Citation Nr: 21002289 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 17-48 899 DATE: January 13, 2021 ORDER Entitlement to a rating in excess of 50 percent for service-connected combat and military sexual trauma (MST) post-traumatic stress disorder (PTSD) with traumatic brain injury (TBI) prior to March 31, 2020 is denied. Entitlement to a rating of 70 percent for service-connected combat and military sexual trauma (MST) post-traumatic stress disorder (PTSD) with traumatic brain injury (TBI) from to March 31, 2020 is granted. REMANDED Entitlement to a rating in excess of 40 percent for service-connected urge incontinence is remanded. Entitlement to service connection for a right hip condition, to include as secondary to service-connected left knee condition and/or service-connected back condition is remanded. Entitlement to service connection for a left hip condition, to include as secondary to service-connected left knee condition and/or service-connected back condition is remanded. Entitlement to service connection for vertigo, to include as secondary to PTSD with TBI is remanded. Entitlement to service connection for syncopial episodes (claimed as hypoglycemia with fainting spells), to include on the basis of clear and unmistakable error (CUE) is remanded. FINDINGS OF FACT 1. Prior to March 31, 2020, the severity, frequency, and duration of the Veteran’s MST and combat PTSD with TBI symptoms do not more closely approximate occupational and social impairment with deficiencies in most areas or total occupational and social impairment. 2. From March 31, 2020, the Veteran’s MST and combat PTSD with TBI has manifested with occupational and social impairment with deficiencies in most areas, but not with total occupational impairment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 50 percent for service-connected MST and combat PTSD with TBI prior to March 31, 2020 have not been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 3.400, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2020). 2. The criteria for entitlement to a rating of 70 percent for service-connected MST and combat PTSD with TBI from March 31, 2020 have been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 3.400 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service with the United States Army from April 2002 to August 2005 and from November 2005 to March 2008. This matter is before the Board of Veterans’ Appeals (Board) on appeal from the June 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) granting an increased evaluation for urge incontinence on the basis of CUE; denying revision of the evaluation of PTSD with TBI; denying revision of decision to deny service connection for hypoglycemia with fainting spells; and denying service connection for left hip strain, right hip strain, and vertigo. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in September 2020. A transcript of the hearing is associated with the electronic claims file. Increased Rating In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. When assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent (“flare-ups”) due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a 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. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, 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 the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In any claim for an increased rating, “staged” ratings may be warranted where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Entitlement to a rating in excess of 50 percent for service-connected combat and military sexual trauma (MST) post-traumatic stress disorder (PTSD) with traumatic brain injury (TBI) prior to March 31, 2020 Entitlement to a rating of 70 percent for service-connected combat and military sexual trauma (MST) post-traumatic stress disorder (PTSD) with traumatic brain injury (TBI) from to March 31, 2020 At the onset, the Board acknowledges and agrees with the Veterans assertion that her service-connected PTSD should include the indication of MST in correlation with her already confirmed combat stressors; and her contention that her TBI should be evaluated separately from her PTSD. See Hearing Testimony, September 2020. A review of the evidence of record reflects that the Veteran was afforded VA examinations in November 2009 and September 2014. The November 2009 examination report noted the description of stressors as combat and sexual assault. See VA Examination, November 2009. The examiner noted that the Veteran described intrusive trauma memories of combat and MST on a daily basis resulting in clear but manageable distress. The September 2014 examination report reflects that the Veteran was noted to have a diagnosis of traumatic brain injury. See C&P Exam, September 2014. The examiner indicated that the Veteran’s TBI, combat PTSD, and MST share so many symptoms that it is not possible to make a differentiation. See C&P Exam, September 2014. The Veteran’s symptoms were noted as depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks; difficulty in understanding complex commands; disturbances of motivation and mood; and inability to establish and maintain effective relationships. In June 2020, the Veteran was afforded a TBI VA examination. Examination revealed objective evidence of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment; mildly impaired judgment; occasionally inappropriate social interaction; occasional disorientation; mildly impaired visual spatial orientation; and irritability. See C&P Exam, June 2020. The Veteran’s diagnosis of PTSD with TBI was confirmed. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. In an effort to avoid pyramiding, the RO combined the Veteran’s PTSD and TBI cognitive impairments into one entitlement. Therefore, the Board finds that the medical evidence of record supports the combined evaluation of the Veteran’s PTSD and TBI as both have manifested with irritability, cognitive impairment, and social impairment which have been found to be undifferentiated. In regard to separate evaluations of other TBI symptoms, the Board notes that the Veteran is currently service connected for headaches and tinnitus associated with TBI. Based on the above, the Board finds that a recharacterization of the issue is warranted to reflect the indication of the Veteran’s MST. As such, the issue has been recharacterized as entitlement to a rating in excess of 50 percent for service-connected MST and combat PTSD with TBI, hereafter referred to as PTSD. Increased rating The Veteran asserts that a rating of 100 percent is warranted for her service-connected PTSD. See NOD, January 2017. The Veteran’s PTSD is currently rated as 50 percent disabling under Diagnostic Code 9411 (DC 9411). Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). Under DC 9411, a 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. 38 C.F.R. § 4.130, DC 9411. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Id. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. Id. VA treatment records and VA examinations show that the Veteran’s PTSD has been manifested by symptoms associated with a 50 percent rating (e.g., depressed mood, anxiety, suspiciousness, panic attacks, irritability, hypervigilance, occasional isolation, and difficulty in establishing and maintaining effective work and social relationships). The Veteran was afforded PTSD examinations in November 2009, September 2014, and March 2020. The November 2009 examiner noted that the Veteran’s symptoms of difficulty falling or stay asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, exaggerated startle response, panic attacks, avoidance, persistent re-experiencing of traumatic event, persistent avoidance of stimuli associated with trauma are chronic and cause clinically significant distress or impairment in social occupational or other important areas of functioning. See VA Examination, November 2009. The examiner indicated that the there was no total occupational and social impairment or reduced reliability and productivity due to PTSD symptoms. However, the examiner noted that the Veteran had occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms with general satisfactory functioning. The examiner assessed that the Veteran was not totally occupationally impaired or unemployable due solely to her mental health symptoms. The September 2014 examiner indicated that the Veteran’s symptoms of depressed mood, suspiciousness, chronic sleep impairment, mild memory loss, short- and long-term memory impairment, difficulty understanding complex commands, disturbances of motivation and mood, and the inability to establish and maintain effective relationships cause occupational and social impairment with reduced reliability and productivity. See C&P Exam, September 2014. The March 31, 2020 examiner indicated that the Veteran’s symptoms of depressed mood, anxiety, suspiciousness panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, flattened effect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a work like setting cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, thinking and/or mood, and judgment. See C&P Exam, March 2020. The examiner noted that the Veteran’s symptoms had worsened since the September 2014 examination and cause significant occupational and social deficits. Based on the March 2020 examiners findings, the Board finds that the criteria for a 70 percent disability rating have been met. See 38 C.F.R. § 3.400. Additionally, the Board finds that prior to the March 2020 VA examination, the severity, frequency, and duration of the Veteran’s listed symptoms more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. Additionally, the level of impairment caused by the Veteran’s symptoms more closely approximated the level associated with a 50 percent rating. Because the disability has not met the criteria for a higher evaluation prior to the March 2020 examination, the Board finds that a staged rating is warranted. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 22 Vet. App. 505 (2007). As such, the entitlement to a rating in excess of 50 percent for service-connected MST and combat PTSD with TBI prior to March 31, 2020 (the date the increase in severity was noted) is denied; and a rating of 70 percent from March 31, 2020 is granted. REASONS FOR REMAND 1. Entitlement to a rating in excess of 40 percent for service-connected urge incontinence The Veteran asserts that a 60 percent rating is warranted because she wears and must change absorbent materials more than 4 times a day. See Hearing Transcript, September 2020. The Veteran’s urge incontinence is currently rated as 40 percent disabling under DC 7517. Under DC 7517, bladder injury is to be rated as voiding dysfunction. See 38 C.F.R. § 4.115b, DC 7517. Under 38 C.F.R. § 4.115a, voiding dysfunction, continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the earing of absorbent materials which must be changed 2 to 4 times per day warrants a 40 percent disability rating. A 60 percent disability rating is warranted if the use of an appliance is required or the wearing of absorbent materials which must be changed more than 4 times per day. Id. When available evidence is too old for an adequate evaluation of the Veteran’s current condition, VA’s duty to assist includes providing a new examination. Weggenmann v. Brown, 5 Vet. App. 281 (1993). However, an examination of the Veteran does not become outdated after any arbitrary amount of time. The duty to get a new examination is triggered only when the available evidence indicates that the previous examination no longer reflects the current state of the Veteran’s disability. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-83 (2007); VAOPGCPREC 11-95 (1995). A remand for a new examination of the Veteran’s level of disability should be based upon a finding that there is an indication in the record that condition has changed. Conversely, if there is no affirmative indication that the condition has changed, then the case should be decided based upon the available evidence and a finding that there is no indication that the condition has changed since the last examination. The Veteran’s urge incontinence has not been evaluated since October 2014. As such, the Board finds that a new examination is warranted in order to fully evaluate the severity of the Veteran’s urge incontinence. 2. Entitlement to service connection for a right hip condition, to include as secondary to service-connected left knee condition and/or service-connected back condition 3. Entitlement to service connection for a left hip condition, to include as secondary to service-connected left knee condition and/or service-connected back condition The Veteran asserts that her bilateral hip condition had its onset during service, in addition to being aggravated by her service-connected left knee condition. See Hearing Transcript, September 2020. A review of the record reflects that during service, the Veteran was afforded a VA examination in November 2009. The Veteran reported that her bilateral hip joint pain began in 2003 without specific injury. See VA Examination, November 2009. The examiner noted that the Veteran pointed to her lumbosacral area while describing her hip pain. The Veteran reported feeling a “popping” in her joints since 2003 and that her back pain radiates to her hip area, but not constantly. The examiner determined that her condition was stable. Upon examination, bilateral tenderness with flexion was noted. A hip radiograph revealed normal hip joints. The examiner found that the Veteran’s current bilateral hip condition was not related to her military service. In a January 2010 rating decision, the Veteran was granted service connection for osteoarthritis at T11-T12 and left sacroiliac joint claimed as lower lumbar pain with an effective date of August 28, 2009. In February 2011, the examiner reported having intermittent hip pain and having fallen several times because of bad knees and hips. See Capri, February 2012. In October 2014, the Veteran was afforded another VA examination. The Veteran reported having difficulty with her hips since 2005 and reported experiencing a worsening in hip pain following knee surgeries. See C&P Exam, October 2014. The Veteran reported having moderately intense flareups weekly and monthly severe flareups. She reported that the flareups causes limitations due to pain and stiffness, lasts 3-5 days, and was currently experiencing a severe flareup. Bilateral limited and painful flexion and extension was noted. The examiner opined that the Veteran’s bilateral hip pain was less likely than not proximately due to or result of the Veteran’s service-connected left knee condition. The examiner stated that the Veteran had intermittent complaints of left hip pain in 2002 prior to having knee issues and no complaints of ongoing right hip pain. The examiner noted that the Veteran had bilateral hips while in service in 2009 due to pelvic pain. Additionally, he noted that the Veteran had three left knee surgeries with no indication of persistently abnormal gait associated with this. He noted, “while intermittent gait disturbances due to the left knee would cause some pain in the associated hip, the pain would be transient and resolve with restoration of gait.” Additionally, the examiner conclude that the pain and restricted range of motion of the right knee is more likely due to severely altered gait currently noted due to hip pain on the left, but without updated x-rays the preponderance of the evidence would suggest a pathology beyond a simple strain and therefore, the Veteran’s bilateral hip pain is less likely than not related to her left knee condition. In November 2014, service treatment records (STRs) were added to the Veteran’s claims file. A review of the STRs reflect that Veteran was seen for pelvic pain and left hip pain in April 2002. See STR-Medical, November 2014 at p.27 of 99. In October 2003, the Veteran reported repeated episodes of instability ever since hyperextending her left knee 4 to 5 months prior. Id. at p.87 of 99. In July 2005, the Veteran reported having a hard fall on her tail bone during basic training. Id. at p.83 of 99. A March 20015 MRI of the left hip found no evidence of fracture, avascular necrosis or edema of the femoral head. See Medical Treatment Record-Non-Government Facility, April 2015. A linear focus of increased STIR signal at the chondral labral junction was noted as suspicious for a nondisplaced labral tear. The Veteran has not been afforded an additional VA examination nor has a new opinion been obtained since the STRs and additional VA treatment records were associated with the Veteran’s claims files. Further, the Board notes that the October 2014 examiner failed to address the Veteran’s 2009 report of back pain radiating to her hips. As such, the Board finds that a new VA examination is necessary in order to properly adjudicate the Veteran’s claim. 4. Entitlement to service connection for vertigo, to include as associated with PTSD with TBI The Veteran asserts that her vertigo is caused by her TBI. See VA 21-4138, April 2014; C&P Exam, June 2020; Hearing Transcript, September 2020;. A review of the evidence of record reflect that in a November 2009 VA examination report reflects a notation of mild TBI with no history of dizziness or vertigo; balance and coordination problems; or hearing loss/tinnitus. See VA Examination, November 2009 at p.34 of 43. VA treatment records associated with the Veteran’s claims file in February 2012 revealed that in September 2005 the Veteran reported having dizzy spells during services associated with high blood pressure medication; and in December 2011, the Veteran reported significant problems with dizziness and black outs associated with an elevation in blood pressure. See Capri, February 2012. In April 2014, the Veteran was diagnosed with benign paroxysmal positional vertigo. See Capri, January 2015. The examiner noted that the Veteran had a history of blast exposure with complaints of vertigo and requested an evaluation for vestibular rehab. Id at p.45 of 199. The examiner noted that the Veteran has vestibular hypofunction. Id. at p.59 of 199. It was also noted that anxiety could cause poor results. Id. A May 2014 physical therapy discharge note reflects that a balance report showed almost no vestibular function for balance. Id at p.41 of 199. In November 2014, STRs were associated with the Veteran’s claims file. In March 2003, the Veteran reported having dizzy spells for one week. See STR-Medical, November 2014 at p.19 of 99. The examiner noted that the Veteran’s dizziness was not vertiginous or associated with head position. Id. The Veteran was diagnosed with chronic intermittent dizziness. Id. An August 2002 report of medical history reflects that the Veteran reported not having a history of dizziness or fainting spells. See STR-Medical, November 2014 at p.66 of 78. In a January 2015, the Veteran was granted service connection for migraines and tinnitus associated with PTSD with TBI. See Rating Decision Codesheet; January 2015. STRs associated with the Veteran’s claims file in May 2016 contain a February 2009 post deployment questionnaire in which the Veteran reported that she experienced memory problems or lapses, ringing in the ears, irritability, and sleep problems following the blast or explosion, but not balance problems, sensitivity to light, or headaches. See STR, May 2016. The Board notes that the no opinion has been obtained as to the nature and etiology of the Veteran’s vertigo. As such, the Board finds that remand is necessary in order to schedule the Veteran an examination and obtain an opinion as to whether the Veteran’s vertigo and/or vestibular hypofunction is related to her military service, to include associated with her TBI. 5. Entitlement to service connection for syncopial episodes (claimed as hypoglycemia with fainting spells), to include on the basis of clear and unmistakable error (CUE) At the onset the Board notes that the medical evidence of record reflects that the Veteran has had syncopial episodes associated with hypoglycemia, asthma, and high blood pressure during service. See STR, November 2014. As such, the Board has recharacterized the issues as entitlement to service connection for syncopial episodes. The Veteran asserts that service connection is warranted because her inservice syncopial episodes are causally related to her military service. As previously noted, the Veteran’s inservice syncopial episodes were attributed to hypoglycemia, asthma, and high blood pressure. The Veteran was diagnosed with post-prandial hypoglycemia and vasovagal syncope. See STR, November 2014. In November 2009, the Veteran was afforded a VA examination. The examiner noted the onset of the Veteran’s hypoglycemia with fainting spells as March 2003. See VA Examination, November 2009. The Veteran reported having 6 fainting spells over a 15 month period while in Korea and being diagnosed with post-prandial hypoglycemia. The examiner found the diagnosis plausible based on the Veteran’s history of missing meals and eating rapidly prior to becoming symptomatic. The examiner determined that although the Veteran’s hypoglycemia with fainting spells occurred during military, it had resolved with good dietary habits with no more episodes and was not present at the time of the examination. A review of VA treatment records reflects that in September 2005 and December 2011, the Veteran has reported having problems with dizziness and black outs associated with elevated blood pressure. See Capri, February 2012 at p.20, 46 of 149. In March 2015, the Veteran was seen and evaluated following a syncopial episode. See Medical Treatment Record-Non-Government Facility, April 2015. Testing was conducted. However, no diagnosis or etiology was provided. A cardiology report reflects a diagnosis of sinus tachycardia. Id. The Board finds that a remand is necessary in order to schedule the Veteran an examination an obtain an opinion regarding whether the Veteran’s current syncopial episodes are causally related to the syncopial episodes during service. The matters are REMANDED for the following action: 1. Schedule a new VA examination to address the current severity of the Veteran’s service-connected urge incontinence. 2. Obtain an opinion to determine the nature and etiology of the any left or right hip condition, to include left nondisplaced labral tear. The claims file must be provided to and reviewed by the examiner. It is left up to the examiner to determine whether physical examination of the Veteran is needed to render an opinion; if so, the Veteran should be scheduled for that examination. The examiner is asked to opine as to: (a) Whether it is at least as likely as not that the Veteran’s current bilateral hip condition had its onset during her military service; (b) Whether it is at least as likely as not that the Veteran’s bilateral hip condition is related to her reported inservice falls or repeated episodes of left knee instability during service; (c) Whether it is at least as likely as not that the Veteran’s bilateral hip condition is proximately due to or causally related to her service-connected back condition; and (d) Whether it is at least as likely as not that the Veteran’s bilateral hip condition has been aggravated beyond its natural progress by any service-connected condition. 3. Obtain an opinion to determine the nature and etiology of the Veteran’s vertigo/vestibular hypofunction. The claims file must be provided to and reviewed by the examiner. It is left up to the examiner to determine whether physical examination of the Veteran is needed to render an opinion; if so, the Veteran should be scheduled for that examination. The examiner is asked to opine as to: (a) Whether it is at least as likely as not that the Veteran’s vertigo/vestibular hypofunction is causally related to the inservice blast exposure; and (b) Whether it is at least as likely as not that the Veteran’s vertigo/vestibular hypofunction is proximately due to or causally related to her service-connected tinnitus associated with PTSD with TBI and/or migraines associated with PTSD with TBI. 4. Obtain an opinion to determine the nature and etiology of the Veteran’s syncopial episodes. The entire claims file must be provided to and reviewed by the examiner. It is left up to the examiner to determine whether physical examination of the Veteran is needed to render an opinion; if so, the Veteran should be scheduled for that examination. The examiner is asked to opine as to whether it is at least as likely as not that the Veteran’s current syncopial episodes are causally related to the syncopial episodes experienced during service. (Continued on the next page)   5. Readjudicate the appeal. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Camille NeSmith, 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.