Citation Nr: 20005679 Decision Date: 01/23/20 Archive Date: 01/23/20 DOCKET NO. 17-28 397 DATE: January 23, 2020 ORDER Entitlement to an initial 70 percent rating, but no higher, from August 6, 2015, for posttraumatic stress disorder (PTSD) with depressive disorder and alcohol dependence is granted, subject to controlling regulations governing the payment of monetary awards. REMANDED Entitlement to service connection for left pointer finger disability is remanded. Entitlement to service connection for respiratory disability is remanded. Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD with depressive disorder and alcohol dependence, is remanded. Entitlement to service connection for nasal disability is remanded. Entitlement to service connection for dental disability for compensation purposes is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REFERRED The Veteran’s October 2015 claim of service connection for dental disability encompasses the issue of entitlement to service connection for dental disability for treatment purposes. See Mays v. Brown, 5 Vet. App. 302 (1993). See also 38 C.F.R. § 3.381 (VBA will adjudicate a claim for service connection for a dental condition for treatment purposes after the VHA determines the Veteran meets the basic eligibility requirements and requests that VBA make a determination of certain questions). Regarding dental claims, the regional office (RO) adjudicates the claim of service connection for compensation benefits and the VA Medical Center (VAMC) adjudicates the claim for outpatient treatment. As this matter stems from an adverse determination by the RO, the appeal is limited to the issue of service connection for dental disability for the purpose of compensation. The claim of service connection for dental disability for the purpose of obtaining VA outpatient dental treatment is referred to the appropriate VAMC for adjudication. FINDING OF FACT Since the August 6, 2015 effective date of service connection, the Veteran’s PTSD with depressive disorder and alcohol dependence has been manifested by occupational and social impairment with deficiencies in most areas, such as work, family relations, judgement, thinking, and mood; symptoms have not more nearly approximated both total social and occupational impairment. CONCLUSION OF LAW The criteria for an initial 70 percent rating, but no higher, for PTSD with depressive disorder and alcohol dependence, from August 6, 2015, are met. 38 U.S.C. § §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from at least March 2003 to March 2005, December 2008 to April 2009, and September 2010 to December 2010. He had additional service with the Air National Guard of West Virginia, to include a period of active duty for training (ACDUTRA) with the Air National Guard of the United States from June 1999 to November 1999. These matters come before the Board of Veterans’ Appeals (Board) from a January 2016 rating decision. In May 2017, a Decision Review Officer assigned an initial 50 percent disability rating for PTSD with depressive disorder and alcohol dependence, from August 6, 2015. The Veteran testified before the undersigned Veterans Law Judge at a November 2019 hearing and a transcript of the hearing has been associated with his claims file. As for characterization of the issues on appeal, the evidence reflects that the Veteran has experienced periods of unemployment during the claim period and he submitted a formal claim for a TDIU (VA Form 21-8940) in November 2019. Entitlement to a TDIU may be an element of an appeal for a higher initial rating where there is evidence of unemployability and the Veteran is seeking the highest rating possible. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). Given that the Veteran seeks the highest initial rating possible for his service-connected PTSD with depressive disorder and alcohol dependence, and the evidence of unemployability, the issue of entitlement to a TDIU is before the Board as part and parcel of the appeal for a higher initial rating for PTSD with depressive disorder and alcohol dependence and the Board has expanded the appeal to include this issue Lastly, in light of the Veteran’s reported symptoms and contentions and to encompass all disorders that are reasonably raised by the record, the Board has re-characterized the claims of service connection for broken left pointer finger/range of motion, acquired respiratory problems (to include sleep apnea and deviated septum), and broken left front tooth as claims of service connection for left pointer finger disability, respiratory disability, sleep apnea, nasal disability, and dental disability for compensation purposes. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that, in determining the scope of a claim, the Board must consider the claimant’s description of the claim, the symptoms described, and the information submitted or developed in support of the claim). Entitlement to an initial rating higher than 50 percent for PTSD with depressive disorder and alcohol dependence Disability ratings are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Where service connection has been granted and the assignment of an initial rating is disputed, separate ratings may be assigned for separate periods of time based on the facts found. In other words, the ratings may be “staged.” Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected. 38 C.F.R. § 4.21. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a). When evaluating the level of disability from a mental disorder, VA will also consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). The schedular criteria for rating psychiatric disabilities incorporate the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 38 C.F.R. §§ 4.125, 4.130. The Veteran’s PTSD with depressive disorder and alcohol dependence is rated under 38 C.F.R. § 4.130, DC 9411 as PTSD. This disability is rated according to the General Rating Formula for Mental Disorders (General Rating Formula). Under the General Rating Formula, a 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such 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; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. Under the General Rating Formula, the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004); Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). Considering the pertinent evidence in light of the applicable rating criteria and considerations, the Board finds that, for the following reasons, the symptoms of the Veteran’s PTSD with depressive disorder and alcohol dependence have resulted in deficiencies in most of the areas needed for a 70 percent rating, but no higher, under the General Rating Formula during the entire period since the August 6, 2015 effective date of service connection. Medical records dated from February 2015 to September 2018 and the report of an October 2015 VA psychiatric examination indicate that the Veteran was divorced, had two children from his prior marriage, and had three siblings. He had close relationships with his siblings and children. He was in two relationships during this period, but went to couples’ therapy with one girlfriend because he did not experience enough affection and his irritability, frustration, hypervigilance, and substance abuse negatively impacted their relationship. He was employed for various periods and owned his own business, but experienced some work stress, occasionally experienced triggering of his psychiatric symptoms due to his interactions with other veterans at work, experienced problems with irritability and cognition at work, had low motivation to go to work and did not wish to be around others, and missed a significant amount of time from work due to his psychiatric disability. He was hospitalized for psychiatric observation in May 2015 after he contemplated suicide with a loaded gun, was again hospitalized from July to August 2015 after becoming suicidal while intoxicated, and attempted suicide while hospitalized. He subsequently received ongoing outpatient psychiatric treatment and was taking medications for his psychiatric disability. He was able to perform his activities of daily living. As for psychiatric symptoms, the Veteran experienced recurrent, involuntary, and marked physiological reactions to internal or external cues that symbolized or resembled an aspect of traumatic events in service; avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with traumatic events in service; avoidance of or efforts to avoid external reminders that aroused distressing memories, thoughts, or feelings about or closely associated with the traumatic events; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; a persistent inability to experience positive emotions; anxiety; occasional psychomotor agitation; depression; low energy; impaired concentration; mild memory loss; low motivation; intrusive thoughts and nightmares about traumatic events in service; impaired sleep; hypervigilance; a hyperstartle response; panic attacks; paranoia; irritable behavior and angry outbursts; impatience; and social avoidance. He reported that he began to experience occasional auditory and visual hallucinations following service (sometimes upon awakening from a nightmare), but he generally denied experiencing any hallucinations or delusions during his psychiatric evaluations. Examinations revealed that the Veteran was occasionally tearful and restless, that his eye contact was occasionally avoidant, that his appearance was occasionally disheveled, that his mood and/or affect were occasionally euthymic/depressed/constricted/blunted/nervous/anxious, and that his insight and judgment were occasionally poor. He was interactive, pleasant, cooperative, alert, and fully oriented, his speech was normal, his thought process was logical, linear, and goal oriented, and his memory was fairly intact. Although he had experienced suicidal ideation prior to his hospitalizations in May and July 2015 and had attempted suicide while hospitalized, he subsequently only experienced occasional passive suicidal ideation and was no longer considered to be at high risk for suicide. The Veteran was diagnosed as having PTSD, unspecified trauma and stressor-related disorder, unspecified mood disorder, depression with psychotic features, depressive disorder not otherwise specified (NOS),bipolar disorder, anxiety NOS, major depressive disorder, attention deficit hyperactivity disorder (ADHD), and alcohol use disorder. The examiner who conducted the October 2015 VA examination concluded that the symptoms of the Veteran’s psychiatric disability met the criteria for a 10 percent rating under the General Rating Formula (i.e., occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication). The Veteran reported during an October 2018 VA psychiatric examination that he was living with his father, that he occasionally spent time with a woman (although he was unable to maintain a relationship), and that he saw his children 1 to 2 times per week. He was estranged from his mother and had seldom contact with his siblings. He was employed with a government agency for a couple of years following service, but his employment triggered painful memories, he did not like his bosses and many coworkers because he did not like being told what to do, and often took sick leave to “avoid blowing up.” He was a partial owner in a construction company at the time of the October 2018 examination and went to “check on things 1-2 days per week.” He used medications and alcohol to cope with his psychiatric symptoms. With respect to psychiatric symptoms, the Veteran experienced recurrent, involuntary, and intrusive distressing memories of traumatic events in service; recurrent distressing dreams in which the content and/or affect of the dreams were related to the traumatic events; intense or prolonged psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of the events; marked physiological reactions to internal or external cues that symbolized or resembled an aspect of the events; avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic events; and avoidance of or efforts to avoid external reminders that aroused distressing memories, thoughts, or feelings about or closely associated with the traumatic events. Also, he experienced a persistent negative emotional state, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, a persistent inability to experience positive emotions, reckless or self-destructive behavior, hypervigilance, a hyperstartle response, problems with concentration, chronic sleep impairment, depression, anxiety, mood swings, panic attacks more than once per week, mild memory loss, a flattened affect, impaired judgement, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances (including work or work like setting), impaired impulse control (such as unprovoked irritability with periods of violence), social avoidance, and feelings of worthlessness. Examination revealed that the Veteran was fairly and casually dressed and groomed, cooperative, and fully alert and oriented. He had good eye contact, his thought content was relevant, his thought process was linear and goal-directed, there were no hallucinations or delusions, and his memory and concentration were good. His mood was depressed, his affect was irritated, and his judgement and impulse control were impaired. He was not experiencing any suicidal ideation and was not in any acute distress. Diagnoses of PTSD and unspecified depressive disorder were provided. The examiner who conducted the October 2018 examination concluded that the symptoms of the Veteran’s psychiatric disability met the criteria for a 50 percent rating under the General Rating Formula (i.e., occupational and social impairment with reduced reliability and productivity). VA treatment records dated from January to October 2019, the report of a November 2019 VA psychiatric examination, and the Veteran’s testimony during the November 2019 Board hearing reflect that he lived with his father and continued to maintain regular contact with his children, that he had occasional contact with his siblings, and that he was in a relationship. He had no contact with his mother and did not have much contact with extended family. He generally preferred to remain alone, often experienced panic attacks when in public, and was anxious most of the time. He was a partial owner of a construction company, but experienced occupational impairment due to his anxiety, inability to deal with others, irritability, and social isolation. As for psychiatric symptoms, the Veteran experienced recurrent, involuntary, and intrusive memories of traumatic events in service; intense or prolonged psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of the traumatic events; marked physiological reactions to internal or external cues that symbolized or resembled an aspect of the traumatic events; avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic events; avoidance of or efforts to avoid external reminders that aroused distressing memories, thoughts, or feelings about or closely associated with the traumatic events; persistent and exaggerated negative beliefs or expectations about himself, others, or the world; a persistent negative emotional state; and marked diminished interest or participation in significant activities. Also, he experienced irritable behavior and angry outbursts, hypervigilance, a hyperstartle response, impaired concentration, nightmares, flashbacks, low energy, anxiety, depression, suspiciousness, chronic sleep impairment, mild memory loss, impaired judgement, occasional tearfulness, feelings of worthlessness and hopelessness, occasional passive thoughts of death (but no active suicidal ideation, plan, or intent), intrusive thoughts of traumatic events in service, and difficulty in establishing and maintaining effective work and social relationship. He used alcohol and medications to cope with his symptoms. Examinations revealed that the Veteran had a casual and appropriate appearance, that he was adequately groomed and dressed, that he was cooperative, friendly, fully alert, and oriented, and that his psychomotor activity and thought process were unremarkable. His speech was normal, he did not experience any delusions or visual/auditory hallucinations, no perceptual abnormalities were reported or observed, and he did not experience any homicidal ideation. His mood was euthymic/depressed/anxious/tired, his affect was mood congruent/restricted, and his insight and judgment were fair to poor. The Veteran was diagnosed as having PTSD, depression, bipolar disorder, and alcohol use disorder. The examiner who conducted the November 2019 examination concluded that the symptoms of the Veteran’s psychiatric disability met the criteria for a 50 percent rating under the General Rating Formula (i.e., occupational and social impairment with reduced reliability and productivity. Initially, the Board notes that the Veteran has been diagnosed as having non-service-connected psychiatric disabilities during the claim period. However, where an examiner is unable to distinguish the symptoms of a service-connected disability from non service-connected manifestations, all the manifestations will be considered part of the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996)). In this case, the Board finds that the symptoms of the Veteran’s service-connected PTSD with depressive disorder and alcohol dependence cannot be clearly distinguished from those of his other diagnosed non service-connected psychiatric disorders. Therefore, the Board will attribute all of the Veteran’s psychiatric symptoms to PTSD with depressive disorder and alcohol dependence for the purposes of assessing the severity of that disability. See Id. The above evidence reflects that the Veteran has had periods of employment during the claim period and is a partial owner of a construction business, but that he has experienced problems at work due to his psychiatric symptoms. For instance, he has missed significant time from work and his employment opportunities have been limited throughout the claim period due to symptoms such as anxiety, irritability, and an inability to get along with others. With respect to family relations, the Veteran is divorced and has experienced relationship difficulties due, at least in part, to his alcohol abuse and the anger and irritability associated with his psychiatric disability. Moreover, his symptoms of fair to poor judgment, impaired memory and concentration, nightmares, paranoia, intrusive thoughts of traumatic events in service, suicidal ideation, anxiety, depression, and irritability are reflective of deficiencies in the areas of judgment, thinking, and mood. The Board acknowledges that the examiners who conducted the October 2015, October 2018, and November 2019 VA examinations indicated that the severity of the Veteran’s psychiatric symptoms met the criteria for 10 percent and 50 percent ratings under the General Rating Formula. However, the question of which criteria the symptoms and impairment more nearly approximate is an adjudicatory rather than a medical determination. 38 C.F.R. § 3.100(a) (delegating the Secretary’s authority “to make findings and decisions... as to the entitlement of claimants to benefits” to, inter alia, VA “adjudicative personnel”); 38 C.F.R. § 4.2 (“It is the responsibility of the rating specialist to interpret reports of examination... so that the current rating may accurately reflect the elements of disability present”). Given the above evidence, the overall symptomatology described and demonstrated during the claim period most closely approximates the criteria for a 70 percent rating under the General Rating Formula and that an initial 70 percent rating for PTSD with depressive disorder and alcohol dependence is warranted since the August 6, 2015 effective date of service connection. The Board also finds, however, that a rating higher than 70 percent is not warranted at any time during the claim period. The Board acknowledges that the Veteran has experienced significant occupational impairment due to his psychiatric disability throughout the claim period and it appears that he has experienced periods of unemployment. Regardless, even if it is conceded that there is evidence approximating total occupational impairment due solely to the Veteran’s psychiatric disability during the claim period, there have not been symptoms or impairment more nearly approximating total social impairment. Although the Veteran is divorced and has been unable to maintain romantic relationships due to his psychiatric disability, he has nonetheless maintained close relationships with his father and children and has been in some relationships throughout the claim period. He has reported some memory loss throughout the claim period, but he has not experienced impaired memory to such an extent or severity that there has been memory loss for names of close relatives, own occupation, or name. The Board acknowledges that there is evidence of some audio and visual hallucinations (generally upon awakening from a nightmare) reported in the Veteran’s treatment records, but any such hallucinations have only been occasional/intermittent and there have been no persistent delusions or hallucination. Also, he has not generally demonstrated gross impairment in thought processes or communication, he has been cooperative with examiners, he has been able to perform activities of daily living, and he has remained fully oriented to time and place. The Board notes that the Veteran was hospitalized prior to the claim period in May 2015 and again from July to August 2015 for suicidal behavior, and that he attempted suicide during his second period of hospitalization. Persistent danger of hurting oneself or others is a symptom listed in the criteria for a 100 percent rating. Here, however, there has been no persistent danger of hurting oneself or others. Thus, the severity, frequency, and duration of the Veteran’s suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. Following his hospitalizations in 2015, although the Veteran has expressed occasional passive suicidal ideation, he has regularly denied any active intent or plan involving self-harm or harm to others, he was determined to no longer be at high risk for suicide following his 2015 hospitalizations, and suicidal ideation is contemplated by a 70 percent rating. Overall, the Veteran has not exhibited most of the symptoms indicative of a 100 percent rating under the General Rating Formula, and total social impairment has not been demonstrated or more nearly approximated during the claim period. In sum, the Board finds that, overall, the Veteran has not exhibited most of the symptoms listed in the criteria for the maximum, 100 percent rating under the General Rating Formula as examples of the type and extent, frequency or severity, as appropriate, to indicate both total social and occupational impairment at any point since the effective date of service connection. Rather, the Veteran’s psychiatric symptoms have most closely approximated the criteria for a 70 percent rating under the General Rating Formula during the entire claim period. The Board is sympathetic to the Veteran and acknowledges his distinguished service but is bound by the laws and regulations that apply to veterans claims. 38 U.S.C. § 7104(c) (2012); 38 C.F.R. §§ 19.5, 20.101(a) (2018). As a final point, the Board notes that in conjunction with the appeal for a higher initial rating for PTSD with depressive disorder and alcohol dependence, other than the issue of entitlement to a TDIU which is addressed below, neither the Veteran nor his representative have raised any other related issues, and no other such issues have been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to service connection for left pointer finger disability is remanded. The Veteran contends that he has current left pointer finger disability that is related to a finger injury that he experienced during a period of ACDUTRA. Specifically, he has reported that he injured his finger while playing basketball during a period of ACDUTRA and that he has experienced problems with his finger ever since that time. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for left pointer finger disability because no VA examiner has determined the nature of any such disability or opined whether any such disability is related to service. Therefore, an appropriate examination should be conducted upon remand. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Also, the Veteran’s service treatment records confirm that he injured his left pointer finger while playing basketball on September 9, 2006. However, as the record currently stands, the Board is unable to determine the nature of the Veteran’s service on this date. Therefore, a remand is necessary to attempt to verify any periods of ACDUTRA or inactive duty training (INACDUTRA) in September 2006. If the Board is in error that the Veteran’s duty status at the time of his September 2006 finger injury is not in the claims file, it apologizes, and requests that the agency of original jurisdiction (AOJ) indicate the location of such evidence in a memorandum to the file. Lastly, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from the Huntington Vista electronic records system (dated to October 2019) and the VA Medical Center (VAMC) in Chillicothe, Ohio (dated to August 2015). Any VA treatment records are within VA’s constructive possession, and must be obtained regardless of their relevance as long as they are sufficiently identified. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). See also Jones v. Wilkie, 918 F.3d 922 (Fed. Cir. 2019) (confirming the holding in Sullivan). A remand is required to allow VA to obtain them. 2. Entitlement to service connection for respiratory disability, sleep apnea, and nasal disability are remanded. The Veteran contends that he has current respiratory disability, sleep apnea, and nasal disability (to include deviated nasal septum) and that all of these disabilities had their onset in service. Specifically, he contends that he was exposed to airborne toxins from burn pits while deployed to Afghanistan in 2012, that he began to experience respiratory and sleep apnea symptoms during this period of service, and that he has continued to experience such symptoms in the years since that time. He has also reported that he broke his nose during this period of service and has continued to experience nasal symptoms in the years since his injury. In the alternative, the Board points out that the Veteran has experienced significant sleep problems due to his service-connected psychiatric disability. Therefore, the evidence indicates that his claimed sleep apnea may be associated with his psychiatric disability. The Board cannot make a fully-informed decision on the issues of entitlement to service connection for respiratory disability, sleep apnea, and nasal disability because no VA examiner has determined the nature of any such disabilities and/or opined whether the disabilities are related to service or service-connected disability. Therefore, appropriate examinations should be conducted upon remand. 38 U.S.C. § 5103A (d); McLendon, 20 Vet. App. at 79. Also, as discussed above, the Veteran has reported a period of deployment to Afghanistan in 2012. A February 2012 pre-deployment health assessment and a June 2012 post-deployment health assessment which are located in his service treatment records appear to reflect that he was deployed to Southwest Asia from March to July 2012. Upon review of the claims file, however, the Board is unable to locate any documentation that verifies the exact nature and beginning and ending dates of the Veteran’s service in 2012. In particular, there is no copy of any “Certificate of Release of Discharge from Active Duty” form (DD Form 214) for this period of service in the claims file. During the November 2019 Board hearing, the Veteran confirmed that he did not have a copy of this DD Form 214 and that it appeared to be missing. Therefore, such documentation should be sought upon remand. If the Board is in error that the Veteran’s DD Form 214 or other documentation verifying the nature and dates of his period of service in Southwest Asia in 2012 is not in the claims file, the AOJ should identify where these records are located in a memorandum to the file. Lastly, all outstanding VA treatment records should be secured upon remand. 3. Entitlement to service connection for dental disability for compensation purposes is remanded. The Veteran contends that he has current dental disability related to a dental injury that occurred in service. Specifically, he contends that he sustained a broken tooth when he was hit in the face by another service member’s elbow and that he has continued to experience dental problems in the years since that time. The Board points out that service connection for compensation purposes is only available for dental disabilities that are the result of osteomyelitis or osteoradionecrosis, or due to the loss, malunion, or limited motion of the mandible, maxilla, ramus, condyloid process, or hard palate, or due to the loss of teeth due to loss of substance of the upper or lower jaw. 38 C.F.R. § 4.150. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for dental disability for compensation purposes because no VA examiner has determined the nature of any such disability or opined whether such disability is related to service. Therefore, an appropriate examination should be conducted upon remand. 38 U.S.C. § 5103A (d); McLendon, 20 Vet. App. at 79. Also, all outstanding VA treatment records should be secured upon remand. 4. Entitlement to a TDIU due to service-connected disabilities is remanded. Since a decision on the remanded service connection matters could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. The issue of entitlement to a TDIU should be adjudicated in the first instance by the AOJ. Also, there is conflicting information as to the Veteran’s employment history. Although he reported on his November 2019 VA Form 21-8940 that he stopped working on a full time basis in July 2018, his VA treatment records dated in 2019 indicate that he was a partial owner of a construction business and continued to work for the business. A treatment record dated as recently as October 2019 suggests that he was still employed (see an October 2019 VA mental health telehealth note which reflects that he was getting ready to drive to work). Upon remand, the AOJ should request that the Veteran clarify his employment and earnings history, as such information would be helpful in adjudicating his TDIU claim. Lastly, all outstanding VA treatment records should be secured upon remand. The matters are REMANDED for the following action: 1. Send the Veteran a notice letter which provides him with notice as to the information and evidence that is required to substantiate his claim for a TDIU. A copy of this letter must be included in his claims file. 2. Ask the Veteran to report his employment history and earnings (to include starting and ending dates of any employment (including self-employment)), especially for the period since August 2015. 3. Ask the Veteran to identify the location and name of any VA or private medical facility where he has received treatment for finger disability, respiratory disability, sleep apnea, nasal disability, and dental disability, to include the dates of any such treatment. Ask the Veteran to complete a VA Form 21-4142 for all records of his treatment for finger disability, respiratory disability, sleep apnea, nasal disability, and dental disability from any sufficiently identified private treatment provider from whom records have not already been obtained. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 4. Obtain the Veteran’s outstanding VA treatment records from the Huntington Vista electronic records system for the period since October 2019; the VAMC in Chillicothe, Ohio for the period since August 2015; and all such relevant records from any other sufficiently identified VA facility. 5. Obtain a copy of any DD Form 214 for the Veteran’s period of service in Southwest Asia in 2012, as well as any other documentation that verifies the nature and dates of this period of service. Document all requests for information as well as all responses in the claims file. If the Board is in error that the Veteran’s DD Form 214 and any documentation verifying the nature and dates of his service in Southwest Asia in 2012 is not in the claims file, the AOJ should indicate the location of such records in a memorandum to the file. 6. Verify all ACDUTRA and INACDUTRA dates for the Veteran’s service in the Air National Guard, to specifically include whether he was serving on ACDUTRA or INACDUTRA on September 9, 2006. If necessary, a request should be made to the Defense Finance and Accounting Service (DFAS). Document all requests for information as well as all responses in the claims file. If the Board is in error that any documentation verifying the nature of the Veteran’s service on September 9, 2006 is not in the claims file, the AOJ should indicate the location of such records in a memorandum to the file. 7. After all efforts have been exhausted to verify the Veteran’s periods of ACDUTRA and INACDUTRA and to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any current left pointer finger disability. The examiner must provide an opinion as to whether any left pointer finger disability experienced by the Veteran since approximately October 2015 at least as likely as not (1) began during any period of active service, ACUDTRA, or INACDUTRA; (2) manifested within one year after separation from any period of active service (in the case of any currently diagnosed arthritis); (3) is related to an injury or disease during a period of service, including his finger injury in September 2006 that is documented in his service treatment records; or (4) was aggravated by a period of service. The examiner must provide reasons for each opinion given. 8. After all efforts have been exhausted to verify the Veteran’s periods of ACDUTRA and INACDUTRA and to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any current respiratory disability. The examiner must opine whether any respiratory symptom experienced by the Veteran since approximately October 2015 is a manifestation of an identifiable disability. If any respiratory symptom is a manifestation of an identifiable disability, the examiner must identify the disability and opine whether the disability at least as likely as not (1) began during any period of active service, ACUDTRA, or INACDUTRA; (2) is related to an injury or disease during a period of service, including his reported respiratory symptoms and exposure to airborne toxins from burn pits; or (3) was aggravated by a period of service. If any current respiratory symptom is not a manifestation of an identifiable disability, the examiner must opine whether the symptom at least as likely as not represents an objective indication of chronic disability resulting from an undiagnosed illness related to service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms. If so, the examiner should also describe the extent to which the illness has manifested. The examiner must provide reasons for each opinion given. 9. After all efforts have been exhausted to verify the Veteran’s periods of ACDUTRA and INACDUTRA and to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any current sleep apnea. The examiner must provide an opinion as to whether any sleep apnea experienced by the Veteran since approximately October 2015 at least as likely as not (1) began during any period of active service, ACUDTRA, or INACDUTRA; (2) is related to an injury or disease during a period of service, including his reported sleep problems in service; (3) was aggravated by a period of service; (4) is caused by service-connected PTSD with depressive disorder and alcohol dependence; or (5) is aggravated by service-connected PTSD with depressive disorder and alcohol dependence. The examiner must provide reasons for each opinion given. 10. After all efforts have been exhausted to verify the Veteran’s periods of ACDUTRA and INACDUTRA and to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any current nasal disability. The examiner must provide an opinion as to whether any nasal disability experienced by the Veteran since approximately October 2015 at least as likely as not (1) began during any period of active service, ACUDTRA, or INACDUTRA; (2) is related to an injury or disease during a period of service, including his reported nasal injury in service; or (3) was aggravated by a period of service. The examiner must provide reasons for each opinion given. 11. After all efforts have been exhausted to verify the Veteran’s periods of ACDUTRA and INACDUTRA and to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any current dental disability. The examiner must provide an opinion as to whether any dental disability experienced by the Veteran since approximately October 2015 at least as likely as not (1) began during any period of active service, ACUDTRA, or INACDUTRA; (2) is related to an injury or disease during a period of service, including his reported dental injury in service; or (3) was aggravated by a period of service. The examiner must provide reasons for each opinion given. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Elwood, 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.