Citation Nr: 20044231 Decision Date: 07/01/20 Archive Date: 07/01/20 DOCKET NO. 13-03 126 DATE: July 1, 2020 ORDER Entitlement to service connection for headaches, to include as secondary to service-connected post-traumatic stress disorder (PTSD) with major depressive disorder, is denied. Entitlement to service connection for a respiratory disorder, claimed as mesothelioma, to include as due to asbestos exposure, is denied. Entitlement to an initial evaluation in excess of 30 percent for service-connected PTSD with major depressive disorder prior to May 1, 2018, is granted. Entitlement to an evaluation in excess of 70 percent for service-connected PTSD with major depressive disorder from May 1, 2018, forward is denied. Entitlement to a total disability rating based upon individual unemployability (TDIU) is granted. REMANDED Entitlement to service connection for left carpal tunnel syndrome is remanded. Entitlement to service connection for right carpal tunnel syndrome is remanded. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected PTSD with major depressive disorder, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record establishes that the Veteran’s reported headaches did not manifest in service and is not otherwise etiologically related to his active duty service. 2. The preponderance of the evidence of record establishes that the Veteran’s reported respiratory disorder did not manifest in service and is not otherwise etiologically related to his active duty service. 3. For the period prior to May 1, 2018, the Veteran’s PTSD with major depressive disorder more closely approximates occupational and social impairment with deficiencies in most areas, consistent with a 70 percent disability rating. 4. For the period from May 1, 2018, forward, the Veteran’s PTSD with major depressive disorder more closely approximates occupational and social impairment with deficiencies in most areas, consistent with a 70 percent disability rating. 5. Resolving all doubt in the Veteran’s favor, his service-connected disabilities render him unable to obtain or maintain gainful employment consistent with his educational and occupational background. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for headaches have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.3, 4.130. 2. The criteria for entitlement to service connection for a respiratory disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.3, 4.130. 3. Prior to May 1, 2018, the criteria for an initial disability rating of 70 percent, but no greater, for service-connected PTSD with major depressive disorder have been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.3, 4.7, 4.130, Diagnostic Code 9411. 4. From May 1, 2018, forward, the criteria for a disability rating in excess of 70 percent for service-connected PTSD with major depressive disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.3, 4.7, 4.130, Diagnostic Code 9411. 5. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3. Introduction The Veteran had active duty service in the United States Army during Peacetime, from June 1981 to November 1981, and in the United States Navy during Peacetime and Gulf War Era, from October 1986 to April 1995. In a final, unappealed October 2011 administrative decision, the Department of Veterans Affairs (VA) Regional Office (RO) determined that the Veteran’s service from October 29, 1990, to April 6, 1995, was dishonorable for VA purposes and a bar to all VA benefits for that period of service. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from April 2012, January 2015, and October 2018 Rating Decisions by the VA RO. In November 2014, the Board issued a decision denying the issues addressed herein, which was ultimately appealed to the Court. According to both the November 2014 Board and March 2016 Court decisions, some of the Veteran’s STRs and military personnel records (MPRs) were deemed missing and presumed destroyed. As a result, the Court reiterated the Board’s “heightened duties to consider and discuss the evidence of record as well as to assist him in developing his claims.” See Washington v. Nicholson, 19 Vet. App. 362, 369-70 (2005). Ultimately, the Board’s November 2014 decision was vacated and remanded by the Court for readjudication. When this matter came before the undersigned Veterans Law Judge (VLJ) in March 2019, the issues of entitlement to service connection for fibromyalgia, neuropsychological symptoms (i.e., muscle twitches), irritable bowel syndrome, chronic fatigue syndrome, skin disorder, cardiovascular disorder, and bilateral ankle disabilities were denied, and the Veteran did not appeal the decision to the United States Court of Appeals for Veterans Claims (Court). Thus, the Board’s decision on those issues is final. The issues addressed herein were remanded by the Board for additional development, essentially, VA examinations, medical nexus opinions, and extraschedular consideration for a TDIU by the Director of Compensation Service. Additionally, the Board’s March 2019 decision held that the Veteran “did not have service in the Persian Gulf from August 2, 1990 to October 28, 1990, which is the only period of the Veteran’s honorable active service that falls during the Persian Gulf War under the provisions of 38 C.F.R. § 3.2.” As such, the issues have been recharacterized accordingly. The additional development has been undertaken and, following issuance of a March 2020 Supplemental Statement of the Case (SSOC) again denying the issues addressed herein, the matter has been returned to the Board for further appellate review. Although the Board sincerely regrets further delay, remand is again necessary for additional development before the issues of entitlement to service connection for bilateral carpal tunnel syndrome and obstructive sleep apnea (OSA) can be decided. Finally, this matter has been advanced on the Board’s docket. 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.900(c). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection requires competent evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or is the result of a service-connected disease or injury, or that a service-connected disease or injury has aggravated the non-service-connected disability for which service connection is sought. See 38 C.F.R. § 3.310. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Moreover, lay evidence can be competent and sufficient evidence of a diagnosis or to establish etiology if: (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau, 492 F.3d at 1376-77. Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Entitlement to service connection for headaches, to include as secondary to service-connected PTSD with major depressive disorder, is denied. In December 2011, the Veteran submitted a Statement in Support of Claim (VA Form 21-4138) wherein he described, among other things, experiencing headaches. As an initial matter, the Board notes that the Veteran’s service treatment records (STRs) are silent for complaints of headaches. The Board has carefully reviewed the Veteran’s VA and non-VA treatment records from March 2006 through December 2019. The Veteran’s records related to his disability benefits application with the Social Security Administration (SSA) are contained in the claims file. In September and November 2009, a private medical provider’s physical examinations were unremarkable for headache issues. In April 2012 and June 2012, VA mental health treatment notes indicate the Veteran reported “many physical problems,” including headaches, and he reportedly took Tylenol as needed for same. However, a VA primary care provider noted in April 2012 no history of dizziness or headaches. The Veteran was started on Venlafaxine and Lorazepam in May 2012, and he reportedly stopped taking Zoloft and Trazadone in the past due to upset stomach. He reported ongoing headaches according to June and July 2012 VA treatment notes. In August 2012, the Veteran reported that Trazadone and Restoril caused him to have headaches, and Ambien, Risperdal, Seroquel, and Lunesta caused nausea and vomiting. In October 2012, a VA treatment note indicated he “has not been routinely taking the Venlafaxine … or the Lorazepam as it causes him upset stomach and diarrhea.” The Veteran reportedly stopped taking Venlafaxine and Lorazepam in December 2012, and complaints of heartburn were noted. He continued to complain of headaches in February 2013; however, in April and May 2013, the Veteran denied experiencing headaches. A VA social worker noted in July 2015 that the Veteran reported “multiple medical issues,” including headaches. However, an August 2015 VA treatment note indicated that a review of the Veteran’s systems was negative for headaches, dizziness, or lightheadedness. The Veteran denied experiencing headache in April 2016. In May 2016, the Veteran underwent a medical examination for purposes of SSA disability benefits. According to the examiner, the Veteran reported “daily headaches” accompanied by “occasional nausea and vomiting,” for which he took over-the-counter medications with some benefit. The examiner noted that the Veteran “has multiple adverse reactions to medications that include nausea, vomiting, or headaches.” At the time, the Veteran was reportedly taking Prazosin. A May 2016 VA treatment note indicates the Veteran stopped taking medications such as Lorazepam, Venlafaxine, Sertraline, Trazadone, Quetiapine, Risperidone, and Diphenhydramine in the past “due to intolerable headaches and/or nausea,” and he was started on Prazosin and reported “slight headaches,” which he attributed to the medication. The Veteran reportedly stopped taking Prazosin in August 2016 “due to headaches.” According to a September 2016 VA treatment note, the Veteran cannot take the Prazosin at bedtime “as he believes it is causing him severe headaches.” He was prescribed Loxapine in September 2016 “to help with thoughts and promote sleep.” In October 2016, a VA treatment note indicated the Veteran stopped taking Loxapine due to being “worried about people stealing from his apartment.” In November 2016, a VA treatment noted indicated that a CT scan of the Veteran’s head revealed no acute pathology. A March 2017 Board decision remanded the issue of entitlement to service connection for headaches so that a VA examination could be conducted. In June 2018, the Veteran underwent a VA examination. The VA examiner noted that the Veteran reported, among other things, ongoing headaches since 1991. As a result, the VA examiner diagnosed headaches on the day of the exam based upon “the Veteran’s subjective report.” The VA examiner also noted “[n]o objective evidence of a chronic condition. However, the Board’s remand in March 2019 determined that the VA examination conducted in June 2018 was inadequate for purposes of determining whether service connection was warranted for a respiratory disorder. Essentially, because the VA examiner provided a negative nexus opinion limited only to headaches on a direct incurrence basis, and not also as secondary to medications taken for service-connected PTSD as noted in VA treatment records, as well as adverse medication reactions (e.g., headaches) noted in an SSA examination, an addendum medical opinion was warranted. As a result, an addendum VA medical opinion was rendered in December 2019. According to the VA examiner, the Veteran’s claimed condition of headaches “is less likely than not … proximately due to or the result of Veteran’s service connected [sic] condition.” By way of rationale, the VA examiner noted that, “review of the medical record shows no evidence of the diagnosis or treatment for chronic, severe or recurrent headaches.” Further, the VA examiner indicated that, “[r]eview of drug literature shows none of the [V]eterans [sic] prescribed medications has any significant risk for chronic headache.” Based upon the same rationale, the VA examiner also opined that the Veteran’s claimed condition of headaches was less likely than not aggravated beyond its natural progression by a service-connected condition. The VA examiner also opined that the Veteran’s claimed condition of headaches “is less likely than not … proximately due to or the result of a qualifying chronic disability, to include an undiagnosed illness, or the Veteran’s service connected [sic] PTSD with major depressive disorder. According to the VA examiner, the conditions are not medically related and the Veteran’s claimed condition of headaches “is a separate entity entirely from the service connected [sic] condition and unrelated to it.” The VA examiner indicated that “[t]he medical literature does not support a medical relationship,” and a “review of the medical record shows no evidence of the diagnosis or treatment for chronic, severe or recurrent headache.” Based upon the foregoing, the Board finds that service connection for the Veteran’s claimed headaches is not warranted. First, the Board observes that when the Veteran initially presented to the VA medical center (VAMC) in April 2012 for mental health treatment, he complained of headaches and was not presently taking medication for mental illness. In May 2012, the Veteran was started on Venlafaxine and Lorazepam which, according to the VA treatment records, he stopped taking it in December 2012 due to upset stomach and diarrhea. Although the VA treatment records rather inconsistently document complaints of headaches thereafter, the Veteran did not resume taking medication for mental illness until he was prescribed Prazosin in May 2016, which he had reportedly stopped taking by August 2016 “due to headaches.” Thereafter, he was prescribed Loxapine in September 2016, but stopped taking it due to being “worried about people stealing from his apartment.” As such, the Board finds there is no direct correlation in time regarding the Veteran’s episodic reports of headaches and his relatively brief usage of medications for mental illness, and the medical evidence suggests he discontinued taking the medications, other than Prazosin, for reasons other than complaints of headaches. Next, the Board observes that no medical provider has offered a nexus opinion attributing the Veteran’s complaints of headaches to his usage of medications for service-connected PTSD with major depressive disorder. While the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomology, he is not competent to diagnose the nature of his reported headaches or opine as to the etiology of same, as the issue of causation of such a medical condition is a medical determination outside the realm of common knowledge of a lay person. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Jandreau, 492 F.3d 1372. Thus, although the Board has carefully considered the Veteran’s contention that he has a headache disorder related to his service, the Board ultimately affords the objective medical evidence of record, which weighs against finding such a connection, greater probative weight than his lay contention. Also, the Board notes that the evidence of record does not suggest a continuity of headache symptomology since the Veteran’s military discharge. Finally, the Board notes an absence of evidence of a current headache disorder and, aside from the VA examiner’s June 2018 diagnosis of headaches based upon his “subjective report,” the last reference to complaints of headaches is dated September 2016. In sum, the Board finds that the most probative evidence of record shows that the Veteran does not have a headache disorder causally or etiologically related to any disease, injury, or event during his honorable period of military service (i.e., June 1981 to November 1981, and October 27, 1986, to October 28, 1990), or as secondary to or aggravated by his service-connected PTSD with major depressive disorder, or any medications taken for same. Consequently, service connection for such disorder is not warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for a headache disorder. As such, the doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Entitlement to service connection for a respiratory disorder, claimed as mesothelioma, to include as due to asbestos exposure, is denied. In December 2011, the Veteran submitted a Statement in Support of Claim (VA Form 21-4138) wherein he described, among other things, experiencing shortness of breath. According to the Veteran, an attending physician in Moorhead, Minnesota believed him to have Mesothelioma and recommended chest “x-rays and a possible biopsy,” which never materialized. Also, the Veteran described working around “asbestos” during military service. As an initial matter, the Board notes that, other than a “minimal” upper respiratory infection with no chronic disease reported, the Veteran’s STRs are silent for complaints of respiratory problems. A March 2017 Board decision remanded the issue of entitlement to service connection for a respiratory disorder so that a VA examination could be conducted. Further, the Board found the Veteran’s statement describing exposure to asbestos on the U.S.S. Nimitz to be credible, and such in-service exposure was conceded. In June 2018, the Veteran underwent a VA examination. The VA examiner noted the Veteran reported, among other things, shortness of breath and limited ability to walk as a result. Although a chest x-ray revealed borderline cardiomegaly with no pulmonary effusion or infiltrates, the VA examiner diagnosed mild obstructive lung disease based upon pulmonary function testing after the Veteran displayed significant shortness of breath after taking off his shoes. However, the Board’s remand in March 2019 determined that the VA examination conducted in June 2018 was inadequate for purposes of determining whether service connection was warranted for a respiratory disorder. Essentially, because the VA examiner provided a negative nexus opinion limited only to mesothelioma, rather than the Veteran’s diagnosed obstructive lung disease, an addendum medical opinion was warranted. As a result, an addendum VA medical opinion was rendered in December 2019, whereby the VA examiner opined that the Veteran’s diagnosed obstructive lung disease “was less likely than not … incurred in or caused by the claimed in-service injury, event, or illness.” By way of rationale, the VA examiner reported that “[r]eview of the STR shows no evidence of the diagnosis or treatment for any chronic respiratory illness,” and that “[m]ild obstructive disease is most likely related to the [V]eteran’s body habitus and history of smoking.” The VA examiner also noted that “[a]sbestos exposure does not cause obstructive respiratory symptoms.” In a separate Medical Opinion Disability Benefits Questionnaire (DBQ), the VA examiner indicated that “review of the medical records shows no evidence the [V]eteran has ever been diagnosed with mesothelioma” and, therefore, it “was less likely than not … incurred in or caused by the claimed in-service injury, event, or illness.” The Board has carefully reviewed the Veteran’s VA and non-VA treatment records from March 2006 through December 2019. The Veteran’s records related to his disability benefits application with the SSA are contained in the claims file. In September and November 2009, a private medical provider’s physical examinations were unremarkable for respiratory issues. A VA Homeless Program note dated December 2010 indicated the Veteran had never complained of chronic obstructive pulmonary disease (COPD) or emphysema. In April 2012, the Veteran’s lungs exhibited good airflow bilaterally with “no added sounds.” Thereafter, in February 2013, the Veteran presented with “course expiratory wheezes” in the lungs and was diagnosed with bronchitis. A May 2013 VA treatment note reported the Veteran’s lungs were clear to auscultation. In November 2013, a VA treatment note indicated the Veteran’s lungs exhibited good airflow bilaterally, and no history of shortness of breath or cough was reported. VA treatment records dated August 2015 and November 2017 indicated the Veteran did not endorse shortness of breath on exertion and respiratory examinations were unremarkable. In May 2016, the Veteran underwent a medical examination for purposes of SSA disability benefits. Although the Veteran reported “some shortness of breath,” he also expressed that “he is not sure if this is from sepsis or any cardiac issues.” Upon physical examination, the examiner noted the Veteran’s lungs were clear to auscultation bilaterally, with no rhonchi, rales, or wheezes. The examiner’s assessment was shortness of breath. The Veteran was hospitalized overnight at the VAMC in November 2016 for an allergic drug reaction and, on the first day, exhibited shortness of breath and reported chronic dyspnea. The next day, however, the Veteran displayed no respiratory distress and his lungs sounded clear. In September 2018, a VA Homeless Program note indicated the Veteran denied ever being told he has COPD. In October 2018, the Veteran did not endorse shortness of breath. Based upon the foregoing, the Board finds that service connection for a respiratory disorder is not warranted. First, the Board notes that the Veteran’s treatment records do not reflect a diagnosis of, or treatment for, a current respiratory condition. Also, the Board notes that the evidence of record does not suggest a continuity of respiratory symptomology since the Veteran’s military discharge. Aside from an isolated episode of bronchitis in February 2013 and an allergic drug reaction in November 2016, and a pulmonary function test administered by the VA examiner in June 2018 which suggested mild obstructive lung disease, no objective evidence of respiratory symptomology is currently of record. The Board recognizes the Veteran reported chronic shortness of breath during the June 2018 VA examination; however, the claims file does not include any additional evidence of chronic respiratory symptomology and, on multiple occasions, treatment records reflect the Veteran expressly denied chronic respiratory problems. Finally, although the Veteran’s exposure to asbestos during military service has been conceded, the December 2019 VA examiner’s addendum opinion stated that, “[a]sbestos exposure does not cause obstructive respiratory symptoms.” While the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomology, he is not competent to diagnose the nature of his claimed respiratory condition or opine as to the etiology of same, as the issue of causation of such a medical condition is a medical determination outside the realm of common knowledge of a lay person. See Barr, 21 Vet. App. 303; Jandreau, 492 F.3d 1372. Thus, although the Board has carefully considered the Veteran’s contention that he has a respiratory disorder related to his service, the Board ultimately affords the objective medical evidence of record, which weighs against finding such a connection, greater probative weight than his lay contention. In sum, the Board finds that the most probative evidence of record shows that the Veteran does not have a respiratory disorder causally or etiologically related to any disease, injury, or event during his honorable period of military service (i.e., June 1981 to November 1981, and October 27, 1986, to October 28, 1990). Consequently, service connection for such disorder is not warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for a respiratory disorder. As such, the doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Increased Ratings Disability evaluations are determined by comparing the Veteran’s current symptomology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two disability evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of, or overlapping with, the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Mental disorders are rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130; Diagnostic Code 9201-9440. PTSD is evaluated under Diagnostic Code 9411. In pertinent part, it provides the following: 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, mild memory loss (such as forgetting names, directions, recent events)......................................................................................................................30 Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.............................................................................................................50 Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships.........................70 Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name...........100 The symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list. Rather, the symptoms 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 (2002). 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 are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. The VA must consider all symptoms of a Veteran’s condition that affect the level of occupational and social impairment, including, if applicable, those identified in the fifth edition of the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Mauerhan, 16 Vet. App. 436. In both initial rating claims and normal increased rating claims, the Board must discuss whether “staged ratings” are warranted, and if not, why not. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of the evaluations shall be applied, the higher evaluation 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. When there is an approximate balance of positive and negative evidence regarding the degree of disability, the benefit of the doubt shall be given to the Veteran. See 38 U.S.C. § 5107; 38 C.F.R. § 4.3. Entitlement to an initial evaluation in excess of 30 percent for service-connected PTSD with major depressive disorder prior to May 1, 2018, is granted. A March 2010 medical opinion was rendered by a private psychiatrist. According to the private psychiatrist, the Veteran’s diagnoses included PTSD and depression. Further, the private psychiatrist opined that the Veteran would not be able to perform any employment in the foreseeable future. The Veteran submitted his claim for service connection for, among other things, PTSD and major depressive disorder in November 2010. Thereafter, he underwent a VA examination in November 2011, at which time the Veteran was diagnosed with a personality disorder and alcohol dependence in partial remission. According to the VA examiner, the Veteran experienced symptoms including depressed mood, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in adapting to stressful circumstances (including in work or work like settings), neglect of personal appearance and hygiene, feelings of hopelessness, guilt, or worthlessness. The VA examiner opined that the Veteran possessed occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. At the time, the VA examiner also opined that the Veteran was not capable of managing his financial affairs. In May 2012, a VA treating psychiatrist diagnosed chronic PTSD, moderate and recurrent major depressive disorder, and alcohol dependence. The VA psychiatrist noted the Veteran endorsed symptoms including fearing for his life and the lives of others, recurrent intrusive thoughts and images, distressing dreams, occasional flashback experiences, depression, feeling numb, detached, and estranged from others, and restricted range of affect, as well as, isolation, loss of interest in previously enjoyed activities, feeling hopeless, sadness, tearfulness, lack of motivation, avoidance of triggers and topic of traumas, insomnia, irritability, and a history of suicidal ideation with various attempts. The Veteran also reportedly experienced being easily startled, bouts of unprovoked anger and rage, and fatigue, with triggers including the smell of diesel fuel, crowds of people, and loud noises. According to the VA psychiatrist, the Veteran stated, “he is currently unemployable due to depression and sleep problems,” and commented that, “due to his chronic sleep deprivation he became unable to perform his job duties safely.” The Veteran reportedly last worked in 2002 doing maintenance on a grain elevator and operating forklifts. A Rating Decision dated January 2013 granted entitlement to service connection for PTSD effective May 22, 2012, “the first date the evidence of record shows an approved type of mental health provider had diagnosed … PTSD in accordance with the DSM-IV criteria,” and assigned a non-compensable rating. The Veteran underwent another VA examination in February 2013, at which time the examiner reported diagnoses including PTSD and alcohol abuse, and opined that his depression was not a separate diagnosis, but rather, part of his PTSD symptomology. The VA examiner indicated the Veteran possessed 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 are controlled by medication. Further, the VA examiner noted symptoms such as recurrent and distressing recollections of the event, recurrent distressing dreams of the event, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, restricted range of affect, difficulty falling or staying asleep, and exaggerated startle response. According to the VA examiner, although the Veteran reported subjective mental health symptoms, those symptoms did not rise to the level of chronicity required for rating or are not objectively identified on mental status examination. As a result, a February 2014 Rating Decision increased the Veteran’s disability rating for service-connected PTSD to 10 percent effective May 22, 2012. A November 2014 Board decision granted entitlement to an earlier effective date, specifically, November 24, 2010, for service-connected PTSD. Also, the Board decision remanded the issue of entitlement to a higher initial rating for service-connected PTSD, finding the February 2013 VA examiner’s opinion “internally inconsistent” and inadequate for rating purposes. Thereafter, a January 2015 Rating Decision granted the Veteran an increased rating of 30 percent for service-connected PTSD with major depressive disorder effective November 24, 2010. In December 2015, the Veteran underwent another VA examination. According to the VA examiner, the Veteran “stated he does not sleep well due to having flashbacks and nightmares nightly,” and reported social isolation. Further, the VA examiner reported symptoms such as recurrent, involuntary, and intrusive distressing memories, recurrent and distressing dreams, dissociative reactions in which the Veteran feels or acts as if the traumatic event was recurring, avoidance behavior, as well as, persistent, distorted cognitions about the cause or consequences of the traumatic event, persistent negative emotional state, feelings of detachment or estrangement from others, irritable behavior and angry outbursts, and sleep disturbances. Although she noted the Veteran’s PTSD symptoms “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning,” the VA examiner opined that the Veteran possessed occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. First, the Board observes that the March 2010 form completed by a private psychiatrist indicated his PTSD and depression were severe enough to prevent him from performing “any employment in the foreseeable future.” Second, the November 2011 VA examiner opined that the Veteran possessed occupational and social impairment with deficiencies in most areas and was not capable of managing his financial affairs. Third, a VA treating psychiatrist reported in May 2012 symptoms such as, inter alia, impaired impulse control with irritability and bouts of unprovoked anger and rage, depression affecting ability to function independently, appropriately, and effectively (e.g., “homeless much of the past 16 years”), recurrent intrusive thoughts with occasional flashbacks, difficulty adapting to stressful circumstances (e.g., avoidance behavior, easily startled, crowds of people, loud noises), issues with establishing and maintaining effective relationships (e.g., “detached and estranged from others), and being “unemployable due to depression and sleep problems,” further noting that, “due to his chronic sleep deprivation he became unable to perform his job duties safely.” Finally, the December 2015 VA examination reported symptoms such as, inter alia, recurrent and intrusive distressing memories, flashbacks, issues with establishing and maintaining effective relationships (e.g., social isolation, avoidance behavior, feelings of detachment or estrangement from others), persistent negative emotional state, irritable behavior and angry outbursts, and noted “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” Based upon the foregoing, the Board finds that, for the period prior to May 1, 2018, the Veteran’s PTSD more closely approximates occupational and social impairment with deficiencies in most areas, consistent with a 70 percent disability rating. Finally, the Board finds no distinct periods of time prior to May 1, 2018, for which staged ratings are warranted. Entitlement to an evaluation in excess of 70 percent for service-connected PTSD with major depressive disorder from May 1, 2018, forward is denied. The Veteran underwent another VA examination in May 2018. According to the VA examiner, the Veteran possessed occupational and social impairment with deficiencies in most areas. The VA examiner reported symptoms including, inter alia, depressed mood, anxiety, chronic sleep impairment, mild memory loss, impaired short and long-term memory, disturbances of motivation and mood, and difficulty adapting to stressful circumstances, including work or a work like setting. Further, the Veteran indicated that he tries “’to get out and do a few things, but it’s hard to do anything’ due to his physical health conditions,” and reportedly “[c]uts firewood and works on small engines” and has interests in fishing, prospecting, and traveling, “’but can’t do nothing without a driver’s license or money.’” The Board finds that the evidence of record does not establish total occupational and social impairment. For example, and not intended as an exhaustive list, the medical and lay evidence does not suggest gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting himself or others, intermittent inability to perform activities of daily living, disorientation to time or place, memory loss for names of close relatives or own name. In sum, the Board finds that for the period from May 1, 2018, forward, the most probative evidence of record shows that the Veteran’s service-connected PTSD with major depressive disorder more closely approximates occupational and social impairment with deficiencies in most areas, consistent with a 70 percent disability rating. The Board also finds no distinct periods of time since May 1, 2018, for which staged ratings are warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 70 percent for service-connected PTSD with major depressive disorder from May 1, 2018, forward. As such, the doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. TDIU A TDIU may be assigned, where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as the result of service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). Consideration may be given to a Veteran’s level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Todd v. McDonald, 27 Vet. App. 79, 85-86 (2014). To qualify for a total rating for compensation purposes, the evidence must show: (1) a single disability rated as 100 percent disabling; or (2) that the Veteran is unable to secure or follow a substantially gainful occupation because of his service-connected disabilities and there is one disability ratable at 60 percent or more, or, if more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent. 38 C.F.R. § 4.16(a). For those Veterans who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a), a TDIU nevertheless may be assigned when it is found that the service-connected disabilities are sufficient to produce unemployability. Such cases are referred to the Director of the VA Compensation Service for extra-schedular consideration. 38 C.F.R. § 4.16(b). Disabilities that are not service connected cannot serve as a basis for a total disability rating. 38 C.F.R. §§ 3.341, 4.19. Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, “entitlement to TDIU is based on an individual’s particular circumstance.” Rice v. Shinseki, 22 Vet. App. 447, 452 (2009) (quoting Thun v. Peake, 22 Vet. App. 111, 116 (2008)); see also Todd, 27 Vet. App. at 85-86. Therefore, in adjudicating a TDIU claim, VA must take into account the individual Veteran’s education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994). The Board notes that the ultimate question of whether a Veteran is capable of substantially gainful employment is a legal determination for VA adjudicators to make rather than a medical question to be answered by healthcare providers. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Thus, VA examiners’ conclusions, as well as those of private medical professionals or vocational experts, are not dispositive. However, the observations of these professionals may provide probative evidence as to a Veteran’s ability to obtain and maintain employment consistent with his or her education and experience. Entitlement to a TDIU is granted. Prior to May 1, 2018, the Veteran’s total combined service-connected disability rating was 40 percent (i.e., 30 percent for PTSD, 10 percent for tinnitus, and a non-compensable rating for bilateral hearing loss). However, an October 2018 SSOC increased the Veteran’s service-connected PTSD rating to 70 percent effective May 1, 2018. In March 2011, a private psychiatrist diagnosed PTSD and depression, and listed depression and anxiety as permanent mental limitations. Further, the psychiatrist opined that the Veteran “will not be able to perform any employment in the foreseeable future.” In November 2011, the VA examiner opined that the Veteran was incapable of managing his financial affairs. A VA treating psychiatrist noted in May 2012 that the Veteran “is currently unemployable due to depression and sleep problems,” and commented that, “due to his chronic sleep deprivation he became unable to perform his job duties safely.” The Veteran reportedly last worked in 2002 doing maintenance on a grain elevator and operating forklifts. The Veteran’s records related to his disability benefits application with the SSA are contained in the claims file. In May 2016, the Veteran underwent a medical examination for purposes of SSA disability benefits. According to the examiner, the Veteran’s “mental health disorders may play a role in his ability to independently hold on employment,” and deferred to the Veteran’s VA mental health provider. According to the Veteran’s Application for Increased Compensation Based on Unemployability (VA Form 21-8940) dated January 2019, he has a high school education with approximately one year of college, and past work in construction, welding, and heavy equipment operation. Throughout the rating period on appeal prior to May 1, 2018, the Veteran did not meet the percentage requirements for a TDIU. 38 C.F.R. § 4.16(a). However, based upon the March 2011 private psychiatric medical opinion, in March 2019 the Board remanded the issue of entitlement to a TDIU prior to May 1, 2018, on an extra-schedular basis, which required referral to the Director of Compensation Service for initial consideration. In March 2020 the Executive Director of Compensation Service (Director) issued an advisory opinion addressing the Veteran’s entitlement to a TDIU on an extra-schedular basis prior to May 1, 2018. 38 C.F.R. § 4.16(b). Upon review, the Director “determined the overall evidence fails to support the contention that any of the service-connected disabilities or a combination of the effects of those disabilities prevents employment.” “[A] Veteran need only demonstrate that there is an ‘approximate balance of positive and negative evidence’ in order to prevail.” Gilbert, 1 Vet. App. 49. Under the benefit of the doubt doctrine established by Congress, when the evidence is in “relative equipoise, the law dictates that the Veteran prevails.” Id. Upon review of the evidence of record, and coupled with the Board’s grant of entitlement to an increased rating of 70 percent for service-connected PTSD with major depressive disorder for the period prior to May 1, 2018 (thereby meeting the percentage requirements under 38 C.F.R. § 4.16(a)), the Board is persuaded that the Veteran is unable to secure or follow a substantially gainful occupation based upon the functional effects of his service-connected PTSD with major depressive disorder and when coupled with his level of education and prior occupational experience. The evidence, at a minimum, is in relative equipoise. As a result, a TDIU is therefore granted. REASONS FOR REMAND Entitlement to service connection for left carpal tunnel syndrome is remanded. The Board’s remand in March 2019 determined that the VA examination conducted in June 2018 was inadequate for purposes of determining whether service connection was warranted for left carpal tunnel syndrome. First, the Board took issue with the VA examiner’s negative nexus opinion that was based largely upon service treatment records (STRs) being silent for a left wrist condition, as well as the VA examiner’s assertion that a positive opinion could not be rendered without resorting to mere speculation. Next, the Board found the VA examiner’s notation that no diagnosis of left carpal tunnel syndrome was found in the Veteran’s claims file was made without the benefit of conducting electromyogram (EMG) testing. Further, the Board found the VA examiner’s opinion unclear as to the presence of a current disability in that it referenced “mild carpal tunnel syndrome,” yet, relied on a lack of a diagnosis as support for the negative nexus opinion. Finally, the Board took issue with the VA examiner’s finding of no complaints until 2015, although a September 2009 private treatment note indicated concern of carpal tunnel in the hands. As a result, the Board found that another VA examination was warranted, which was conducted in February 2020. The VA examiner did not report a diagnosis of left carpal tunnel syndrome and relied upon an October 2015 EMG nerve conduction study as support for the absence of a current disability. Because the VA examiner did not acknowledge a current disability of left carpal tunnel syndrome, the examiner did not offer a nexus opinion regarding the claimed condition. The Board finds the February 2020 VA examiner’s opinion inadequate for purposes of determining whether service connection for left carpal tunnel syndrome is warranted. The VA examiner was directed to conduct any indicated diagnostic tests and studies, “to include EMG testing, if warranted to provide a diagnosis.” The VA examiner’s reliance upon the October 2015 EMG nerve conduction study to support a lack of a present disability did not constitute substantial compliance with the Board’s previous remand directives. Further, as with the June 2018 VA examiner’s opinion, which was previously deemed inadequate by the Board, the March 2020 SSOC once again referred to “mild carpal tunnel syndrome diagnosed October 6, 2015,” however, said EMG did not reveal left carpal tunnel syndrome. The VA examiner also did not address the September 2009 private treatment note reflecting concern of carpal tunnel in the hands. As such, the Board finds there has not been substantial compliance with its previous remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Thus, another VA examination addressing the Veteran’s claimed left carpal tunnel syndrome is warranted. Entitlement to service connection for right carpal tunnel syndrome is remanded. The Board’s remand in March 2019 determined that the VA examination conducted in June 2018 was inadequate for purposes of determining whether service connection was warranted for right carpal tunnel syndrome. First, the Board took issue with the VA examiner’s negative nexus opinion that was based largely upon service treatment records (STRs) being silent for a left wrist condition, as well as the VA examiner’s assertion that a positive opinion could not be rendered without resorting to mere speculation. Next, the Board took issue with the VA examiner’s finding of no complaints until 2015, although a September 2009 private treatment note indicated concern of carpal tunnel in the hands. As a result, the Board found that another VA examination was warranted, which was conducted in February 2020. The VA examiner acknowledged a diagnosis of right carpal tunnel syndrome based upon the October 2015 EMG nerve conduction study. However, the VA examiner opined the condition “was less likely than not … incurred in or caused by the claimed in-service injury, event or illness.” According to the VA examiner, the Veteran’s “mild right carpal tunnel syndrome diagnosed [October 2015] is a new and separate condition not related to military service.” Additionally, the VA examiner noted “[t]he majority of medical evidence documented in the medical literature does not suggest the job description of [a]vionics technician as a risk factor/causative etiology of carpal tunnel syndrome,” and that “[t]he diagnosis of mild carpal tunnel syndrome dated [October 2015] is consistent with recent onset.” The Board finds the February 2020 VA examiner’s opinion inadequate for purposes of determining whether service connection for right carpal tunnel syndrome is warranted. The VA examiner was directed to conduct any indicated diagnostic tests and studies, “to include EMG testing, if warranted to provide a diagnosis.” The VA examiner’s reliance upon the almost four-and-a-half-year-old October 2015 EMG nerve conduction study diagnosing mild right carpal tunnel syndrome, to support the opinion of “recent onset,” did not constitute substantial compliance with the Board’s previous remand directives. Further, aside from the VA examiner’s cursory statement that the October 2015 EMG nerve conduction study revealing mild right carpal tunnel syndrome is consistent with recent onset, the examiner did not provide a medical basis to doubt the history of symptomology since military service provided by the Veteran. The Board finds the VA examiner’s reliance on the October 2015 diagnosis of mild right carpal tunnel syndrome is particularly diminished by a November 2017 VA treatment note reporting “severe” right carpal tunnel syndrome for which eventual surgery was anticipated. Finally, the VA examiner also did not address the September 2009 private treatment note reflecting concern of carpal tunnel in the hands. As such, the Board finds there has not been substantial compliance with its previous remand directives. See Stegall, 11 Vet. App. at 271. Thus, another VA examination addressing the Veteran’s diagnosed right carpal tunnel syndrome is warranted. Entitlement to service connection for OSA, to include as secondary to service-connected PTSD with major depressive disorder, is remanded. In December 2011, the Veteran submitted a Statement in Support of Claim (VA Form 21-4138) wherein he described, among other things, experiencing sleep disturbances, including, OSA. As an initial matter, the Board notes that the Veteran’s STRs are silent for complaints of sleep disturbances or OSA. The Veteran underwent a sleep study/polysomnography assessment with a non-VA medical provider in January 2010. The assessment revealed evidence of mild OSA “resulting in some sleep fragmentation and no desaturations,” and periodic limb movement with and without arousals. The Veteran’s VA treatment records report difficulty falling and staying asleep, as well as fatigue. A VA treatment note dated May 2012 indicated the Veteran’s sleep issues “started while in the service,” however, reportedly due to “having survivor’s guilt.” In August 2019, he was noted to still be waiting for a CPAP machine. A March 2017 Board decision remanded the issue of entitlement to service connection for OSA so that a VA examination could be conducted. Thereafter, the Veteran underwent a VA examination in May 2018. However, the Board’s remand in March 2019 determined that the VA examination conducted in May 2018 was inadequate for purposes of determining whether service connection was warranted for OSA. Essentially, because the VA examiner provided a negative nexus opinion without addressing the possibility of aggravation of OSA by the Veteran’s service-connected PTSD with major depressive disorder or the effects of medications taken for same, an addendum medical opinion was warranted. In December 2019, an addendum VA medical opinion was rendered. According to the VA examiner, the Veteran’s OSA is “less likely than not … proximately due to or the result of the Veteran’s service connected [sic] condition” of PTSD with major depressive disorder. The VA examiner also opined that the Veteran’s OSA was less likely than not aggravated beyond its natural progression by his service-connected PTSD with major depressive disorder. By way of rationale, the VA examiner explained that the Veteran’s STRs “show no evidence of the diagnosis or treatment for [OSA] or diagnostic polysomnography while on active duty.” Additionally, the VA examiner noted that, “[m]edical literature does not support a mental health condition (PTSD) as causative or the potential for aggravation of the physiologic condition of OSA which is due to upper airway soft tissue abnormalities/[o]besity.” The Board finds the December 2019 VA examiner’s opinion inadequate for purposes of determining whether service connection for OSA, to include as secondary to the Veteran’s service-connected PTSD with depressive disorder, is warranted. The VA examiner was directed to provide an opinion regarding whether the Veteran’s OSA was proximately due to or aggravated by his service-connected PTSD with major depressive disorder, to include as due to any psychiatric medication prescribed. However, the VA examiner’s opinion fails to address what effect, if any, the various mental health medications the Veteran has taken, albeit infrequently and inconsistently, have had on his OSA. As discussed previously herein, the Veteran did express concern about the impact Loxapine was having on his sleep. As such, the Board finds there has not been substantial compliance with its previous remand directives. See Stegall, 11 Vet. App. at 271. Thus, another VA examination addressing the Veteran’s diagnosed OSA, to include as secondary to the Veteran’s service-connected PTSD with major depressive disorder, is warranted. Accordingly, the matters are REMANDED for the following action: 1. Schedule the Veteran for a medical examination with a physician (preferably a neurologist) possessing suitable expertise to fully assess and provide an opinion regarding the nature, severity, and etiology of the Veteran’s claimed bilateral carpal tunnel syndrome for the entire period on appeal. All pertinent evidence of record, as well as this remand Order, must be made available to and reviewed by the examiner. Any indicated studies, including EMG/NCV testing, should be performed. The examiner must obtain a full history from the Veteran. It should be noted the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner must provide a fully-reasoned explanation. All pertinent symptomology, including continuity of symptomology since military service, and findings must be reported in detail. Based upon a review of all pertinent documents in the Veteran’s claims file, including medical records and the examination results, the examiner must provide an opinion as to: (a.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran has left carpal tunnel syndrome. (b.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s claimed bilateral carpal tunnel syndrome is due to, related to, or otherwise etiologically associated with an in-service injury, event, or disease, including as due to repetitive wiring as an avionics technician, during a qualifying period of honorable active duty service (i.e., from June 1981 to November 1981, or October 27, 1986, to October 28, 1990). The examiner must address and discuss as necessary the September 2009 private treatment note reflecting concern of carpal tunnel in the hands. A complete rationale for any opinion expressed must be provided. If it is not possible to provide the above-requested opinions without resorting to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts), a deficiency in the record (i.e., additional facts are required), or the examiner (i.e., does not possess the necessary knowledge or training). 2. Schedule the Veteran for a medical examination with a board-certified sleep specialist (preferably a neurologist) possessing suitable expertise to fully assess and provide an opinion regarding the nature, severity, and etiology of the Veteran’s OSA for the entire period on appeal. All pertinent evidence of record, as well as this remand Order, must be made available to and reviewed by the examiner. Any indicated studies, including a sleep study, should be performed. If the examiner is unable to conduct the required testing, or concludes any such testing is not necessary, he or she must explain why that is so. The examiner must obtain a full history from the Veteran. It should be noted the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner must provide a fully-reasoned explanation. All pertinent symptomology, including continuity of symptomology since military service, and findings must be reported in detail. Based upon a review of all pertinent documents in the Veteran’s claims file, including medical records and the examination results, the examiner must provide an opinion as to: (a.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s OSA is proximately due to, related to, or otherwise etiologically associated with service-connected PTSD with major depressive disorder, to include as due to any previously or currently prescribed psychiatric medications. (b.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s OSA has been aggravated beyond its natural progression by service-connected PTSD with major depressive disorder, to include as due to any previously or currently prescribed psychiatric medications. A complete rationale for any opinion expressed must be provided. If it is not possible to provide the above-requested opinions without resorting to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts), a deficiency in the record (i.e., additional facts are required), or the examiner (i.e., does not possess the necessary knowledge or training). T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Worsham, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.