of GERD that was at least as likely as not (50 percent or greater probability) incurred in or caused by military service, the examiner stated that the claimed condition was less likely than not (less than 50% probability) incurred in or caused by the inservice injury, event or illness. The examiner was requested to explain whether the Veteran’s disability was (1) an undiagnosed illness, (2) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis. In response, the examiner stated that the Veteran’s hiatal hernia was a disease with a clear and specific etiology and diagnosis. It was reported that the service treatment records revealed that the Veteran he had no diagnosis of GERD, or treatment for it, during service. His past EGD had revealed a hiatal hernia with duodenitis, which was a structural disorder, and not functional. Therefore, his hiatal hernia (causing GERD) was a disease with a clear and specific etiology and diagnosis. He also diagnosed with GERD in 2013 and this was far removed from his service discharged in January 1993. His symptoms of GERD were more likely due to his hiatal hernia and duodenitis. The Veteran testified at the videoconference that no one had ever told him that medications for his PTSD could cause GERD. Page 20. However, attorney alleged at the videoconference that service connection for GERD was claimed as secondary to medications for PTSD. Page 4. The Board also notes that the Veteran testified that he had had GERD ever since being overseas in Iraq, having been around oil well fires and the smoke from the fires had caused difficulty breathing as well as a burning sensation in his throat and chest. Pages 24 and 25. Although the VA examination on January 17, 2018, addressed theories of entitlement to service connection which had been alleged as of that time, it is clear that the allegations of additional theories of entitlement to service connection, requires that an addendum to the January 2018 examination be obtained which addresses these newly asserted theories of entitlement. 3. The issue of entitlement to a compensable evaluation for hearing loss of the right ear is remanded. At an April 2017 VA psychiatric examination, it was noted that the Veteran wore hearing aids. At the September 2019 Board hearing, the Veteran, through his attorney, averred that his hearing loss in the right ear had increased in severity since his last VA audiological rating examination in 2016. Page 3. He testified that he now had to read lips. Page 18. The Court has held that where the Veteran claims that a disability is worse than when originally rated, and the available evidence is too old to adequately evaluate the current state of the condition, VA must provide a new examination. See Olsen v. Principi, 3 Vet. App. 480, 482 (1992), citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992); see also Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991) (observing that where the record does not adequately reveal the current state of the claimant's disability, a VA examination must be conducted). Thus, the Veteran should be afforded an up-to-date VA audiology examination to evaluate the severity of his service-connected hearing loss in the right ear. 4. The issue of entitlement to a TDIU rating is remanded. The attorney stated at the videoconference that the Veteran had been granted Social Security Administration (SSA) benefits. Page 4 of the transcript. The Board notes that SSA records are on file. The Veteran testified that he had stopped working in 2015, after having work in the coal mining industry for 22 years. Page 15. He stated that his psychiatric disorder had affected him at work, due to a lot of anxiety and depression, but he did not get into conflicts with co-workers. Page 16. He had anxiety attacks at work because he had to fill out a lot of paperwork. Page 17. He also testified that he had 2 years of work experience at a hydraulic shop. Page 20. He had done more paperwork than actual mining of coal. Page 28. However, the Veteran also testified that he had left his job in the coal mining industry due to anxiety as well as problems with his knees, neck, and back. Page 33. A TDIU rating is warranted in the absence of less than a total schedular rating when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Here, in light of the grant of a 70 percent schedular rating for PTSD, the Veteran now meets the schedular criteria for a TDIU, but it may only be awarded if his service-connected disabilities, irrespective of any advancing age and impairment from nonservice-connected disorders precludes securing or following a substantially gainful occupation. However, the RO has not yet had the opportunity to adjudicate, in light of the grant of a 70 percent rating for PTSD and meeting the schedular criteria within 38 C.F.R. § 4.16(a), whether the Veteran’s service-connected disabilities preclude securing or following a substantially gainful occupation. Also, any potential grant of service connection for OSA or GERD could impact upon a determination as to entitlement to a TDIU rating. Thus, for these reasons, the RO must first be allowed to readjudicate the claim for a TDIU rating. The matters are REMANDED for the following action: 1. Afford the Veteran a VA examination for the purpose of determining, if possible, the etiology of his claimed OSA. The examiner should have access to the Veteran’s VA electronic claim file. The examiner should be requested to render an opinion as to the following: * is the Veteran’s OSA due to his military service, including any reported exposure to toxins or smoke from burning oil wells, and whether his OSA? * is the Veteran’s OSA caused or aggravated by his PTSD? * is the Veteran’s OSA caused or aggravated by any medication for PTSD? * is the Veteran’s OSA caused or aggravated by medication for PTSD caused obesity which in turn caused OSA? * is the Veteran’s OSA caused or aggravated by nonservice-connected thyroid dysfunction, including any hypothyroidism? * is the Veteran’s OSA caused or aggravated by any medication, i.e., Synthroid, for nonservice-connected thyroid dysfunction, including any hypothyroidism, caused or aggravated obesity which in turn caused OSA? If the examiner cannot respond without resort to speculation, he or she should so state, and explain why it is not feasible to provide a medical opinion. 2. Return the case to the examiner that conducted the January 17, 2018, VA examination for an addendum opinion. If for any reason that examiner is not available, return the case to another VA clinician for an addendum opinion. An opinion should be expressed as to whether any hiatal hernia or any GERD which the Veteran now has was caused or aggravated by (a) inhalation of smoke from burning oil wells in the Persian Gulf Conflict; and (b) whether any hiatal hernia or any GERD which the Veteran now has was caused or aggravated by any medication for service-connected PTSD. If the examiner cannot respond without resort to speculation, he or she should so state, and explain why it is not feasible to provide a medical opinion. 3. Schedule the Veteran for a VA audiological examination to determine the current level of severity of his service-connected hearing loss of the right ear. The Veteran’s electronic medical records should be made available to and be reviewed by the examiner, if needed. Any tests or studies deemed necessary should be conducted, to specifically include audiometric testing, and the results should be reported in detail. The examiner must also fully describe the functional effects caused by the Veteran's hearing disability. If the auditory thresholds from the current examination differ significantly from the results of other tests, the VA examiner should explain the reason why there is a difference, if possible. 4. After the development requested above has been completed, the record should again be reviewed, and the claims addressed herein should be readjudicated. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished with a Supplemental Statement of the Case (SSOC) and be given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Fussell, 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.