Citation Nr: 21066710 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 17-38 196 DATE: November 1, 2021 ORDER Entitlement to service connection for dizziness is denied. Entitlement to service connection for a sinus disorder is denied. Entitlement to service connection for a respiratory disorder is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for right ear hearing loss is granted. Entitlement to a disability rating higher than 70 percent for the service-connected mental disability, is denied. Prior to July 13, 2016, entitlement to a disability rating higher than 0 percent for the service-connected migraines, is denied. Since July 13, 2016, entitlement to a disability rating higher than 30 percent for the service-connected migraines, is denied. REMANDED Entitlement to service connection for obstructive sleep apnea is remanded. FINDINGS OF FACT 1. Dizziness is not related to service. 2. A sinus disorder is not related to service. 3. A respiratory disorder is not related to service. 4. Hypertension is not related to service. 5. The Veteran has a right ear hearing loss disability that is related to service. 6. The service-connected mental disability is manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; he does not have total occupational and social impairment. 7. Prior to July 13, 2016, the service-connected migraines were manifested by less frequent attacks than contemplated for the rating of 10 percent. 8. Since July 13, 2016, the service-connected migraines are manifested by characteristic prostrating attacks occurring on an average once a month over last several months. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for dizziness are not met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The criteria for entitlement to service connection for a sinus disorder are not met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303. 3. The criteria for entitlement to service connection for a respiratory disorder are not met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303. 4. The criteria for entitlement to service connection for hypertension are not met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 5. The criteria for entitlement to service connection for right ear hearing loss are met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 6. The criteria for a disability rating higher than 70 percent for the service-connected mental disability are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411. 7. Prior to July 13, 2016, the criteria for a disability rating higher than 0 percent for the service-connected migraines were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8100. 8. Since July 13, 2016, the criteria for a disability rating higher than 30 percent for the service-connected migraines are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had active duty service from April 1976 to April 1979. This appeal comes before the Board of Veterans' Appeals (Board) from July 2014 and January 2016 rating decisions of the Department of Veterans Affairs (VA). In June 2019, the Board remanded this appeal for additional evidentiary development, having also reopened claims of entitlement to service connection for hypertension and bilateral hearing loss based on new and material evidence. The appeal has since been returned to the Board for further appellate action. The Board also denied earlier effective dates for the service-connected mental disability and migraines. The Board's decision with respect to those claims is final. See 38 C.F.R. § 20.1100. The agency of original jurisdiction subsequently granted service connection for left ear hearing loss, which resolved the appeal as to that issue. TDIU is in effect for the entire period on appeal. Therefore, the matter is not reasonably raised for any portion of the appeal period. Service ConnectionLaw and Regulations VA law provides that, for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war, or other than a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation, except if the disability is a result of the veteran's own willful misconduct or abuse of alcohol or drugs. 38 U.S.C. §§ 1110, 1131. Entitlement to service connection on a direct basis requires (1) evidence of current nonservice-connected disability; (2) evidence of in-service incurrence or aggravation of disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current nonservice-connected disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Saunders v. Wilkie, 886 F.3d 1356 (2018). Service connection on a secondary basis requires (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability caused or aggravated the current nonservice-connected disability. 38 C.F.R. § 3.310. For specific enumerated diseases designated as "chronic" there is a presumption that such chronic disease was incurred in or aggravated by service even though there is no evidence of such chronic disease during the period of service. In order for the presumption to attach, the disease must have become manifest to a degree of 10 percent or more within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Presumptive service connection for the specified chronic diseases may alternatively be established by way of continuity of symptomatology under 38 C.F.R. § 3.303(b). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a) Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The presumptive chronic disease include hypertension and sensorineural hearing loss, but do not include dizziness, sinusitis, sleep apnea, asthma, or chronic obstructive pulmonary disease (COPD). In order for hypertension to have become manifest to a degree of 10 percent, there must be evidence to substantiate that diastolic pressure is predominantly 100 or more; or, that systolic pressure is 160 or more; or, that there is a history of diastolic pressure predominantly 100 or more and that continuous medication for control is required. See 38 C.F.R. § 4.104, Diagnostic Code 7101. For VA rating purposes, hypertension means that diastolic blood pressure is predominately 90 mm. or greater; isolated systolic hypertension means that the systolic blood pressure is predominately 160 mm. or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels) over a range of frequencies (in Hertz). Hensley v. Brown, 5 Vet. App. 155, 158 (1993). Impaired hearing will be considered to be a "disability" when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. When audiometric test results at separation from service do not meet the regulatory requirements for establishing a "disability" at that time, he or she may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley, 5 Vet. App. 155. In a case where the degree of hearing loss noted on a veteran's entrance examination did not meet VA's definition of a "disability" for hearing loss under § 3.385, the United States Court of Appeals for Veterans Claims (Veterans Court) held that that veteran was entitled to the presumption of soundness under 38 U.S.C. § 1111. Further, the Veterans Court held that the demonstrated hearing loss was not a "defect"; and that the term "defect" should be narrowly interpreted so that it does not encompass a level of hearing impairment that is not considered a "disability" under 38 C.F.R. § 3.385. See McKinney v. McDonald, 28 Vet. App. 15 (2016). Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. See Barr v. Shinseki, 21 Vet. App. 303, 311 (2007). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir 2007). Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 ('sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer'); 38 C.F.R. § 3.159(a)(2). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), Gilbert at 54. Entitlement to service connection for dizziness. Entitlement to service connection for a sinus disorder. Entitlement to service connection for a respiratory disorder. Entitlement to service connection for hypertension. Entitlement to service connection for right ear hearing loss. The Veteran contends that his sinus disorder and respiratory disorder has existed since service. He maintains that his hypertension is related to his headaches and sinus disorder. He maintains that his dizziness is related to his headaches. He maintains that right ear hearing loss is related to noise exposure in service. The Veteran has been diagnosed with benign essential hypertension (Record 03/04/2014 at 4). The Veteran was been diagnosed with sinusitis (Record 03/04/2014 at 11). The Veteran has been diagnosed with asthma and COPD (Record 05/22/2017 at 75). The Veteran has been diagnosed with right ear hearing loss. Dizziness appears to be a symptom related to his service-connected migraines. The Veteran entered active duty service on April 26, 1976. Service treatment records reveal no complaint of, treatment for, or diagnosis of, hypertension, or respiratory disorders during his service. An October 12, 1978, clinical note records his complaint of headaches associated with dizziness. He also reported that his sinuses had been giving him trouble. His blood pressure was recorded as 112/78. A report of medical examination performed on January 25, 1979, reveals normal findings for the sinuses, head, vascular system, lungs and chest. The Veteran's blood pressure was 116/66 (Record 09/29/2008 at 37). Clear tone thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 10 10 A report of medical history completed by the Veteran on January 25, 1979, reveals the Veteran's statement that he had no history of, or current, sinusitis, dizziness, high blood pressure, or shortness of breath (Record 09/29/2008 at 27). The Veteran was separated from active duty on April 25, 1979. He filed claims for service connection for hearing loss and hypertension in 2008, almost 30 years later. He filed the current claims in 2013 and 2014. On October 2, 1998, blood pressure was 160/112 (Record 12/02/2008 at 5). On March 16, 2000, The Veteran's physician noted sinus disease (Record 12/02/2008 at 22). On May 23, 2000, The Veteran's physician cleaned eschar out of his sinuses (Record 12/02/2008 at 20). A VA audio examination in June 2014 reveals the following clear tone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 30 25 Speech recognition was 96 percent. The Veteran stated: "I don't understand what is said, a lot of the time. People are always having to repeat themselves so that I am able to hear correctly. I also have problems hearing anything if there is any background noise, or more than one person is talking at the same time" (Record 07/14/2014). The Veteran was seen at the emergency room on November 20, 2014, with complaint of dizziness, headaches, and blurred vision for years. He noted a syncopal episode (Record 05/22/2017 at 114). In August 2015, the Veteran reported a persistent cough which had been ongoing for a couple of months (Record 10/05/2018). A September 1, 2015, private emergency department note reveals a diagnosis of COPD and a 40 pack per year cigarette smoking history (Record 10/05/2018). A March 21, 2016, VA primary care note reveals a diagnosis of essential hypertension (Record 05/22/2017 at 43). A VA sinus examination in April 2017 reveals a diagnosis of chronic pansinusitis confirmed by CT scan. There was no impact of the condition on the Veteran's ability to work (Record 04/23/2017). The examiner opined that sinusitis is less likely than not (less than 50 percent probability) related to service. The rationale was that a review of the medical records shows a visit in 1978 for symptoms that included "trouble with sinuses." There is no further evidence found to indicate an ongoing problem. The separation exam is negative for a sinus condition. The Veteran had a visit in 2000, specialty evaluation for sinus condition with reported symptoms in 1999. This is 20 years post discharge from service. Based on the lack of evidence of chronicity while in the service and appearance of chronic symptoms 20 years after service, it is unlikely that the current sinus condition was incurred in or caused by his complaint of sinus trouble while in the service (Record 04/23/2017). A June 10, 2019, emergency department note reveals complaint of headaches for 2 days. The Veteran reported them as mild and thought they were due to high blood pressure (Record 02/05/2020 at 39). A VA audio examination in November 2019 reveals pure tone thresholds as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 30 35 Speech discrimination was 96 percent. the Veteran reported trouble hearing people, background noise, and difficulty understanding group conversations. "The TV is loud when I am watching it" (Record 11/26/2019). A VA hypertension examination in December 2019 reveals a diagnosis of hypertension. The examiner noted that the condition was diagnosed on the service separation examination. There was no impact of the condition on the Veteran's ability to work (Record 12/06/2019). On September 9, 2020, the Veteran denied recent or current dizziness (Record 04/21/2021 at 40). A VA audio examination in March 2021 reveals pure tone thresholds as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 30 30 45 40 Speech recognition was 84 percent. The Veteran reported constant difficulty understanding people in all situations (Record 03/11/2021). In May 8, 2021, a private physician, A. Ali, MD, essentially opined that all of the claimed disorders were related to service (Record 06/28/2021). Dr. Ali opined that it is more likely than not that the Veteran's hypertension began while in service. The rationale was that the December 2019 VA examiner notes that the Veteran was diagnosed with hypertension on his exit exam in 1979. It is unlikely that the Veteran developed hypertension just on that one day; it is more likely that the Veteran had elevated blood pressure in the days, perhaps weeks, preceding the date of the exit examination. Dr. Ali opined that the Veteran's dizziness is more likely than not due to his service-connected headaches, and sinus infections. The rationale was that the Veteran reported that he develops dizziness with his headaches. Additionally, the Veteran is noted in his service medical records to have dizziness associated with sinus congestion. Dr. Ali opined that it is more likely than not that the Veteran's recurrent sinus problems began while in service. The rationale was that the Veteran is noted to have been seen for sinus congestion while in service. The Veteran noted that his sinus congestion continued to be an issue since service. Dr. Ali disagreed with the 2014 examiner that there is no further evidence to indicate an ongoing problem. The Veteran has stated the opposite of this. He also disagreed with the 2014 examiner that, because there was no sinus condition on the separation examination there is no service connection. As noted in the literature provided, recurrent sinusitis symptoms can wax and wane. He noted that he had frequently seen individuals not seeking treatment for their recurrent mild to moderate sinus symptoms. Therefore, it is not unusual for the Veteran's symptoms to have onset in service and over the years become more frequent. After a review of all of the evidence, the Board finds that the criteria for entitlement to service connection for right ear hearing loss are met. However, the criteria for entitlement to service connection are not met regarding any of the remaining claimed disorders. As demonstrated in the March 2021 examination, the Veteran has right ear hearing loss that meets the criteria set out under 38 C.F.R. § 3.385. The November 2019 VA examiner related right ear hearing loss to service. The Veteran is already service-connected for left ear hearing loss. Accordingly, the criteria for service connection are met. As this represents the full benefit sought on appeal, there is no prejudice resulting from any deficiency in the duties to notify or assist. Regarding hypertension, the Board acknowledges the positive nexus opinion in May 2021. However, the rationale was that hypertension actually began in service. The private examiner notes the statement of the December 2019 VA examiner that the Veteran was diagnosed with hypertension on his exit examination in 1979. The Board notes that, just because the December 2019 examiner said hypertension was diagnosed on the service separation examination does not mean that it actually was diagnosed. Citing an inaccurate statement does not make it accurate. An actual review of the service separation examination clearly shows that hypertension was not diagnosed. This brings into question the care in which the evidence was reviewed, if at all, by the private physician. In fact, the service separation examination makes no mention of hypertension, it includes a normal clinical examination of the heart and vascular system. These findings directly contradict the assertion that hypertension was diagnosed. The service separation examination also includes a blood pressure reading of 116/66, which is manifestly not hypertensive under VA law. In October 1978, it was 112/78. For VA rating purposes, hypertension means that diastolic blood pressure is predominately 90 mm. or greater; isolated systolic hypertension means that the systolic blood pressure is predominately 160 mm. or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Moreover, the private examiner did not discuss or even acknowledge the diagnosis of "essential" hypertension in February 2013 and March 2016. Essential hypertension is defined as hypertension occurring without discoverable organic cause. Dorland's Illustrated Medical Dictionary 909 (31st ed., 2007). The use of the descriptor "essential" would naturally imply that the examiners did not intend any association with any known condition. The private examiner's opinion is inconsistent with the evidence and with basic VA law, and is therefore unpersuasive. As there is no injury or disease in service, a VA medical opinion regarding hypertension is not necessary. As there is no substantiation of hypertension to a degree of 10 percent or more in service or within one year of service separation, service connection is not available on a presumptive basis. The same private examiner opined that the Veteran's recurrent sinus problems began while in service, noting that the Veteran was seen for sinus congestion in service. The examiner also noted that sinusitis symptoms can wax and wane, and that many individuals do not seek treatment for their sinus symptoms. However, the examiner's opinion does not address a crucial piece of evidence. The focus on whether the Veteran sought treatment on one occasion during service is not the complete picture. The Veteran completed a report of medical history in conjunction with his service separation examination. That report bears his signature. He not only affirmed that he had no current sinusitis, he also affirmed that he had no history of sinusitis. This directly contradicts his current statement that he had chronic sinusitis in service, upon which the private examiner's opinion is based. A single lay report of trouble with his sinuses seems a scant basis to conclude he had chronic sinusitis. The Veteran is not competent to determine that his sinuses were actually involved, as opposed to some other nasal complaint. It must be noted that the October 12, 1978, examiner did not diagnose any form of sinus disease. The conclusion of the actual hands-on examiner must be given greater probative weight than an opinion given years after the event. In weighing the conflicting statements provided by the Veteran, the point in time in which the statement was made is important because a description of an event which is closer to the time that event allegedly occurred is naturally less likely to be affected by errors in memory. See Seng v. Holder, 584 F.3d 13, 19 (1st Cir. 2009) (noting that, notwithstanding the declarant's intent to speak the truth, statement may lack credibility because of faulty memory). Thus, the contemporaneous nature of the statement of medical history at discharge is significant. Furthermore, because that account was presented in the context of routine medical evaluation, it seems likely that he would report events carefully and accurately. The "medical diagnosis or treatment" exception to the hearsay rule (Fed. R. Evid. 803) provides that "statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care." Recourse to the Federal Rules of Evidence is appropriate where they will assist in articulation of the Board of Veterans' Appeals' reasons. Rucker v. Brown, 10 Vet. App. 67 (1997). There is no question that the Veteran is competent to relate events as he currently remembers them. Thus, his competency is not at issue with regard to recounting the events of service. Rather, it is the accuracy of the Veteran's recent account which the Board finds is lacking. Simply put, the report of medical history at separation from service is more persuasive, as it was made at the time, whereas his current assertion was made more than 30 years later. The private examiner opined that the Veteran's dizziness is more likely than not due to his service-connected migraines, and sinus infections. The sinus infections are not service-connected. While dizziness may be a symptom of the service-connected migraines, it is reasonably contemplated by the criterion of prostrating attacks. Migraines are manifested by a variety of symptoms. These include dizziness. See https://my.clevelandclinic.org/health/diseases/5005-migraine-headaches. The scope of the rating schedule for migraines appears to be non-specific as to what symptoms may be associated with an individual's migraines. Prostration is the key criterion, as is economic inadaptability at the highest rating. Particular symptoms are not specified. Therefore, to the extent the Veteran's dizziness is associated with his migraines, it does not constitute a separate disability, and it is reasonably encompassed by the current criteria as prostration. Regarding asthma and COPD, the private examiner opined that, although smoking is a primary risk factor for the development of COPD, fume and vapor exposure are also significant "possible" causes. Therefore, it is at least as likely as not that both smoking and in-service fume and vapor exposure led to the Veteran's COPD. (Record 06/28/2021). Despite the use of the inconclusive term "possible," which then convinced Dr. Ali that it was probable, service connection is expressly precluded for any disability related to chronic tobacco use for claims received by VA after June 9, 1998, which is the case here. See 38 U.S.C. § 1103; 38 C.F.R. § 3.300; Internal Revenue Service Restructuring and Reform Act of 1998, Pub. L. No. 105-206, 112 Stat. 685, 865-66 (1998). This prohibition is broadly stated and is not strictly limited to smoking. It relates to all forms of tobacco use. Therefore, service connection on the basis posited by the Veteran and his private physician is precluded as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). If the examiner was referring to anything other than tobacco fumes or vapor, he did not specify what fumes or vapor was indicated. To this extent, the opinion is mere speculation. This in an inadequate basis to establish nexus. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). For the reason set in detail above, the Board finds the opinions of the Veteran's private physician, A. Ali, MD, to be not well informed by the evidence, or in some cases completely inconsistent with the evidence. The Board finds his sinusitis opinion to be less persuasive than the opinion of the April 2017 VA examiner. There is no nexus opinion that is consistent with long-standing VA law regarding COPD and asthma. The Veteran's symptom of dizziness is already a compensated symptom of a service-connected disability. The notation of the December 2019 VA examiner that hypertension was noted on the service separation examination is simply incorrect, and the opinion of the Veteran's private physician that is based on that statement is not factually based. As there was no injury or disease in service that may be related to current hypertension, there is no necessity to obtain a VA medical opinion. In sum, the Board finds that right ear hearing loss is related to service, but that the claimed dizziness, sinus disorder, respiratory disorder, and hypertension, are not related to service. In light of these findings of fact, the Board concludes that service connection for right ear hearing loss is warranted, but that service connection for the remaining claimed disorders is not warranted. In reaching the conclusion against service connection, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. INCREASED RATINGLAW AND REGULATIONS Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). The rating must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. 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). Entitlement to a disability rating higher than 70 percent for the service-connected mental disability. The current appeal arises from a service connection claim received at VA on March 25, 2013. In a July 2014 rating decision, VA granted service connection for a mental disability and assigned an initial disability rating of 50 percent under Diagnostic Code 9411, effective March 25, 2013. In a May 2017 rating decision, the disability rating was increased to 70 percent, effective March 25, 2013, encompassing the entire period on appeal. In the process of evaluating a psychiatric/mental disorder, VA is required to consider a number of pertinent factors, such as the frequency, severity, and duration of a veteran's psychiatric symptoms and the veteran's capacity for adjustment during periods of remission. After consideration of these factors, and based on all the evidence of record that bears on occupational and social impairment, VA must assign a disability rating that most closely reflects the level of social and occupational impairment a veteran is suffering rather than based solely on the examiner's assessment of the level of disability at the moment of examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. See 38 C.F.R. § 4.126. The VA Secretary, acting within his authority to adopt and apply a schedule of ratings, chose to create one General Rating Formula for Mental Disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, the VA Secretary anticipated that any list of symptoms justifying a particular rating would, in many situations, be either under- or over-inclusive. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128 (1997). See Mauerhan v. Principi, 16 Vet. App. 436, 442 (1992). The schedular criteria incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 38 C.F.R. §§ 4.125, 4.130. The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The Federal Circuit has embraced the Mauerhan interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Psychiatric disorders are to be rated on the severity, frequency, and duration their respective signs and symptoms. See Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). Pertinent to the claim on appeal, the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: A 100 percent rating contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating, may be assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 50 percent rating is warranted if it is productive of 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 compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 30 percent rating is warranted if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). A 10 percent rating is warranted if there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 0 percent rating is warranted where a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. 38 C.F.R. § 4.130. A review of the pertinent evidence includes a February 2013 clinical note which reveals that the Veteran had been depressed for 34 years, feels hot and cold, hostility, moody and sometimes somber and suicidal thoughts. The last time he felt suicidal was a month ago. He was driving and was thinking of driving off the bridge. He reported stress at work. He is unhappy most of the time, with low energy and low motivation. He had to push himself to go to work. He reported confusion and memory lapses. He had low self-esteem and had recently been fired from a job. He gets overwhelmed and anxious. He wakes up sweating, has flashbacks, jumpiness, hypervigilance, and watches his back. Speech was normal in tone, volume, and prosody. Mood was depressed. Affect was mood congruent. Thought processes were linear, logical and to the point. Thought content showed some paranoia. He was well oriented to place, person and time, but complained of poor memory and forgetfulness. He had concrete thinking. Insight, judgment, and impulse control were poor (Record 06/25/2013 at 1). A VA mental disorder examination in April 2014 reveals a reported history of arrests for assault and drunk driving. Symptoms included depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss such as forgetting names, directions or recent events, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. On examination, the Veteran was alert and oriented x4. The Veteran's mood was extremely anxious with congruent affect. The Veteran was alert and cooperative, demonstrated good grooming and hygiene, and made appropriate eye contact. Speech was of normal rate, rhythm and volume. When discussing traumatic events, the Veteran became tearful. The Veteran reported a remote history of suicidal ideations but denied any attempts. The Veteran denied any current suicidal or homicidal ideation, intent, or plan during the evaluation. The Veteran denied any hallucinations or delusions. The Veteran reported independent management of activities of daily living. The examiner diagnosed posttraumatic stress disorder (PTSD) and major depressive disorder. The examiner opined that the disability resulted in occupational and social impairment with reduced reliability and productivity (50 percent criteria) (Record 04/21/2014). An undated treatment report received in August 2014 states that the Veteran had recently separated from his wife and was on his way to California to live with children and grandchildren. He reported that work was very stressful and family life was also stressful. He sometimes gets confused about things and has a hard time trying to sort out things. He reported that he has memory losses and feels exhausted easily. He wakes up at night, sweating and has flashbacks and jumpiness. He is very hypervigilant. He has to watch his back and is uncomfortable in his surrounding and is always on the watch. Two of his brothers committed suicide. On examination, speech was normal in tone, volume and prosody. Mood was depressed. Affect was mood congruent. Thought process was linear and logical to the point. Thought content indicated some paranoia and he has nightmares and flashbacks. There were no specific hallucinations. He was well oriented to place person and time, but complained of poor memory and forgetfulness. Abstract thinking, concrete thinking, and general knowledge appeared to be fair. Insight, judgment and impulse control appeared to be poor at times. The diagnosis was major depressive disorder chronic recurrent and severe and PTSD (Record 08/13/2014). A VA mental examination in January 2015 reveals the Veteran's PTSD symptoms of recurrent thoughts and memories regarding a past attack, nightmares, distress reactions to triggers resembling the trauma, avoidance of people, feelings, thoughts and places, persistent distorted thinking that he is not safe among people, persistent fear and anger, detachment from others, diminished participation in activities, irritability, startle response, poor concentration and chronic sleep impairment. The symptoms of depression were episodes of sad mood, low motivation, poor concentration, which overlaps with PTSD, increased difficulty in sleep, recurrent negative thoughts about himself, such as that he is a failure, and suicidal ideation, at times with particular thoughts as to how he would do it, such as driving or jumping off a bridge, during his last job. He denied persistent thoughts of suicide at this time, and related that he does not have plans. He stated that taking care of his family is and has been a reason that he does not let suicidal thinking get out of hand. For the substance abuse disorder, he has tended to use alcohol inappropriately to medicate himself, has had multiple attempts to quit alcohol, but unsuccessfully, and has continued to drink despite legal consequences and relationship and emotional consequences. He has a history of operating machinery while under the influence. He also tends to need more of the alcohol to get the same effect. With his increase in PTSD symptoms and having depressed symptoms, he fears he will have a full relapse to alcohol use, or one in which he is drinking heavily and not just a drink on occasion. He has recurrent thoughts of failure. He related that his depression is recurrent. The Veteran reported that he got a DUI in the past for which he was in jail for 7 days, and had to pay a fine monthly for about one year, while also getting tested for alcohol and drugs. The Veteran related that he was self-medicating his conditions for years with alcohol. He received substance abuse treatment in 1999, and then 2009 through 2010. He stated that he has picked up drinking a little in recent months and stated that his fear of returning to drinking again given the increase in his symptoms of PTSD is a reason that he has been asking for treatment at the VA. Symptoms included a depressed mood, anxiety, suspiciousness, chronic sleep impairment, and disturbances of motivation and mood. The PTSD and symptoms of major depression impair his social functioning in that he withdraws from social activities and from interacting with others due to feeling anxious, irritable and angry when around people. His symptoms affected his previous job, especially, because he had a difficult time due to the symptoms mentioned, symptoms which overlap significantly in the two disorders, in managing the interpersonal stressors inherent in the job, which was in sales. He reported being very anxious and depressed during that job, from which he was fired, according to the Veteran. Judging from the information available, the Veteran is not able to do well with jobs in which a high degree of interpersonal involvement, with tension more likely than not being part of it, is expected. He is like to become severely depressed and turn to drinking, a habitual coping mechanism for him, in such jobs. He may be able to handle jobs in which he works with not a lot of people and not a high degree of pressure or responsibility, both factors were present at his last job. The examiner diagnosed PTSD, major depressive disorder, and alcohol use disorder. The examiner opined that the Veteran's disability was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) (30 percent criteria) (Record 01/21/2015). A February 4, 2015, VA mental health note reveals the Veteran's complaint that sleep is horrible. He sleeps about 2-3hrs and is often woken up by nightmares and/or knee pain. He complains of hypervigilance and irritability. He also complains of depressive symptoms of poor energy level and lack of motivation. He had suicidal ideation 3 years prior with plans to jump off the bridge. The last time he had suicidal ideation was one month prior, but at that time it was vague and without a plan. He also endorses auditory hallucination of multiple voices. He denies VH, no paranoia or delusions elucidated. He talked extensively about grudges he has had against several people spanning several years, from people he had conflict while in the military to the people who murdered 2 of his brothers in 1979 and 1992. He admitted to choking a coworker in 2004. On examination, the Veteran was well groomed; activity was normal; attitude was cooperative, attentive, and interested; speech was fluent, relevant, and coherent; mood was numb; affect was depressed; no abnormality in perception was found; flow of thought was spontaneous, logical, and goal-directed; there was no abnormality in thought content identified; he denied suicidal ideation and homicidal ideation; Judgment was fair; insight was fair; and he was alert and oriented to all spheres (Record 05/22/2017 at 95). The Veteran has reported to being "a very angry person" (Record 05/22/2017 at 103). A VA mental disorders examination in November 2019 reveals the Veteran's symptoms included depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, circumstantial, circumlocutory or stereotyped speech, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationships, and suicidal ideation. He also reported night sweats and hypervigilance. The Veteran was found capable of managing his financial affairs. The evidence opined "I do not believe this Veteran/Service Member should be considered a current imminent or increased risk." The examiner diagnosed major depressive disorder and characterized the severity as moderate. In terms of occupational and social impact, the examiner opined that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner did not indicate that there was total occupational and social impairment (Record 11/18/2019). A December 30, 2019, VA mental health note reveals past struggles with audio and visual hallucinations but had not experienced this in several years. The Veteran reported that he struggles with sleeping and a mistrust of people. He often avoids triggers and isolates himself. He has had several traumas and has had multiple deaths in his family that further complicate his symptoms. He has also dealt with depression and anxiety throughout his life. He was also on medication for PTSD in Virginia that helped keep him calm and his hypertension under control. However, his care providers were changed, and he was abruptly taken off all medications. The examiner assessed normal speech, linear flow of thought, no hallucinations, alert and oriented x3, and intact insight and judgment (Record 02/05/2020 at 20). The Veteran stated to his private examiner in a May 2021 report that: "My psychiatric symptoms are very troubling... my anxiety can be crippling... I take clonazepam and quetiapine to take the edge off" (Record 06/28/2021). After a review of all of the evidence, the Board finds that the criteria for a rating of 100 percent for the service-connected mental disability are not met. While the Veteran has a history of audio/visual hallucinations, the February 2020 VA mental health note indicates that he has not experienced them in years. Functional areas such as speech, flow of thought, and orientation have typically been normal, although occasionally impaired. The Veteran has been found capable of handling his own finances. The Veteran clearly has social impairment, manifested by anger and suspiciousness, and avoidance of crowds. He has poor judgment and impulse control. However, to meet or approximate total social impairment, the evidence would have to show that he is totally unable to function socially. This is an extreme level of impairment which is not evident from the record. The Board acknowledges that the Veteran finds it very difficult to function in an employment environment, especially one that requires social interactions. However, to meet or approximate total occupational impairment, the evidence would have to show that he is totally unable to function occupationally. This again is an extreme level of impairment which is not evident from the record. The November 2019 VA examination found his symptomatology to be consistent with a rating of 70 percent, but did not indicate that he was totally occupationally impaired and totally socially impaired. Moreover, the examiner characterized the Veteran's condition as moderate. A finding that an individual is entitled to TDIU does not equate to a finding that an individual is entitled to a 100 percent rating for a mental disability. Entitlement to a rating of 100 percent for a mental disability requires symptoms of the type and degree representative of serious impairments of thought, memory, communication, behavior, and orientation, such as to result in total social impairment and total occupational impairment. Here, the Board finds that the gross impairment of behavior resulting in severe disorientation, which is contemplated by the 100 percent rating criteria, is simply not evident in this case at any time. In sum, the Board finds that the service-connected mental disability is manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In light of these findings of fact, the Board concludes that a disability rating higher than 70 percent for the service-connected mental disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Entitlement to an increased disability rating for the service-connected migraines, currently rated at 0 percent prior to July 13, 2016, and 30 percent since July 13, 2016. The current appeal arises from a service connection claim received at VA on March 25, 2013. In a July 2014 rating decision, VA granted service connection for migraines and assigned an initial disability rating of 0 percent under Diagnostic Code 8100, effective March 25, 2013. In a May 2017 rating decision, the disability rating was increased to 30 percent, effective July 13, 2016. Under Diagnostic Code 8100 (migraine), a rating of 50 percent is assigned with very frequent completely prostrating and prolonged attacks; a rating of 30 percent is assigned with characteristic prostrating attacks occurring on an average once a month over last several months; a rating of 10 percent is assigned with characteristic prostrating attacks averaging one in 2 months over last several months; and, rating of 0 percent is assigned with less frequent attacks. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The rating criteria do not define "prostrating" as used in Diagnostic Code 8100. By way of reference, the Board notes that according to Webster's New College Dictionary, 909 (3rd Ed. 2008), "prostrate" is defined as "physically or emotionally exhausted." "Incapacitated" is listed as a synonym. A very similar definition is found in Dorland's Illustrated Medical Dictionary, 1554 (31st Ed. 2007), in which "prostration" is defined as "extreme exhaustion or powerlessness." Similarly, the regulations provide no clarification as to the meaning of the phrase "productive of severe economic inadaptability." The Veterans Court, however, has issued a precedent decision which focuses on the meaning of this phrase. In Pierce v. Principi, 18 Vet. App. 440 (2004), the Veterans Court interpreted the phrase as follows: "nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50% rating" because "[i]f 'economic inadaptability' were read to import unemployability," a claimant who "met the economic-inadaptability criterion, would then be eligible for a rating of total disability based on individual unemployability [(TDIU)]... rather than just a 50% rating." Id. The Veterans Court therefore rejected the notion that "severe economic inadaptability" was equivalent to an inability to secure or follow a substantially gainful occupation, the unemployability standard for TDIU. Id. (citing 38 C.F.R. § 4.16 (a). In addition, the Veterans Court in Pierce acknowledged the VA Secretary's concession that the phrase "productive of severe economic inadaptability" in Diagnostic Code 8100 should be construed as either "producing" or "capable of producing" severe economic inadaptability. Id. at 445. Unlike most rating codes, 38 C.F.R. § 4.124a Diagnostic Code 8100 for headaches is successive and cumulative, meaning that all the criteria for a higher rating must be met for the higher rating to be warranted. Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018). The VA Adjudication Procedure Manual provides guidance on the frequency of headaches. It provides that very frequent means less than a month apart of the last several months and less frequent means more than two months apart over the last several months. M21-1.III.iv.4.N.7.f. A review of the pertinent evidence includes a May 2014 VA migraines examination. This reveals the Veteran's complaint of constant head pain with sensitivity to light and changes in vision. These last less than one day. There were no prostrating attacks. The impact on work was "I am unable to take the pain medication and focus on what I have to do and driving. I used as an area director for a health club." The examiner diagnosed tension and cluster headaches (Record 05/04/2014). The Veteran submitted a statement in July 2016 noting constant head pain with nausea, changes in vision and sensation and sensitivity to light and sound. The Veteran reported prostrating attacks more frequently than once per month. He reported very frequent prostrating attacks and prolonged attacks. He reported that the headaches leave him in a stupor and he is rendered socially impaired (Record 07/13/2016). A VA migraines examination in April 2017 reveals the Veteran's complaint of constant head pain with vomiting and sensitivity to light and sound. Prostration occurs once per month. There were no very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability. The examiner diagnosed tension and cluster headaches (Record 04/23/2017). A VA migraines examination in December 2019 reveals the Veteran's complaint of daily headaches. Symptoms at that time included nausea, and light sensitivity. Pain would last less than one day. The Veteran reported no prostrating attacks. There was no impact of the condition on the Veteran's ability to work (Record 12/06/2019). After a review of all of the evidence, the Board finds that the criteria for entitlement to a disability rating of 50 percent for the service-connected migraines are not met since July 13, 2016, and the criteria for a compensable rating were not met prior to that date. The change in rating from 0 percent to 30 percent is based on the Veteran's report in July 2016 that he had very frequent prostrating attacks and that they occurred more frequently than once per month. While the statement was written on a DBQ form, it was not completed or signed by a medical professional. The Veteran is referred to in the first person. It is truly not evident that this represents a worsening of the disability as examinations prior to and after this statement have found symptoms of less severity. Nevertheless, the Board will not change a favorable finding by the agency of original jurisdiction. The evidence prior to July 13, 2016, did not substantiate characteristic prostrating attacks averaging one in 2 months over last several months, as required for a rating of 10 percent. Indeed, the evidence showed no prostrating attacks. Accordingly, a noncompensable rating is appropriate. Since July 13, 2016, the Board finds that the April 2017 and December 2019 VA examination reports are the most persuasive regarding whether the criteria for a higher rating are met. While the Veteran is competent to describe his symptoms and the effect they have on employment, to the extent his descriptions are accurate at the time he recorded them, any exacerbation of the condition was apparently not long-lived, as the examination less than one year later did not substantiate the criteria for the 50 percent rating, and the examination in December 2019 indicated there would be no impact of the condition on employment. In sum, the Board finds that, prior to July 13, 2016, the service-connected migraines were manifested by less frequent attacks than contemplated for the rating of 10 percent; and, since July 13, 2016, the service-connected migraines is manifested by characteristic prostrating attacks occurring on an average once a month over last several months. In light of these findings of fact, the Board concludes that a disability rating higher than 0 percent is not warranted prior to July 13, 2016; and, a rating higher than 30 percent is not warranted since July 13, 2016. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366, 371. REASONS FOR REMAND Entitlement to service connection for sleep apnea. The Veteran has been diagnosed with obstructive sleep apnea (Record 03/04/2014 at 6). An August 18, 2010, report from Sleep Solutions of Fredericksburg shows a diagnosis of very mild obstructive sleep apnea (Record 06/25/2013 at 13). An August 25, 2010, sleep study follow-up reveals poor sleep hygiene with complaints of fatigue and painful joints (Record 08/13/2014). In a VA sleep apnea examination in December 2019 the examiner diagnosed obstructive sleep apnea (Record 12/06/2019). The examiner opined that sleep apnea was less likely than not (less than 50 percent probability) related to his mental disability. The rationale was that the Veteran's obstructive sleep apnea was obstructive in nature, and this cannot be attributed to PTSD (Record 12/06/2019). However, a private examiner opined that it is more likely than not that the Veteran's obstructive sleep apnea due to a combination of PTSD, medications used to treat his PTSD specifically benzodiazepines, recurrent sinusitis, and COPD. Along with this opinion, the Veteran submitted articles which appear to relate obstructive sleep apnea to sleep apnea. An article from the Mayo Clinic on obstructive sleep apnea addressed the prevalence of obstructive sleep apnea in younger veterans with PTSD. It found that the prevalence is higher, but acknowledged that there was a dearth of information on the relationship between PTSD and obstructive sleep apnea among this population (Record 06/28/2021 at 9). Thus, it is not clear whether this relationship is causal or coincidental. These submissions suggest a possible role of causation or aggravation of obstructive sleep apnea by PTSD itself, or the medications used to treat PTSD. The VA opinion simply dismisses a relationship without giving an adequate rationale. An opinion is necessary to address this relationship in more detail and to distinguish it from the effects of the nonservice-connected COPD and sinusitis. The matter is REMANDED for the following action: 1. Schedule an appropriate VA examination to determine the nature and etiology of his obstructive sleep apnea. The relevant documents in the claims file should be made available to the VA examiner. All indicated tests and studies should be accomplished. The VA examiner is requested to please review the pertinent evidence, to include the opinion of Dr. Ali dated May 8, 2021, and the articles attached to that document, and offer an opinion as to whether it is at least as likely as not (i.e., to at least a 50-50 degree of probability) that the claimed sleep apnea (1) is causally or etiologically related to the Veteran's active service; or, (2) is proximately due to or the result of the service-connected PTSD to include medications taken in treatment thereof; or (3) has been aggravated (i.e., increased in severity beyond natural progression of the disease) proximately due to or the result of the service-connected PTSD, to include medications taken in treatment thereof. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but that the medical evidence for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation or worsening as it is to find against causation or worsening. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, the examiner is asked to please provide complete explanations stating why this is so. In so doing, the examiner is asked to explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that the examiner has exhausted the limits of current medical knowledge in providing an answer to that particular question. 2. Readjudicate the remanded claim. If the benefit sought on appeal is not granted, the Veteran and his representative should be provided a supplemental statement of the case and an appropriate time period for response. The case should then be returned to the Board for further consideration, if otherwise in order. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Cramp 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.