Citation Nr: 20020002 Decision Date: 03/18/20 Archive Date: 03/18/20 DOCKET NO. 18-22 853A DATE: March 18, 2020 ORDER Service connection for fibromyalgia (claimed as large and small joint pain), as a qualifying chronic disability to include undiagnosed illness, is granted. Service connection for asthma, including as a qualifying chronic disability to include undiagnosed illness, is denied. Service connection for chronic obstructive pulmonary disease (COPD), including as a qualifying chronic disability to include undiagnosed illness, is denied. Service connection for residuals of a traumatic brain injury (TBI) is denied. Service connection for obstructive sleep apnea (OSA), including as due to asthma and/or COPD and/or as a qualifying chronic disability to include undiagnosed illness, is denied. Service connection for dizziness, including as a qualifying chronic disability to include undiagnosed illness, is denied. A higher initial disability rating of 50 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted. An increased (compensable) disability rating for bilateral hearing loss is denied. REMANDED Service connection for essential tremor (claimed as tremors of the hands), including as a qualifying chronic disability to include undiagnosed illness, and/or as secondary to the service-connected fibromyalgia, is remanded. A total disability rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War. 2. The Veteran’s current fibromyalgia with large and small and joint pain is a medically unexplained chronic multi-symptom illnesses that has manifested to a compensable degree during a six-month period since service. 3. The Veteran is not currently diagnosed with asthma. 4. The respiratory problems claimed as asthma did not manifest during service, have not manifested to a compensable degree during a six-month period since service, and are not a manifestation of an undiagnosed illness or medically unexplained chronic multi-symptom illness. 5. The Veteran is not currently diagnosed with COPD. 6. The respiratory problems claimed as COPD did not manifest in service, have not manifested to a compensable degree during a six-month period since service, and are not a manifestation of an undiagnosed illness or medically unexplained chronic multi-symptom illness. 7. The Veteran did not experience a TBI event during service. 8. The Veteran’s sleep disorder symptoms have been medically attributed to a diagnosed disability of obstructive sleep apnea (OSA), which first manifested many years after service separation; the current OSA is not otherwise etiologically related to active service, or to an injury or disease sustained during any period of active duty for training (ACDUTRA) or injury during inactive duty for training (INACDUTRA) service. 9. The Veteran does not have, and has not had at any time proximate to or during the course of this appeal, a currently diagnosed disability manifested by symptoms of dizziness. 10. The claimed dizziness problems have not manifested to a compensable degree during a six-month period since service, and is not a manifestation of an undiagnosed illness or medically unexplained chronic multi-symptom illness. 11. For the initial rating period on appeal from February 5, 2015, the service-connected PTSD has manifested in symptoms of such severity, frequency, and duration that more nearly approximate occupational and social impairment with reduced reliability and productivity, and did not cause occupational and social impairment with deficiencies in most areas. 12. For the entire increased rating period on appeal from February 5, 2015, the bilateral hearing loss has manifested in no more than level III hearing in the right ear and level II hearing in the left ear. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for fibromyalgia as a qualifying chronic disability have been met. 38 U.S.C. §§ 101, 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303, 3.317. 2. The criteria for service connection for asthma, including as a qualifying chronic disability, have not been met. 38 U.S.C. §§ 101, 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303, 3.304, 3.310, 3.317. 3. The criteria for service connection for COPD, including as a qualifying chronic disability, have not been met. 38 U.S.C. §§ 101, 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303, 3.304, 3.310, 3.317. 4. The criteria for service connection for TBI residuals have not been met. 38 U.S.C. §§ 101, 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303, 3.304. 5. The criteria for service connection for OSA, including as claimed as due to asthma, COPD, and/or as a qualifying chronic disability, have not been met. 38 U.S.C. §§ 101, 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303, 3.304, 3.310, 3.317. 6. The criteria for service connection for dizziness, including as a qualifying chronic disability to include undiagnosed illness, have not been met. 38 U.S.C. §§ 101, 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303, 3.317. 7. Resolving reasonable doubt in favor of the Veteran, for the initial rating period on appeal from February 5, 2015, the criteria for a higher initial disability rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 8. For the increased rating period on appeal from February 5, 2015, the criteria for an increased (compensable) disability rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.3, 4.7, 4.10, 4.21, 4.85, Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, served on active duty from November 1966 to October 1969, March 1989 to January 1990, January 1991 to July 1991, and from October 1993 to April 1994, with various periods of ACDUTRA and INACDUTRA service with the U.S. Air Force Reserves. Service Connection Legal Criteria Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). “Active military, naval, or air service” includes any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of INACDUTRA during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty. See 38 U.S.C. § 101(21), (24); 38 C.F.R. § 3.6(a), (d); Biggins v. Derwinski, 1 Vet. App. 474, 477 78 (1991). ACDUTRA is defined as full-time duty in the Armed Forces performed by Reserves for training purposes, and includes full-time duty performed by members of the National Guard of any State. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c)(1). Service connection for INACDUTRA is permitted only for injuries, not diseases, incurred or aggravated in line of duty. See Brooks v. Brown, 5 Vet. App. 484, 485 (1993). VA’s General Counsel has interpreted that it was the intention of Congress when it defined active service in 38 U.S.C. § 101(24) to exclude inactive duty training during which a member was disabled or died due to nontraumatic incurrence or aggravation of a disease process. See VAOPGCPREC 86-90. With any claim for service connection (under any theory of entitlement), it is necessary for a current disability to be present. See Brammer v. Derwinski, 3 Vet. App. 223 (1992); see also McClain v. Nicholson, 21 Vet. App. 319 (2007) (service connection may be warranted if there was a disability present at any point during the claim period, even if it is not currently present); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (when the record contains a recent diagnosis of disability immediately 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). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id.; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Service connection may be granted on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on qualifying chronic disability, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Laypersons are competent to report objective non-medical indicators of illness. The term “Persian Gulf veteran” means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). Military personnel records show the Veteran served in Southwest Asia for various periods in 1990 and 1991; therefore, the Veteran is a “Persian Gulf veteran” (i.e., had active military service in the Southwest Asian Theater of operations during the Gulf War) as defined by 38 C.F.R. § 3.317. A “qualifying chronic disability” for VA purposes is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or functional gastrointestinal disorders that include IBS and dyspepsia) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and 13) menstrual disorders. 38 C.F.R. § 3.317(b). The Veteran is currently diagnosed with essential tremors (as an organic disease of the nervous system), which are “chronic diseases” under 38 C.F.R. § 3.309(a). Therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) for “chronic” in-service symptoms and “continuous” post service symptoms apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. For the showing of “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as organic diseases of the nervous system, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. 1. Service connection for fibromyalgia The Veteran generally contends that symptoms of fibromyalgia have persisted since service separation and are the result of service in the Persian Gulf. Initially, the Board finds the Veteran is currently diagnosed with fibromyalgia. See February 2020 VA examination report. Fibromyalgia is on the list of medically unexplained chronic multisymptom illnesses subject to presumptive service connection. 38 C.F.R. § 3.317. Accordingly, nexus evidence is not required for presumptive service connection. Gutierrez, 19 Vet. App. at 10. The evidence shows symptoms of fibromyalgia are consistent with at least a (compensable) 10 percent disability rating. Under the rating schedule, fibromyalgia would be rated under 38 C.F.R. § 4.71a, Diagnostic Code 5025. Under Diagnostic Code 5025, a 10 percent rating is warranted for symptoms that require continuous medication. A 20 percent rating is warranted for symptoms that are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time. The highest rating of 40 percent is warranted for symptoms that are constant, or nearly so, and refractory to therapy. A March 2019 VA treatment record reflects the Veteran reported pain in the hands, wrists, shoulders, feet, ankles, and knees for the last 15 years, and being treated with prescription medication in February 2019, which was not effective. A July 2019 VA treatment record reflects a diagnosis of fibromyalgia for which Cymbalta and Neurontin were prescribed for control. A February 2020 VA examination report reflects the Veteran was still taking the Cymbalta and Neurontin, but he was still experiencing diffuse discomfort involving muscle and joints nonetheless. As the evidence of record reflects the fibromyalgia requires continuous medication for control, the Board finds that symptoms of the Veteran’s fibromyalgia are consistent with a 10 percent disability rating under Diagnostic Code 5025. 38 C.F.R. §§ 4.3, 4.7, 4.71a. Based on the foregoing evidence, the Board finds that presumptive service connection for fibromyalgia as a medically unexplained chronic multi-symptom illness is warranted. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. The grant of presumptive service connection as due to a qualifying chronic disability renders other theories of service connection moot. 2. Service connection for asthma 3. Service connection for COPD The Veteran seeks service connection for asthma and COPD, including as a qualifying chronic disability to include undiagnosed illness. See July 2018 VA Form 646; February 2020 Appellate Brief. After a review of all the lay and medical evidence of record, the Board finds that the weight of the evidence demonstrates that the Veteran is not currently diagnosed with asthma or COPD. VA treatment records throughout the relevant claim period on appeal do not reflect any treatment or diagnoses for asthma or COPD. Instead, service treatment records reflect routine spirometer tests were all within normal limits, post-service VA and private treatment records show the Veteran denied respiratory symptoms, and that X-rays of the chest were clinically normal. See e.g. October 2001 service treatment record; January 2002 private treatment record; February 2015 private treatment record; March 2019 VA treatment record. Therefore, in the absence of a current clinical diagnosis, service connection for asthma and COPD must be denied on a direct basis. As noted above, because the Veteran is a Persian Gulf veteran, the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 apply. However, the evidence of record does not show objective evidence of asthma or COPD related symptoms have manifested during service or to a compensable degree during a six-month period since service separation. 38 C.F.R. § 3.317(a)(1)(i). As such, the Board finds that service connection is not warranted under the Persian Gulf War presumption. 38 C.F.R. § 3.317. As discussed above, VA treatment records do not reflect any complaints or treatment for asthma or COPD related symptoms since service separation; instead, the only complaints of respiratory-related symptoms appears in a February 2019 VA Environmental Agents Exposure Examination report, wherein the Veteran reported symptoms of a cough with sputum and shortness of breath. Another February 2019 VA treatment record reflects the Veteran was treated for acute bronchitis. Subsequent VA treatment records reflect the respiratory symptoms relating to acute bronchitis had resolved. See March 2019 VA treatment record (denied cough; shortness of breath); March 2019 VA treatment record (X-rays of the chest normal). VA treatment records do not reflect any further complaints, symptoms, or treatment for respiratory-related problems. Based on the foregoing, the Board finds that the preponderance of the evidence weighs against finding objective evidence of asthma or COPD related symptoms that have manifested to a compensable degree during a six-month period since service separation, and service connection on a presumptive basis is not warranted, and these claims must be denied. 4. Service connection for residuals of a TBI The Veteran contends that he suffered two serious brain injuries during active service. The first occurred when he was running and ran into a truck; the second occurred when he slipped and fell in the bathtub. See August 2015 VA examination report. After a review of all the evidence of record, both lay and medical, the Board finds that the weight of the evidence demonstrates the Veteran did not sustain a TBI event during active service or during a period of ACDUTRA or INACDUTRA service. Service treatment records do not reflect treatment or symptoms of a TBI event in service. A December 1967 service treatment record reflects the Veteran reported being hit by truck in November 1967 and had been experiencing headaches and vomiting after breakfast since then. The Veteran reported going to the hospital at the time of the incident but that X-rays were not taken at that time. The Veteran was prescribed medication to treat the headaches; however, service treatment records after December 1967 do not reflect any further complaints related to the November 1967 incident. A subsequent July 1969 service separation examination shows a neurological examination of the Veteran was clinically normal and the Veteran denied a history of a head injury and other neurological symptoms on the corresponding July 1969 Report of Medical History. A March 1988 service examination report shows the Veteran reported suffering a concussion without loss of consciousness after walking into a piece of metal on the side of a building in 1987, which was not during a period of active, ACDUTRA, or INACDUTRA service. See November 1987 private treatment record (CT scan of the brain and electroencephalogram both normal). Subsequent service examinations found the Veteran to be neurologically normal throughout service. See November 1985 service treatment record; March 1988 service treatment record; October 1989 service treatment record; September 1991 service treatment record; October 1994 service treatment record; August 1997 service treatment record. The record reflects that in March 1999 the Veteran stepped out of the tub and slipped, hitting his head without losing consciousness; the Veteran reported for evaluation and was found to have sustained no injuries other than bruises. See March 1999 Line of Duty Determination. The record includes a January 2015 private medical letter from Dr. P.Y. stating the Veteran was seriously injured in a pedestrian vehicle accident during service when he was hit by a truck. Dr. P.Y. states the Veteran sustained blunt head trauma from the accident that left him semi-conscious and severely disoriented, which is contrary to contemporaneous service treatment records from December 1967. The January 2015 private medical letter also includes a diagnosis for a TBI and Dr. P.Y.’s opinion that residuals of a TBI are casually related to the pedestrian vehicle accident during service. A medical opinion such as this one that is premised upon an unsubstantiated account of a claimant are of no probative value and does not serve to verify the occurrences described. See Swann v. Brown, 5 Vet. App. 229, 233 (1993); Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Contrary to the Veteran’s post-service reports of sustaining two serious head injuries during service, the competent evidence in the record in the form of the Veteran’s contemporaneous reports shown in service treatment records reflect that the Veteran never lost consciousness at any time during service, or that he sustained a head injury that caused traumatically induced structural injury and/or physiological disruption of brain function, which is one of the required showings of a TBI event. As discussed above, neurological examinations of the Veteran throughout service were clinically normal, and the Veteran denied a history of a head injury on the July 1969 Report of Medical History. The only evidence of a serious head injury in the form of a concussion occurred in March 1988, which was not during a period of active, ACDUTRA, or INACDUTRA service. While the Veteran contends experiencing a TBI event during service, the Veteran is not competent to opine as to whether he suffered a TBI during service. While the Veteran is competent to relate symptoms experienced at any time, he is not competent in this case to opine as to the underlying pathology of the symptoms is TBI. Such a medical diagnosis requires specific medical knowledge and training regarding traumatic brain injuries, which is a complex medical condition involving physical, neurological, and psychiatric processes and symptoms, that the Veteran has not been shown to possess. As noted above, the Veteran underwent a VA examination in August 2015, the examination report for which shows the Veteran reported running into a truck during service and that he did not remember whether he lost consciousness or not. The Veteran also reported an incident where he slipped and fell while getting out of the bathtub and that he did not lose consciousness. Based in part on the Veteran’s descriptions of these two incidents, the August 2015 VA examiner determined that the Veteran does not have, and has never had, a TBI or residuals of a TBI due to these events. The August 2015 VA examiner explained that the Veteran did not describe a history and symptoms consistent with a TBI. Although the Veteran reported symptoms such as depression, irritability, and anger, the August 2015 VA examiner noted these symptoms are better explained by the Veteran’s service-connected PTSD. For the foregoing reasons, the Board finds the weight of the credible evidence demonstrates that the Veteran did not experience a TBI event during active service, ACDUTRA, or INACDUTRA service. Because the Veteran did not experience a TBI event during service, the claim for service connection for residuals of a TBI must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Service connection for obstructive sleep apnea The Veteran generally asserts that obstructive sleep apnea had its onset during active service and/or is a qualifying chronic disability to include undiagnosed illness. Alternatively, the Veteran contends that OSA is caused or worsened beyond its normal progression by asthma and/or COPD. See January 2015 private medical letter. Initially, the Board finds the Veteran is currently diagnosed with OSA. See January 2002 private treatment record. As the Veteran’s sleeping disorder symptoms have been attributed to clinically diagnosed OSA, the presumptive service connection provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 are not for application. After reviewing all the lay and medical evidence of record, the Board finds that the weight of the evidence shows that the current OSA did not have its onset during service and is not otherwise etiologically related to active service, to an injury or disease sustained during ACDUTRA service, or to an injury sustained during INACDUTRA service. Service treatment records do not reflect any complaints, symptoms, or diagnosis for OSA or any other sleeping disorder. The weight of the evidence shows that OSA had its onset after active service, that the Veteran was not treated for sleep apnea until many years after service, was not treated for sleep disordered breathing until May 2001, and was not diagnosed with OSA until January 2002. See May 2001 private treatment record; January 2002 private treatment record. The record includes a January 2015 private medical letter from Dr. P.Y., in which Dr. P.Y. writes that it is more likely than not that the Veteran’s OSA is directly and causally related to military service; however, as Dr. P.Y. does not provide a rationale for the opinion rendered, the Board finds that the statement is of no probative value in establishing a nexus between the currently diagnosed OSA and military service. As the evidence of record shows that symptoms of sleep apnea did not begin in service and does not include a competent medical opinion establishing a nexus between the current OSA and an injury, disease, or event during service, or to an injury or disease sustained during ACDUTRA service, or to an injury sustained during INACDUTRA service, the Board finds that the weight of the evidence is against direct service connection for OSA. As discussed above, service connection for asthma and COPD have been denied; therefore, as a matter of law, the Veteran is unable to receive service connection for OSA, which was claimed as due to the non-service-connected asthma and COPD. As a theory of secondary service connection is based on the law and not the facts of the case, secondary service connection must be denied on a lack of entitlement under the law. Sabonis v. Brown, 6 Vet. App. 426 (1994). 6. Service connection for dizziness The Veteran generally seeks service connection for an undiagnosed illness characterized by dizziness as a result of service in the Southwest Asia Theatre of operations during the Persian Gulf War. After a review of all the evidence, lay and medical, the Board finds that the evidence does not show the Veteran has a currently diagnosed dizziness disorder or any other disability manifesting in symptoms of dizziness. 38 C.F.R. § 3.303. Therefore, in the absence of a current clinical diagnosis, service connection for dizziness must be denied on a direct basis. See Brammer, 3 Vet. App. at 225 (in the absence of proof of the presently claimed disability, there can be no valid claim); McClain, 21 Vet. App. 319; Romanowsky, 26 Vet. App. 289. As noted above, because the Veteran is a Persian Gulf veteran, the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 apply. However, the evidence of record does not show objective evidence of dizziness problems have manifested to a compensable degree during a six-month period since service separation. 38 C.F.R. § 3.317(a)(1)(i). As such, the Board finds that service connection is not warranted under the Persian Gulf War presumption. 38 C.F.R. § 3.317. The medical evidence of record does not reflect any complaints or treatment for dizziness problems since service separation, except during a February 2019 Persian Gulf War Exposure Examination. Conversely, the medical evidence of record reflects the Veteran denied symptoms such as vertigo during regular medical visits. See e.g. August 2009 VA treatment record; December 2018 VA treatment record. Based on the foregoing, the Board finds that that the preponderance of the evidence weighs against finding objective evidence of dizziness that have manifested to a compensable degree during a six-month period since service separation. For these reasons, service connection on a presumptive basis is not warranted and this claim must be denied. Disability Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability 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. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 7. Rating PTSD For the entire initial rating period on appeal from February 5, 2015, the Veteran is in receipt of an initial 30 percent rating for the service-connected PTSD under Diagnostic Code 9411. 38 C.F.R. § 4.130. The Veteran generally contends that a higher initial disability rating is warranted. See November 2015 Notice of Disagreement. Pertinent to this case, the General Rating Formula for Mental Disorders provides that a 10 percent rating is assigned for 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 continuous medication. 38 C.F.R. § 4.130. A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is provided when 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is provided when there is evidence that the psychiatric disability more closely approximates 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); and inability to establish and maintain effective relationships. Id. A 100 percent rating requires evidence of 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; and memory loss for names of close relatives, own occupation, or own name. Id. 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, 117 (2013), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that VA “intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms.” 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.” For the initial rating period on appeal from February 5, 2015, the Board finds that the service connected PTSD has manifested in symptoms that more nearly approximate occupational and social impairment with reduced reliability and productivity due to symptoms such as depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances to warrant a higher initial 50 percent rating. A February 2015 private examination report shows the Veteran’s PTSD had manifested in symptoms such as persistent reexperiencing thoughts, intrusive thoughts, nightmares, verbal outbursts, insomnia, irritability, hypervigilance, and panic attacks. The Veteran reported symptoms of exaggerated startle response, panic attacks, and cognitive difficulties including diminished ability to think and indecisiveness. The Veteran endorsed recurrent thoughts of death, but denied any suicidal or homicidal ideation. An August 2015 VA examination report reflects the VA examiner’s assessment that the service-connected PTSD had been formally diagnosed, but that symptoms were not severe enough to interfere with occupational and social functioning or to require continuous medication. The August 2015 VA examination report shows positive findings for anxiety, suspiciousness, and chronic sleep impairment. The Veteran underwent another VA examination in February 2019, the report for which shows the VA examiner’s assessment that the service-connected PTSD resulted in occupational and social impairment with reduced reliability and productivity due to symptoms such as depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances. The findings contained in the February 2019 VA examination report are consistent with the symptoms noted in the February 2015 private examination report, which are also consistent with the symptoms reported during regular mental health treatment sessions, and more nearly approximate the criteria for a higher initial 50 percent disability rating under Diagnostic Code 9411. See e.g. January 2016 VA treatment record; January 2019 VA treatment record; April 2019 VA treatment record. Based on the foregoing evidence, and resolving reasonable doubt in favor of the Veteran, the Board finds that, for the initial rating period on appeal from February 5, 2015, the criteria for a higher initial disability rating of 50 percent under Diagnostic Code 9411 have been met. 38 C.F.R. §§ 4.3, 4.7. The Board further finds that, for the initial rating period on appeal from February 5, 2015, the lay and medical evidence of record does not demonstrate that the service-connected PTSD has manifested in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood to warrant a higher initial 70 percent disability rating under Diagnostic Code 9411. The evidence of record demonstrates that, throughout the initial rating period on appeal from February 5, 2015, the Veteran was consistently observed to be alert and oriented, to be appropriate in appearance and behavior, to have logical thought content and normal speech, without severe symptoms such as obsessive rituals which interfere with routine activities, illogical speech, suicidal and homicidal ideation, spatial disorientation, or any audio or visual hallucinations. See e.g. February 2015 private examination report; January 2016 VA treatment record; January 2019 VA treatment record. Furthermore, the evidence shows the Veteran was still able to maintain social relationships and activities such as traveling abroad, planning a birthday party for his brother, interacting with supportive people, and attending social events with other veterans. See February 2019 VA treatment records; April 2019 VA treatment record. Based on the foregoing, the Board finds that for the initial rating period on appeal from February 5, 2015, the weight of the evidence is against a higher (70 percent) disability rating under Diagnostic Code 9411, and that the weight of the competent and probative lay and medical evidence of record is against a rating in excess of 50 percent for the service connected PTSD for the period from February 5, 2015. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 8. Rating bilateral hearing loss For the entire rating period on appeal from February 5, 2015, the Veteran is in receipt of a noncompensable (0 percent) disability rating for the service-connected bilateral hearing loss. The Veteran generally asserts that an increased 20 percent rating is warranted for the service-connected bilateral hearing loss. See November 2015 Notice of Disagreement. Ratings for service-connected hearing loss range from noncompensable (0 percent) to 100 percent. These ratings are based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination testing together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1,000, 2,000, 3,000 and 4,000 cycles per second. In rating service-connected hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Diagnostic Code 6100 provides a table for rating purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment. The hearing impairment is established by a state licensed audiologist including a controlled speech discrimination test and the pure tone threshold average, which is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz (Hz), divided by four. See 38 C.F.R. § 4.85. Table VII is used to determine the percentage rating by combining the Roman numeral designations for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. Id. Under 38 C.F.R. § 4.86(a), when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table IV or Table VIa, whichever results in the higher numeral. Each ear is to be evaluated separately. The provisions of 38 C.F.R. § 4.86(b) provide that when the pure tone threshold is 30 decibels or less at 1000 Hz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be evaluated to the next higher Roman numeral. After a review of all the evidence, lay and medical, the Board finds that, for the entire rating period on appeal from February 5, 2015, the weight of the competent and probative lay and medical evidence demonstrates that an increased (compensable) disability rating for the service connected bilateral hearing loss is not warranted. The most relevant evidence for this claim consists of an August 2015 VA examination report, December 2018 VA treatment record, and February 2019 VA examination report. The Veteran underwent a VA examination in August 2015. At that time, relevant pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 25 20 65 65 LEFT 25 25 75 80 Speech recognition scores conveyed speech discrimination of 92 percent in the right ear, and 90 percent in the left ear. Based upon the results of the August 2015 examination, a Roman numeral I is designated for the right ear from Table VI of 38 C.F.R. § 4.85, and a Roman numeral II is designated for the left ear. Intersecting the numeric designations to the applicable row and column for the right and left ear, a 0 percent rating is derived from Table VII of 38 C.F.R. § 4.85. The intersection point for these categories shows that the hearing loss does not exceed the levels contemplated for a 0 percent schedular rating. The Veteran underwent a VA audiometric examination in December 2018. At that time, relevant pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 10 10 65 60 LEFT 5 15 70 80 Speech recognition scores conveyed speech discrimination of 100 percent in the right ear and 100 percent in the left ear. Based upon the results of the December 2018 VA audiometric examination, a Roman numeral I is designated for the right ear from Table VI of 38 C.F.R. § 4.85, and a Roman numeral I is designated for the left ear. Intersecting the numeric designations to the applicable row and column for the right and left ear, a 0 percent rating is derived from Table VII of 38 C.F.R. § 4.85. The intersection point for these categories shows that the hearing loss does not exceed the levels contemplated for a 0 percent schedular rating; thus, this audiometric and speech recognition evidence also does not support a finding of a compensable rating. The Veteran underwent another VA examination in February 2019. At that time, relevant pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 20 25 65 65 LEFT 20 30 75 80 Speech recognition scores conveyed speech discrimination of 76 percent in the right ear, and 92 percent in the left ear. Based upon the results of the February 2019 VA examination, a Roman numeral III is designated for the right ear from Table VI of 38 C.F.R. § 4.85, and a Roman numeral I is designated for the left ear. Intersecting the numeric designations to the applicable row and column for the right and left ear, a 0 percent rating is derived from Table VII of 38 C.F.R. § 4.85. The intersection point for these categories shows that the hearing loss does not exceed the levels contemplated for a 0 percent schedular rating. The provisions of 38 C.F.R. § 4.86(a) (exceptional patterns of hearing impairment) are not for application as the results of the VA audiometric examinations discussed above do not show pure tone thresholds of 55 decibels or greater in all four of the relevant frequencies in either of the ears. The provisions of 38 C.F.R. § 4.86(b) are also not applicable as neither ear has shown to manifest 30 decibels or less at 1000 Hz and 70 decibels or more at 2000 Hz. The application of the rating schedule to the audiometric findings does not establish entitlement to a compensable disability rating for bilateral hearing loss for the entire rating period from February 5, 2015. The weight of the competent and probative lay and medical evidence of record is against a compensable disability rating for bilateral hearing loss for the entire rating period appeal from February 5, 2015. REASONS FOR REMAND 1. Service connection for essential tremor is remanded. The Veteran generally seeks service connection for an undiagnosed illness characterized by tremors of the hands that is the result of active service, to include service in the Southwest Asia Theater of operations. See July 2018 VA Form 646. Alternatively, the Veteran asserts that tremors of the hands are either caused or worsened beyond its natural progression by the now service-connected fibromyalgia. See February 2020 Appellate Brief. The record does not include a medical opinion as to whether the currently diagnosed essential tremor is either caused or worsened beyond its normal progression by the now service-connected fibromyalgia. As such, remand for a VA addendum opinion is needed. 2. A TDIU is remanded. As the Board’s instant decision grants service connection for fibromyalgia, the Regional Office will assign an initial disability rating for the now service-connected fibromyalgia. Accordingly, the issue of entitlement to a TDIU will be deferred because it is inextricably intertwined with the question of rating the additional functional and occupational impairments caused by the now service-connected fibromyalgia. The matters are REMANDED for the following actions: 1. Request that a VA medical professional review the electronic file and provide the VA medical opinions requested below regarding the secondary service connection questions regarding the claimed essential tremor. The relevant documents in the electronic file should be made available to, and be reviewed by, the VA examiner. The VA examiner should note such review in the requested medical opinion. If the VA examiner determines that additional examination(s) of the Veteran is necessary to provide reliable opinions as to causation, such examination(s) should be scheduled; however, the Veteran should not be required to report for an examination as a matter of course, if it is not found to be necessary. The VA examiner should provide the following opinions: a. Is it at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran’s essential tremor was caused by the service-connected fibromyalgia? b. Is it at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran’s essential tremor was worsened beyond normal progression by the service-connected fibromyalgia? The term “at least as likely as not” does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. A rationale should be given for all opinions and conclusions rendered. The opinions should address the particulars of this Veteran’s medical history and the relevant medical science as applicable to this claim. 2. Adjudicate the downstream elements of the initial disability rating for the service-connected fibromyalgia, and readjudicate the issue of TDIU considering the functional impairment caused by the now service-connected fibromyalgia. J. PARKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Eva Choi 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.