Citation Nr: 21071136 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 17-44 622 DATE: November 29, 2021 REMANDED Entitlement to service connection for a sleep disorder, to include sleep apnea, is remanded. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to an initial rating in excess of 10 percent for dyspnea is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty from August 2000 to August 2004. This appeal to the Board of Veterans' Appeals (Board) is from an April 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is in the record. At the hearing, it was agreed that the record would remain open for 60 days to provide the Veteran and his attorney additional time to submit evidence. The Board observes that the Veteran tried to appoint a new attorney via the submission of a March 2021 VA Form 21-22a. However, the form was not signed and dated by the attorney. The Veteran was informed of this in March 2021. However, he has not responded. Therefore, the Veteran's representative remains as listed on the title page of this remand. 1. Entitlement to service connection for a sleep disorder, to include sleep apnea, is remanded. The Veteran had a sleep study in 2016 that did not find evidence of obstructive sleep apnea, but a September 2016 treatment record indicated he had insomnia. See December 2016 CAPRI records. The specific findings of the July 2016 test are in Vista and, therefore, must be printed and associated with the records. The Veteran is service connected for PTSD, which includes sleep impairment. An opinion is needed to determine if the Veteran's insomnia is a disorder apart from his PTSD and, if so, if it is related to service or secondary to the Veteran's service-connected PTSD. 2. Entitlement to an initial rating in excess of 50 percent for PTSD. The Veteran had a VA examination in March 2017. During the February 2021 hearing, the Veteran's attorney asserted that the examination did not adequately portray the severity of the Veteran's PTSD. Thus, another examination is needed. 3. Entitlement to an initial rating in excess of 10 percent for dyspnea is remanded. Although a July 2017 VA treatment record noted that an "employer function test" had been normal, that record does not appear to be in the claims file. Consequently, a copy of the results should be obtained. 4. Entitlement to a TDIU is remanded. At the February 2021 hearing, TDIU was raised; therefore, the Veteran should submit a completed claim form for TDIU since it will contain relevant information in adjudicating the claim. These matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the claims file. 2. The Veteran had a sleep study in 2016 that did not find evidence of obstructive sleep apnea, but a September 2016 treatment record indicated he had insomnia. See December 2016 CAPRI records. The specific findings of the July 2016 test are in Vista and, therefore, must be printed and associated with the records. 3. Ask the Veteran to identify where he had any prior lung function tests that were required by a past employer and have him complete the necessary release to allow VA to obtain those records. The Veteran should be informed that he may also submit those records on his own. 4. Ask the Veteran to complete and submit the application form for TDIU. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's sleep disorder. The claims file must be made available to the examiner to review. The examiner should obtain a complete history from the Veteran and report all relevant findings. Based on the examination and the examination and review of the claims file, the examiner should respond to the following: a) Identify any sleep disorder to include insomnia, if present. b) Is the Veteran's sleep disorder at least as likely as not (50 percent probability or greater) a disorder distinctly separate from his PTSD? c) Does the Veteran at least as likely as not have a sleep disorder that is related to service? d) Does the Veteran have a sleep disorder that is (a) caused or (b) aggravated by his PTSD? e) The clinician must explain the rationale for each opinion expressed. 6. Schedule the Veteran for a VA examination to determine the severity of his PTSD. Make the claims file available to the examiner to review. He or she should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. The examiner should also identify the symptoms that would impact the Veteran's ability to work and describe how they would impact him occupationally. (Continued on the next page) 7. Schedule the Veteran for a VA examination to determine the severity of his dyspnea. Make the claims file available to the examiner to review. He or she should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. The examiner should also identify the symptoms that would impact the Veteran's ability to work and describe how they would impact him occupationally. 8. Thereafter, readjudicate the claims on appeal, to include the claim for TDIU. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Bredehorst, 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.