Citation Nr: 20054797 Decision Date: 08/19/20 Archive Date: 08/19/20 DOCKET NO. 20-03 769 DATE: August 19, 2020 ORDER As new and material evidence has been presented, the claim for ischemic heart disease is reopened. Entitlement to an effective date earlier than August 14, 2018, for the assignment of a 30 percent rating for bilateral hearing loss is denied. Entitlement to service connection for chronic kidney disease as secondary to diabetes mellitus, type II, is granted. Entitlement to service connection for obstructive sleep apnea (OSA) as secondary to PTSD is granted. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is denied. Entitlement to service connection for prostate cancer is denied. Entitlement to service connection for peripheral neuropathy of the right upper extremity is denied. Entitlement to service connection for peripheral neuropathy of the left upper extremity is denied. Entitlement to service connection for peripheral neuropathy of the left lower extremity (previously claimed as numbness left foot and ankle) is denied. Entitlement to service connection for skin cancer, to include as due to herbicide exposure, is denied. Entitlement to service connection for tongue cancer, to include as due to herbicide exposure, is denied. Entitlement to service connection for a heart disorder, including ischemic heart disease and sinus bradycardia, is denied. Entitlement to an increased disability rating greater than 30 percent for bilateral hearing loss is denied. Entitlement to an increased disability rating of 70 percent for posttraumatic stress disorder (PTSD) is granted. Entitlement to a total rating based upon individual unemployability (TDIU) due to service-connected disabilities, beginning May 05, 2016, is granted. REMANDED Entitlement to a disability rating greater than 70 for PTSD is remanded. FINDINGS OF FACT 1. The January 2011 rating decision denying the Veteran’s claim for service connection for ischemic heart disease is final. 2. Evidence associated with the claims file since the January 2011 rating decision is new and raises a reasonable possibility of substantiating the claim for entitlement to service connection for a heart disability. 3. The Veteran’s claim for a compensable disability rating for bilateral hearing loss was received on August 14, 2018, and the November 2018, VA examination showed an increase in his hearing severity. 4. The preponderance of the evidence reflects that the Veteran’s kidney disease is caused by his service-connected diabetes mellitus, type II. 5. The preponderance of the evidence reflects that the Veteran’s OSA is caused by his service-connected PTSD. 6. The preponderance of the evidence reflects that the Veteran does not have a current diagnosis of COPD at any time since he filed his claim or within proximity thereto. 7. The preponderance of the evidence reflects that the Veteran does not have a current diagnosis of prostate cancer, due to any incident of his active duty service, to include herbicide exposure. 8. The preponderance of the evidence reflects that the Veteran does not have a current diagnosis of peripheral neuropathy of the right upper extremity at any time since he filed his claim or within proximity thereto. 9. The preponderance of the evidence reflects that the Veteran does not have a current diagnosis of peripheral neuropathy of the left upper extremity at any time since he filed his claim or within proximity thereto. 10. The preponderance of the evidence reflects that the Veteran does not have a current diagnosis of peripheral neuropathy of the left lower extremity at any time since he filed his claim or within proximity thereto. 11. The preponderance of the evidence reflects that the Veteran does not have skin cancer, or residuals therefrom, due to any incident of his active duty service, to include herbicide exposure. 12. The preponderance of the evidence reflects that the Veteran does not have tongue cancer, or residuals therefrom, due to any incident of his active duty service, to include herbicide exposure. 13. The Veteran’s sinus bradycardia is not among the listed disabilities presumed to be caused by herbicide exposure, and the probative evidence of record does not reflect that it is due to service or any incidents thereof. 14. The Veteran does not have ischemic heart disease. 15. During the appeal period, the Veteran’s bilateral hearing loss was manifested by no worse than a Level VII in the right ear and Level VI in the left ear. 16. During the appeal period, the Veteran’s PTSD symptoms manifested as occupational and social impairment with deficiencies in most areas. 17. The Veteran’s service-connected PTSD precludes him from securing or following substantially gainful employment beginning May 05, 2016. CONCLUSIONS OF LAW 1. The criteria for reopening a final claim for denial of service connection for ischemic heart disease are met. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. §§ 3.156 (a), 3.160 (d), 19.20, 19.52, 20.1103. 2. 2. The criteria for an effective date before August 14, 2018, for the assignment of a 30 percent rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 5107 (b), 5110 (2012); 38 C.F.R. §§ 3.102, 3.155, 3.400. 3. The criteria for service connection for a kidney disorder have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for OSA have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for establishing service connection for COPD have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for establishing service connection for prostate cancer have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for establishing service connection for peripheral neuropathy of the right upper extremity have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. The criteria for establishing service connection for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 9. The criteria for establishing service connection for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 10. The criteria for establishing service connection for skin cancer have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 11. The criteria for establishing service connection for tongue cancer have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303. 12. The criteria for establishing service connection for sinus bradycardia have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303. 13. The criteria for a rating higher than 30 percent for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.385, 4.1-4.14, 4.85, 4.86, Diagnostic Code 6100. 14. The criteria for a 70 percent disability rating for PTSD have been approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.125, 4.130, Diagnostic Code 9411. 15. Beginning May 05, 2016, a TDIU is warranted. 38 U.S.C.§§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1966 to September 1969. The issues come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The rating decision of October 2016 continued the 30 percent rating for PTSD and denied service connection for numbness in left foot and ankle, peripheral neuropathy of the right and the left upper extremities, and prostate cancer. The rating decision of November 2018 increased the noncompensable disability rating for bilateral hearing loss to 30 percent disabling, effective August 14, 2018, and denied service connection for COPD, skin cancer, tongue cancer, and kidney disease secondary to service-connected diabetes mellitus, type II. The rating decision of January 2019 denied service connection for OSA and sinus bradycardia (claimed as ischemic heart disease). The rating decision of December 2019 increased the disability rating for PTSD from 30 percent disabling to 50 percent, effective May 05, 2016, and granted TDIU, effective August 14, 2018. In October 2019, the Veteran was afforded a decision review officer (DRO) hearing. A copy of the DRO Conference Report is of record. In January 2020, the Veteran attested that his hearing loss disability is worse than 30 percent and requested a new examination. VA’s duty to assist includes providing a new medical examination when a Veteran asserts or provides evidence that a disability has worsened, and the available evidence is too old for an adequate evaluation of the current condition. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); 38 C.F.R. § 3.326 (a). Here, however, the Veteran has not provided any examples of a worsening of his hearing loss disability since his November 2018 examination, less than two years ago. The medical evidence also does not reflect an increase in severity. As such, the Board will proceed with the adjudication of the claim. In January 2020, the Veteran’s representative provided VA Form 20-0995, Decision Review Request: Supplemental Claim, and attempted to withdraw the issues of an increased rating for hearing loss and an earlier effective date for hearing loss from the legacy system, by marking “opt[ing]-in” from the Statement of the Case (SOC) of December 2019. In April 2020, the RO notified the Veteran that the appeal has been activated by the Board of Veterans’ Appeals and no longer qualifies for processing under AMA. The issue of an increased rating for PTSD has been bifurcated because it is more favorable to the Veteran. The bifurcation allows the Board to grant an increased rating of 70 percent disability rating for PTSD, beginning May 05, 2016, but then remand the issue of entitlement to a still higher rating for additional development. This results in a partial grant benefits and payment, while development for the remaining aspects of the increased rating issue is developed on remand. VA is free to bifurcate a claim and adjudicate it in separate pieces. Tyrues v. Shinseki, 23 Vet. App. 166, 186 (2009) (en banc), aff’d, 631 F.3d 1380 (Fed. Cir. 2011); rev’d on other grounds, 132 S.Ct. 75 (2011). Further, “[b]ifurcation of a claim generally is within the Secretary’s discretion.” Locklear v. Shinseki, 24 Vet. App. 311, 315 (2011). Although the AOJ did not certify the issue of a TDIU as part of this appeal, the Board will consider the issue of entitlement to a TDIU, beginning May 05, 2016, as part of the claims for increased ratings. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). I. As new and material evidence having been presented, the claim for ischemic heart disease is reopened. In June 2009, the Veteran filed a claim for ischemic heart disease due to presumptive exposure to herbicide exposure in Vietnam. The rating decision of January 2011 denied service connection based on a finding of no disability. The RO considered the Veteran’s service treatment (STRs) and personnel records, post-service treatment records, and lay statements. The Board notes that the VA post-service treatment entry showed a July 2008 clinical notation of “LP, lipids at target for non-overt CAD.” In its denial, the RO noted a finding of no diagnosis of ischemic heart disease or a history of myocardial infarction, coronary bypass surgery, congestive heart failure, or heart transplant, in its denial of the claim. Significantly, the RO noted that the VA heart examination of August 2010 found no current disability. The Veteran was informed of the rating decisions and what to do if he disagreed or had questions. The Veteran did not provide notice of disagreement (NOD) or provide new and material evidence within one year of the rating decisions promulgation. Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2011); Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). Hence, the January 2011 rating decision denying entitlement to service connection for ischemic heart disease is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.160 (d), 19.20, 19.52, 20.1103. The Board has no jurisdiction to consider a claim based on the same factual basis as a previously disallowed claim. 38 U.S.C. § 7104 (b) (2012); King v. Shinseki, 23 Vet. App. 464 (2010); DiCarlo v. Nicholson, 20 Vet. App. 52, 55 (2006) (holding that res judicata generally applies to VA decisions). However, the finality of a previously disallowed claim can be overcome by the submission of new and material evidence. 38 U.S.C. § 5108 (2012). New evidence means existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). In determining whether evidence is new and material for purposes of deciding whether a claim should be reopened, “the credibility of the evidence is to be presumed.” Savage v. Gober, 10 Vet. App. 488 (1997); Justus v. Principi, 3 Vet. App. 510, 513 (1992). Only in cases in which the newly submitted evidence is “inherently false or untrue” does the presumption of credibility not apply. Duran v. Brown, 7 Vet. App. 216, 220 (1994). New evidence raises a reasonable possibility of substantiating the claim if, when considered with the evidence already of record, it would trigger the Secretary’s duty to assist by providing a medical opinion. Shade v. Shinseki, 24 Vet. App. 110 (2010). The evidence received since the January 2011 rating decision includes additional lay statements, a December 2018 VA examination, and additional VA and private treatment records. The Board notes that the VA treatment records include a September 2018 VA notation that “[b]ased on our discussions, Veteran and spouse were encouraged to meet with VSO about the presumptive conditions of Diabetes and CAD, …” Additionally, a January 2019 letter from VA Staff Psychologist, S. R. H. Ph.D., stated that the Veteran “has a blockage in his carotid arteries and diabetes and coronary artery disease are presumptive conditions associated with exposure to Agent Orange.” Moreover, a May 2019 notation indicating that the Veteran had an “ejection fraction of 55-65% [and an] exercise Myoview scan of April 2018 revealed no indication of ischemia.” The Board finds the above evidence is not redundant of what was in the file at the time of the January 2011 rating decision. Therefore, this evidence is deemed new and material evidence. Accordingly, the Board finds that the evidence received since the January 2011 rating decision is new and material, raises a reasonable possibility of substantiating the claim for ischemic heart disease. 38 U.S.C. § 5107 (2012); Annoni, 5 Vet. App. 463. The claim is thus, reopened. II. Entitlement to an effective date earlier than August 14, 2018, for the assignment of a 30 percent rating for bilateral hearing loss is denied. In September 2004, the Veteran filed a claim for service connection for bilateral hearing loss. In a rating decision of March 2005, granted service-connection at a noncompensable rating, effective September 17, 2004. The Veteran did not file a NOD, nor did he provide additional evidence. Thus, that rating became final. The Veteran contends that he is entitled to an effective date earlier than August 14, 2018, for the assignment of a 30 percent rating for bilateral hearing loss. In a November 2018 rating decision, the RO increased the Veteran’s bilateral hearing loss from noncompensable to 30 percent, effective August 14, 2018, based upon his claim for an increased rating that was received on the said date. Generally, the effective date of an evaluation and award of compensation for an increased rating claim is the date of receipt of the claim, or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400 (o)(1). An exception to 38 C.F.R. § 3.400 provides that in cases involving increases for disability compensation, the effective date will be the earliest as of which it is factually ascertainable that an increase in disability had occurred if the claim is received within one year from such date; otherwise, the effective date will be the date of receipt of the claim. 38 U.S.C. § 5110 (b)(2); 38 C.F.R. § 3.400(o)(2); Harper v. Brown, 10 Vet. App. 125, 126 (1997). The question of when an increase in disability is factually ascertainable is based on the evidence in the Veteran’s claims folder. Quarles v. Derwinski, 3 Vet. App. 129, 135 (1992). On August 14, 2018, the RO received a VA Form 21-526b, the Veteran’s Supplemental Claim or Compensation, requesting a compensable disability rating for bilateral hearing loss. In November 2018, the Veteran underwent a hearing loss examination, which showed the average an average decibel loss in the right ear at 80, and the left at 74. There is no competent medical or lay evidence of record, reflecting the Veteran’s bilateral hearing loss or symptoms thereof, before the November 2018 VA examination. Thus, the earliest medical evidence of record showing an increase in severity was the November 2018 VA examination. The November 2018 date is less favorable than August 14, 2018, the date the RO received the Veteran’s claim for increase. Further, the Board notes that the Veteran has not at any point alleged a clear and unmistakable error (CUE) in the November 2018 rating decision that increased his bilateral hearing loss to 30 percent. CUE is another potential avenue of recovery, in seeking to demonstrate that a very serious substantive error of law or fact (not merely weighing of fact, or failure to fully develop the claim) that the outcome of the decision would have been manifestly different. Accordingly, an effective date earlier than August 14, 2018, for an increased rating of 30 percent for bilateral hearing loss date is denied. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (o) (2). III. Service connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity for certain diseases. 38 C.F.R. §§ 3.303 (a), (b), 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). To establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303; Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Secondary service connection may also be established for a nonservice-connected disability, which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing before the aggravation. 38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). To establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331(Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. The Board must then determine if the evidence is credible or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The third step of this inquiry requires the Board to weigh the probative value of the evidence considering the entirety of the record. The standard of proof to be applied in decisions on claims for veterans’ benefits is outlined in 38 U.S.C. § 5107 (2012). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. Alemany v. Brown, 9 Vet. App. 518 (1996). In March 2020, VA conceded in a memorandum, the Veteran’s exposure to herbicides based on the Veteran’s duty or visitation (boots on the ground) in the Republic of Vietnam. If a veteran was exposed to a herbicide agent (to include Agent Orange) during active service, specific diseases and conditions should be service-connected if the requirements of 38 C.F.R. § 3.307 (a)(6) are met, even though there is no record of such disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307 (d) are also satisfied. Service connection for a disability claimed as due to exposure to herbicide agents may be established by showing that a disorder resulting in disability or death was, in fact, causally linked to such exposure. Brock v. Brown, 10 Vet. App. 155, 162-64 (1997); Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994), citing 38 U.S.C. § 1113 (b) and 1116 and 38 C.F.R. § 3.303. 1. Entitlement to service connection for chronic kidney disease as secondary to diabetes mellitus, type II, is granted. 2. Entitlement to service connection for OSA as secondary to PTSD is granted. The Veteran contends that he has a kidney disorder due to his service-connected diabetes mellitus, type II. He also contends that entitlement to service connection for OSA is warranted secondary to his PTSD. The Board finds that since there are current chronic kidney disorder and OSA. The Veteran is also service connected for diabetes mellitus and PTSD. Thus, the first two elements are met. Wallin, 11 Vet. App. 509, 512 (1998). Regarding the kidney disorder, the Veteran provided an independent medical opinion from Dr. L. H., MD, citing support for a nexus, that the Veteran’s chronic renal failure secondary to diabetes mellitus, type II. Dr. L. H. explained that the Veteran’s diagnosis of microalbuminuria in September 2017 and May 2019, noted with elevated blood urea nitrogen (BUN). As the Veteran …did not have any renal artery stenosis, and the fact that he had microalbuminuria, means that he has a microvascular renal disease from Type II Diabetes Mellitus. It is absolutely more likely than not that this Veteran’s albuminuria and decrease in kidney function are secondary to his service-connected diabetes type II. Regarding OSA, the Veteran provided a positive nexus opinion from Dr. J. S. S., who noted a relationship between the Veteran’s OSA and his service-connected PTSD. Dr. J. S. S. explained that PTSD disrupts the sleep system, from the hypothalamus down. The Veteran experienced chronic sleep disturbances over the last 18 years plus, by way of sleep loss and inability to fall asleep related to “my brain won’t stop” and hypervigilance to the level of paranoia, and by way of sleep fragmentation with the sudden awakening from both nightmares and nighttime hypervigilance; where the Veteran will then engage in nighttime safety checks around the house. Further, he cited a research study that shows sleep fragmentation and sleep deprivation leads to esophageal collapsibility, which is the core medical definition of OSA. Moreover, he noted that PTSD causes cravings for high-caloric foods, weight gain, and obesity, which are is major factors in the development of OSA. Especially, he noted the Veteran’s historical pattern of eating and drinking excessively high caloric foods such as “snacks...cookies...[and “2-3 six-packs a week” of] beer” to the point of the Veteran becoming “pre-diabetic” and reaching “225 [pounds] or a BMI of 30.5/Obesity.” Both Drs. Dr. L. H. and J. S. S. acknowledged a thorough review of the Veteran’s claims file and lay statements in generating the opinions. The Board finds both opinions and examinations probative. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (noting that the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion.) Furthermore, there are no contradictory medical opinions of record. As the evidence of record is reflective of a finding that the Veteran’s kidney disorder is caused by his service-connected diabetes mellitus, and his OSA is caused by his PTSD, the Board finds that the nexus element of the secondary service connection claims are satisfied. Wallin, 11 Vet. App. at 512. Accordingly, the Board finds that the preponderance of the evidence is in favor of service connection for a kidney disorder and OSA. 38 U.S.C. § 5107(b) (2012). Service connection for a kidney disorder as secondary to the service-connected diabetes mellitus, type II, and OSA secondary to PTSD is, thus, granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 3. Entitlement to service connection for COPD is denied. 4. Entitlement to service connection for prostate cancer is denied. 5. Entitlement to service connection for peripheral neuropathy of the right upper extremity is denied. 6. Entitlement to service connection for peripheral neuropathy of the left lower extremity is denied. 7. Entitlement to service connection for peripheral neuropathy of the left upper extremity is denied. The Veteran contends that he is entitled to service connection for the above-said disabilities. The Veteran’s STRs from his period of active duty service are absent complaint, diagnosis, or treatment of lung/respiratory, prostate, or neuropathy disorder. STRs, however, do show a March 1966 complaint of coughing up blood. The clinician diagnosed bronchitis. In February 1968, a complaint of a “bad cough for weeks.” Treatment notes dated in May 1969 notes that chest X-ray findings showed no abnormality. As for COPD, further treatment records show heart and pulmonary systems were within normal limits, absent any acute cardiopulmonary process. A July 2016 record reported clear and equal breath sounds without abnormal findings on auscultation of chest/lungs. During a VA examination of October 2018, the examiner found no current disability. Private treatment records show a diagnosis of benign prostatic hyperplasia (BPH), mild prostate enlargement, non-tender. The Veteran has not been diagnosed with prostate cancer. Presumptive service connection is therefore not warranted. The Veteran has not asserted, nor does the evidence show that the Veteran’s BPH is related to service. The Veteran also has not been diagnosed with peripheral neuropathy in the bilateral upper or left lower extremity. In October 2017, the Veteran reported numbness and tingling in his feet, but neuropathy was not diagnosed. In August 2018, he had a sensory examination performed on his feet and it was normal. The probative evidence of record is void of any VA or private treatment notes showing symptoms or diagnoses of any other above disabilities the appeal period. The Board has considered the Veteran’s lay statements. He is competent to describe observable symptoms. However, the Veteran has not provided a lay description of his symptoms. He has only stated that such disabilities are present and are a result of service. The Board must determine on a case by case basis whether a particular condition is the type of condition that is within the competence of a layperson to provide an opinion as to etiology. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Veteran, in this case, is not competent to self-diagnose his claimed disabilities. Diagnosing COPD, prostate cancer, and neuropathy involves understanding of internal physical processes not observable to a lay person and the record does not show that he has the experience, skills, or medical training needed to self-diagnose these disabilities. His lay statements are not probative evidence in support of a finding of said disabilities during the appeal period. The Veteran has not shown that he has breathing symptoms, prostate symptoms, or neuropathy symptoms that cause functional impairment of earning capacity. Accordingly, as the probative and competent medical evidence does not reflect a current disability during the appeal period, the first element of a service connection claim is not met. Shedden, 381 F.3d 1163. Thus, a service connection for COPD, prostate cancer, peripheral neuropathy of the bilateral upper extremity, and peripheral neuropathy of the left upper extremity is not warranted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (“Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability,” and held that “[i]n the absence of proof of a present disability[,] there can be no valid claim.”); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the claims, the doctrine is not for application. 38 U.S.C. § 5107 (2012); Gilbert, 1 Vet. App. 49 (1990). 8. Entitlement to service connection for skin cancer, to include as due to herbicide exposure, is denied. 9. Entitlement to service connection for tongue cancer, to include as due to herbicide exposure, is denied. 10. Entitlement to service connection for a heart disorder, including ischemic heart disease and sinus bradycardia, is denied. The Veteran’s private treatment record show a diagnoses of sinus bradycardia, tongue cancer, melanoma, and resulting excisions which the Veteran attributes to exposure to herbicide during his confirmed service in Vietnam. Nonetheless, neither sinus bradycardia, skin nor tongue cancer is afforded a presumptive service connection based on exposure to herbicides. He does not have ischemic heart disease. 38 C.F.R. §§ 3.307, 3.309. As presumptive service is not afforded, the Veteran could still establish service connection with competent evidence that the disability was incurred in service, was present during other presumptive periods, or by submitting medical or scientific evidence that it was in fact due to herbicide exposure during service. Stefl v. Nicholson, 21 Vet. App. 120 (2007); Combee, 34 F.3d at 1042. Here, the Veteran’s service treatment records (STRs) do not show complaints, treatment, or diagnoses of a heart, skin, or oral disability. At his separation in September 1969, no heart, tongue or skin cancer was reported. Private treatment notes treatment records dated in August 2013, show that the Veteran had leukoplakia removed from his tongue. A January 2016 Problem List/Past Medical noted cancer of the tongue. Private treatment notes documented a diagnosis of skin cancer at the right lip, status-post excision in December 2016. Similarly, in August 2018, private treatment notes indicate a history of skin cancer/squamous cell carcinoma. Upon examination, the clinician assed inflamed seborrheic keratosis, actinic keratosis, lentigo, benign neoplasm of the skin, cherry angioma, seborrheic keratosis, and purpura simplex. Treatment records dated in October 2019, noted a normal tongue. The record is absent any current diagnoses or of tongue, skin cancer, or residuals therefrom, during the appeal period. Regarding a heart disorder, the Veteran ‘s post-service record includes a September 2010 VA examination, noting no diagnosed heart disability. During a December 2018 Heart Conditions DBQ, the Veteran reported occasional dyspnea on exertion with walking up the stairs or up a hill, constant dizziness (which he had not yet to have evaluated and not associated with position changes). He also reported that although he had a history of hypertension, he had no history of cardiac abnormalities. The examiner diagnosed the Veteran with having sinus bradycardia and concluded that it was related to his use of the beta blocker medication, Carvedilol, which is prescribed for the Veteran’s nonservice-connected hypertension. The Board notes that the only heart disability diagnosed during the appeal period was sinus bradycardia. After consideration of the record, the Board finds that service connection for sinus bradycardia, skin, and tongue cancer is not warranted. The record lacks any competent evidence suggesting a causal relationship between such disorders and the Veteran’s active service. The Veteran’s sole contention is that he was exposed to herbicide agents. He has not advanced any other theory and has not stated that it was otherwise due to service. Furthermore, regarding tongue and skin cancer, there is no showing of record the disabilities, or residuals thereof, manifested to a compensable degree within a year of active service. The Veteran’s treatment record shows that his tongue cancer was diagnosed in 2013, and his skin cancer circa 2016, decades after his active service period ended. As for his diagnosis of sinus bradycardia, the December 2018 VA examiner concluded that it was related to his use of the beta blocker medication, Carvedilol, which he takes for his high blood pressure. The Board notes that the Veteran is competent to report his observable skin, tongue, and heart symptoms. Lay persons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, the Veteran, in this case, is not competent to offer an etiology opinion of his skin and tongue cancers, and sinus bradycardia. Such a determination requires medical inquiry into internal physiological processes that are not readily observable and are not within the competence of the Veteran who, in this case, have not been shown by the evidence of record to have the necessary training, experience, or skills. Thus, the Board finds the lay opinion not competent. Accordingly, the preponderance of the medical evidence of record is against finding that the Veteran’s skin, tongue cancers, and/or residuals thereof, and sinus bradycardia were incurred in service, or in any way related to his active service period, including exposure to herbicide agents. Therefore, service connection is not warranted for tongue and skin cancers, and sinus bradycardia. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the claims, the doctrine is not for application. Gilbert, 1 Vet. App. 49 (1990). III. Disability Rating Disability ratings are determined by applying the criteria established in VA’s Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.20. Where there is a question as to which of two evaluations shall be applied under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the claimant. 38 C.F.R. § 4.3. Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a competent source. Second, the Board must determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303 (2007). Third, the Board must weigh the probative value of the evidence considering the entirety of the record. 1. Entitlement to a disability rating greater than 30 percent for bilateral hearing loss is denied. The Veteran contends that he is entitled to an increased rating greater than 30 percent for his bilateral hearing loss disability. Hearing loss is evaluated under 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100, Tables VI, VIA, and VII of VA’s rating schedule. The Rating Schedule provides a table for rating purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, established by a state-licensed audiologist, including a controlled speech discrimination test (Maryland CNC), and based upon a combination of the percent of speech discrimination and the pure tone threshold average, which is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz divided by four. 38 C.F.R. § 4.85. Table VII is used to determine the percentage evaluation 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. If impaired hearing is service-connected in only one ear, the non-service-connected ear is a Roman numeral designation of Level I. 38 C.F.R. § 4.85 (f). There are certain exceptional patterns of hearing impairment. When the pure-tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, 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. Each ear will be evaluated separately. 38 C.F.R. § 4.86 (a). When the pure-tone threshold is 30 decibels or less at 1000 Hertz 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 elevated to the next higher Roman numeral. 38 C.F.R. § 4.86 (b). The Veteran was afforded a hearing loss disability benefits questionnaire (DBQ) in November 2018. His pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 40 55 90 90 85 LEFT 40 60 75 80 80 The average pure tone threshold was 80 decibels in the right ear, and 74 in the left ear. Speech audiometry revealed speech recognition ability of 76 in the right ear and 88 in the left ear. Based on those results with the utilization of Table VI, the Veteran demonstrated Level V hearing impairment in the right ear and Level III in the left ear. Applying Level V for the right ear and Level III for the left ear, under Table VII, results in a 10 percent rating. 38 C.F.R. § 4.85, Diagnostic Code 6100 (2018). As shown above, by the November 2018 VA examination, the Veteran’s bilateral ear demonstrates an exceptional pattern of hearing loss as outlined in 38 C.F.R. § 4.86 (a). Each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) registered 55 decibels or more. Applying the Veteran’s pure tone threshold to Table VIA, his right ear has Level VII hearing loss for the right ear and VI in the left ear. Applying Level VI for the right ear and Level VII to the left ear, under Table VIA, results in a 30 percent disability rating. 38 C.F.R. § 4.86 (a). The Board notes that the VA audiological examination report describes the effects of the Veteran’s hearing impairments on his daily life, consistent with the requirements of Martinak v. Nicholson, 21 Vet. App. 447 (2007). Specifically, the Veteran has stated in his November 2018 VA examination that “Certain sounds and frequency are not recognizable to me. It is very difficult to communicate with some people, even with hearing aids.” During the entire initial rating period on appeal, no other audiological examination is of record. The Board notes that the Veteran is competent to report symptoms such as decreased hearing acuity, and his statements are credible. Kahana v. Shinseki, 24 Vet. App. 428 (2011). To the extent that the Veteran contends that his hearing loss is more severe than currently evaluated, he is not competent to report that his hearing acuity is of sufficient severity to warrant a certain percent evaluation under VA’s tables for rating hearing loss disabilities. Such an opinion requires medical expertise (training in administering audiological testing and evaluating hearing impairment), which he does not possess. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau, 492 F.3d 1372, 1377 (Fed. Cir. 2007). While the Board is sympathetic to the Veteran’s contention that he is unable to recognize certain sounds and frequency and has difficulty communicating even with wearing hearing aids, the VA rating criteria are definitive and provide for a precise result based on audiometric test results. His subjective report of difficulty hearing under situational circumstances is contemplated in the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Board is bound to apply the VA rating schedule, under which the rating criteria are defined by audiometric test findings involving hearing acuity in a controlled laboratory environment. Based on the above, the criteria for a 30 percent rating, but no higher, have been met based upon the results of the November 2018 examination. As such, a rating greater than 30 percent is not warranted for the Veteran’s bilateral hearing loss. 38 C.F.R. §§ 4.3, 4.7. As the Veteran’s symptoms of his bilateral hearing loss disability have not met the criteria for a rating greater than 30 percent at any time during the appeal period, the Board may not stage his rating. The Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran or his representative, as required by Schafrath, 1 Vet. App. 589 (1991). The Board has found no section that provides a basis for which to assign a higher rating for his bilateral hearing loss disability. Accordingly, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert, 1 Vet. App. 49 (1990). 2. Entitlement to a rating a 70 percent rating for PTSD, effective May 5, 2016 is granted. The Veteran’s PTSD is currently rated at 50 percent disabling, effective May 05, 2016, under Diagnostic Code 9411. PTSD is evaluated under the General Rating Formula for Mental Disorders. Under the General Rating Formula for Mental Disorders, an evaluation of 50 percent is warranted for 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 effective work and social relationships. Id. A 70 percent rating is assigned when there is an occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 is assigned for total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability 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. Symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). 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. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Additionally, while symptomatology should be the primary focus when deciding entitlement to a given disability rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused the requisite occupational and social impairment. Id. The Veteran contends that a higher initial rating higher than 50 percent is warranted for his PTSD. The Veteran was afforded a VA Initial PTSD DBQ in September 2016. The examiner diagnosed PTSD and indicated that the level of occupational and social impairment as 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. The Veteran reported that he remained married to his second wife of 16 years, and the marital relationship was “good.” He also reported having a “good” relationship with his three adult children and enjoys fishing with “a few friends;” but “for the most part [he would] rather be a recluse.” The Veteran also reported receiving mental health treatment at the VA until January 2015 and, for the past year, participated in individual counseling with Roman’s National Family Health in Lynn Haven, Florida. The examiner noted that the following symptoms apply to the Veteran’s PTSD diagnosis: depressed mood; anxiety; suspiciousness; and chronic sleep impairment. The examiner noted that the Veteran had no other symptoms attributable to PTSD and that he was capable of managing his financial affairs. Upon examination, the examiner noted that the Veteran was casually dressed, adequately groomed, hygienic, and interacted in a calm and pleasant manner. His mood/affect was normal and appropriate to the situation. He did not appear unusually anxious, and his speech was normal and easily understood. The examiner noted no signs of psychosis or unusual behavior. The examiner remarked that Veteran described the following symptoms/problems: “on his anger management; biting his nails over road rage; if he goes to restroom at night, it takes him hours to get back to sleep because he cannot turn off his brain -feels like somebody is going to sneak up on him, so he stays up looking out the windows, and sleeping with his handgun with his hand on it.” The Veteran also reported as he cannot sleep at night, “sleep deprivation makes him like a rattlesnake, coiled up and ready to strike.” The examiner noted that the Veteran endorsed symptoms of depression in the lower end of the severe range, and moderate to severe symptoms of PTSD. He remarked that the Veteran’s PTSD would result in reduced productivity and reliability in a stressful work setting where high productivity is required. This is due to problems with irritability, fatigue, impaired sleep, anxiety, and anhedonia. However, he is alert and oriented with intact judgment. There is no evidence of psychosis or a thought disorder. He is able to communicate effectively and follow, at least, simple instructions and complete routine tasks. The Veteran underwent a second VA examination in October 2018. The Veteran reported living with his second wife of 20 years and has three adult children. The examiner noted that the Veteran’s post-trauma symptoms included nightmares/poor sleep, exaggerated startle response, hypervigilance/social withdrawal, heightened anxiety states, intrusive memories, irritability, disrupted focus, and arousal to/avoidance of cues/triggers. He denied suicidal or homicidal ideation/plans/intentions. He was prescribed Zoloft. Regarding the Veteran’s level of occupational and social impairment, the examiner noted that the Veteran had 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. The following symptoms actively applied to the Veteran’s diagnosis: depressed mood; anxiety; suspiciousness; chronic sleep impairment; and mild memory loss. Regarding the other symptoms attributable to the Veteran’s PTSD, the examiner noted nightmares/poor sleep, exaggerated startle, hypervigilance/social withdrawal, heightened anxiety states, intrusive memories, irritability, disrupted focus, and arousal to/avoidance of cues/triggers. The examiner also noted that the Veteran was capable of managing his financial affairs and did not appear to pose any threat of danger or injury to self or others. Additionally, of record are statements from the Veteran’s wife. In a February 2017 statement, she reported that the VA staff only sees the Veteran in a controlled setting, not in reality. However, at home, the Veteran is always on edge, angry, and keyed up like a rattle snake ready to strike. He packs defense on his person “just in case he needs it” walks the property looking for anything suspicious. At nights, it is magnified. He gets little sleep and walks around the house to check on things. In the August 2018 statement, she again stated that the Veteran is not social, and he has no interest in going anywhere with her or socializing. He has very few acquaintances. They have been married since 1999, and the children have only visited twice, for there is nowhere to sit in the house because of the Veteran’s hoarding. He has very few friends with whom he fishes at the lake in the backyard twice per month. He has no interest in intimacy, there had been no marital relations in eight years. He told her that he killed people in Vietnam, and one night while watching television, the picture of a sexual perpetrator came on the screen, and he held up his hand in the shape of a gun and shot at the tv screen with an intense look in his face. He attributed his vigilantism outlook on the Vietnam War. He has explosive mood swings and is easily startled. She does not go to his workshop anymore because one night, when she did, she startled him, and he pulled his gun and pointed it at her. Also, he is armed all of the time and checks and rechecks doors and windows several times a night. He has nightmares and bouts of road rage. Also of record are private treatment records dated from November 2015 to April 2016, which consistently noted the Veteran to be alert, oriented, with good eye contact ad clear speech. A mental status examination (MSE) of November 2015 noted affect constricted, blunted. Mood anxious, fearful, and irritable, uneasy. His speech was clear, pressured, and spontaneous. His insight was noted as good, and judgment was fair. His thought process was intact, and his thought content unremarkable. No current suicidal or homicidal ideations noted. MSE of December 2015 noted appearance as casual and well-nourished. His affect was appropriate to affect constricted, blunted. The mood was happy, anxious, depressed, and uneasy. His speech was clear, pressured, and spontaneous. His insight was noted as good, and his judgment was good-fair. His thought content preservations. No current suicidal or homicidal ideations noted. Notably, treatment notes dated in February 2016 indicate the Veteran’s increased sadness from the death of the neighbor and suicide of a friend who borrowed one of his guns and used it in the commission of the act. MSE during that month reported affect appropriate and constricted. Mood happy, anxious, and pressured, whispering, and talkative. His speech was clear, pressured, and spontaneous. His insight was noted as fair, and judgment was poor. His thought process was flight of ideas. No current suicidal or homicidal ideations noted. VA treatment notes dated in March 2018 reports the veteran’s complaint of memory loss, starting three to four years ago. The veteran denied suicidal and homicidal ideations and indicated ownership of guns. MSE conducted that same month, indicated that the Veteran was casually dressed and groomed and appeared his stated age. His behavior was cooperative and polite. His speech was of normal rate, rhythm, and volume. His affect was appropriate, mood-congruent, and full range, which his mood was frustrated. His thought process was clear, logical, and linear, absent a thought disorder. His content revealed no suicidal/homicidal orientation; nor delusions. He was alert and oriented to person, place, time, and situation. His memory was deemed grossly intact to recent and remote events and his judgment good with fair insight. July 2018, during a clinical visit, the Veteran reported poor mood with worsening health, including hearing and memory loss. MSE noted that the Veteran was casually dressed and groomed and appeared his stated age. His behavior was cooperative and polite. His speech was of normal rate, rhythm, and volume. His affect was smiling and joking, full range, and mood “okay.” His thought process was clear, logical, and linear, absent a thought disorder. His content revealed no suicidal/homicidal orientation; nor delusions. He was alert and oriented to person, place, time, and situation. His memory was deemed grossly intact to recent and remote events and his judgment good with fair insight. In support of his claim, the Veteran provided a January 2019 letter from VA Staff Psychologist, S. R. H. PhD., who noted that the Veteran continues to have persistent and severe disturbance in mood and motivation. Furthermore, he experiences rapidly alternating moods and a persistent state of arousal that continue to lead to a marked change in his ability to regulate his mood, tolerate frustration, work under pressure, interact with others, focus on and sustain attention, process sensory information, and make decisions that are essential to maintaining effective relationships. He is also prone to isolation and social withdrawal. He has extreme difficulty trusting others along with extreme social anxiety, which leads to difficulty establishing and maintaining relationships, and near inability to adapt to stressful circumstances. Also, of evidence is a private medical opinion provided by J. S. S. PhD., HSPP of COPE Behavioral Consulting, dated August 2018. Dr. J. S. S. noted that the Veteran had PTSD with hypervigilance, which persistently rises to the level of paranoia and which creates chronic excessive brain activity, and which regularly awakes the Veteran to engage in household safety checks through the night-is severe, and has been severe from July 2009 to the present; and has resulted in occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood; with this severe impairment is due to symptoms including obsessional rituals [to include extreme/chronic hoarding, and multiple safety checks per night around the house] which interfere with routine activities; 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); difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. During the MSE, it was noted that the Veteran has fair grooming and hygiene. The Veteran was fully oriented to person and place but, related to the sphere of time, he had to consult electronic devices to tell the correct date. His mood was anxious and agitated. His affect was appropriate to mood. Ideas contributing to mood include the unrelenting sense that others are watching him, out to get him, and going to harm him [all of which indicates paranoia]; and the Veteran presented as repeatedly confused throughout this exam process. Concerning vegetative symptoms, the Veteran reported sleep as chronically poor; stating, “Usually it takes an hour or two every night to go to sleep if I can ever get my brain turned off... usually [a total sleep] of 4-1/2 to 6 hours per night “with the Veteran’s wife stating here that “I think he’s generous when he says he gets 4-1/2’ hours of sleep a night.” The Veteran stated that this specific pattern of sleep has been going on” for about six years, to which his wife added: “He’s constantly up checking the windows and doors... Every time he’s up, he has to check everything.” The Veteran also reported: “I have nightmares... waking me up...a few times a month …[which] are tied in with my experiences from Vietnam ... It makes me hypervigilant... 1 get upset...always somebody trying to get me [indicating paranoia] ... sneak upon me, and you’ll get hurt. Regarding focus and concentration, the Veteran complained of being distracted easily and having poor recent memory, with “problems remembering words, names of people, and to which his wife added, “he doesn’t remember to tell him things, appointments.” The examiner noted that the Veteran’s thoughts were generally logical and coherent, with the Veteran acknowledging frequent suspiciousness/paranoia; stating, “If tools go missing, I suspect these people are getting them ... I have to ‘eat crow’ if I find’ em [the tools] again.” Regarding social activity, the Veteran reported not having much social life...” I do not wat to around people... [with the veteran noting that he is very critical of others and that he is] a home body.” The veteran’s wife added that the Veteran is" a recluse.”. The veteran described his recreational activity as highly limited; stating, “mostly fishin’[solitary] ...I used to go to the guitar’ pickins’...country singin’...I about quit them now." The Veteran was found the veteran to be competent in his mental capacity to control and manage his finances. After a review of the evidence presented above, the Board finds that the frequency, severity, and duration of the Veteran’s PTSD symptoms reported or more nearly approximate the 70 percent evaluation than they do the 50 percent evaluation. The Board notes that the examiner in the September 2016 VA examination found the Veteran to be occupationally and socially impaired 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. He later contradicted his earlier findings and remarked that the Veteran’s “moderate to severe symptoms of PTSD” would result in reduced productivity and reliability in a stressful work setting where high productivity is required. The latter findings were supported by the November 2018 examiner when he, too, summarized the Veteran’s level of occupational and social impairment as occupational and social impairment reduced reliability and productivity. Nonetheless, the Board finds most persuasive the findings of Dr. J. S. S. in conjunction with the Veteran’s wife’s competent and credible statements, most probative to a grant of 70 percent. Specifically, Dr. J. S. S. noted that the Veteran had PTSD with hypervigilance, which persistently rises to the level of severe paranoia and which exhibits in household safety checks through the night-is severe, since from 2009 to the present. The Veteran also endorsed severe obsessional rituals [to include extreme/chronic hoarding, and multiple safety checks per night around the house] which interfere with routine activities; 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); difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Thus, a 70 percent disability rating is granted from May 05, 2016. The issue of entitlement to a disability rating greater than 70 percent for PTSD is addressed in the Remand section below. IV. TDIU is warranted from May 05, 2016. The Board notes that the Veteran in May 2016 filed claims for an increased rating for PTSD and entitlement for a TDIU due to his PTSD. The RO in a December 2019 rating decision granted a 50 percent rating for PTSD, effective May 05, 2016, and a TDIU, effective August 14, 2018, the date the schedular criteria were met. The Veteran contends that his service-connected PTSD prevents him from engaging in substantially gainful employment. Total disability is considered to exist when there is any impairment, which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (a)(1). A total disability rating for compensation purposes may be assigned based on individual unemployability: that is when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one service-connected disability, it must be rated 60 percent or more; if there are two or more service-connected disabilities, at least one disability must be rated 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). Individual unemployability must be determined without regard to any nonservice-connected disabilities or the Veteran’s advancing age. 38 C.F.R. §§ 3.341(a), 4.19 (2017); Van Hoose v. Brown, 4 Vet. App. 361 (1993). When the Board conducts a TDIU analysis, it must consider the Veteran’s education, training, and work history. Pederson v. McDonald, 27 Vet. App. 276 (2015). Here, the Veteran’s PTSD is rated at 70 percent as granted in this decision. Thus, he meets the rating threshold for a schedular TDIU beginning on May 05, 2016. The Board finds that the symptoms described above show the Veteran is unable to secure and follow a substantially gainful occupation as a result of his service-connected PTSD. The Veteran reported that he stopped working because of his PTSD symptoms. The medical and lay evidence of record also documented the Veteran’s continued obsessional rituals, including extreme/chronic hoarding, and multiple safety checks nightly around his house, and being armed 100 percent of the time with his hand on the gun, even while sleeping. Further, in multiple lay statements, the Veteran acknowledged an inability to control anger, as evident by his road rages. Resolving reasonable doubt in the Veteran’s favor, the Board finds a TDIU is warranted beginning May 05, 2016. Thus, when giving the benefit of the doubt to the Veteran, the Board finds that a TDIU is warranted. The ultimate responsibility for a TDIU determination is a factual rather than a medical question and is an adjudicative determination made by the Board or the AOJ. Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). Reviewing the totality of the evidence, however, including the Veteran’s current medical findings detailing the severity of his service-connected disabilities, the competent and credible lay assertions of unemployability due to limitations caused by the service-connected disabilities, and the cumulative objective evidence of record, the Board finds that the Veteran’s service-connected disabilities, coupled with his educational/training background and employment history, likely precludes him from securing and following any substantially gainful employment. Accordingly, resolving all doubt in the Veteran’s favor, the Board finds that entitlement to TDIU is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49 (1990). REASONS FOR REMAND Entitlement to an initial disability rating greater than 70 percent for PTSD is remanded. During the September 2016 VA Initial PTSD DBQ, the Veteran reported receiving mental health treatment “for the past year, participated in individual counseling with at Roman’s National Family Health in Lynn Haven, Florida. While some of the Veteran’s treatment records therefrom were affiliated with the claims file, his treatment records from the individual counseling sessions with W. K. are not associated with the claims file. The RO should attempt to procure these outstanding individual counseling sessions records. Accordingly, the matter is REMANDED for the following action: 1. Ask the Veteran to provide an executed authorization for VA to obtain and associate with the claims file the private treatment records from his outside individual counselor, W. K., at Roman’s National Family Health in Lynn Haven, Florida. If he returns the requested information, attempt to obtain the records. All negative replies from the health care provider should be documented. 2. Then, readjudicate the claim. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Stevens, 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.