Citation Nr: 21074431 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 18-29 187 DATE: December 15, 2021 ORDER Entitlement to service connection for a vitamin D deficiency, to include as secondary to diabetes mellitus, type II, is denied. Entitlement to a disability rating for posttraumatic stress disorder in excess of 10 percent from April 24, 2014 to April 23, 2016 is denied. Entitlement to a disability rating of 30 percent, but no higher, for posttraumatic stress disorder for the period from April 24, 2016 to September 19, 2017 is granted. Entitlement to a disability rating for posttraumatic stress disorder in excess of 10 percent from September 20, 2017 to August 18, 2019 is denied. Entitlement to a disability rating for posttraumatic stress disorder in excess of 30 percent from August 19, 2019 to July 6, 2021 is denied. Entitlement to a disability rating for posttraumatic stress disorder in excess of 70 percent from July 7, 2021 onward is denied. REMANDED Entitlement to a total disability rating based on individual unemployability is remanded. FINDINGS OF FACT 1. The weight of the evidence is against a finding that the Veteran's vitamin D deficiency had its onset in or is the result of an event, injury, or occurrence during active service, to include exposure to herbicide agents. 2. The weight of the evidence is against a finding that the Veteran's vitamin D deficiency is the result of, or has been aggravated by, a service-connected disability, to include diabetes mellitus, type II. 3. For the period from April 24, 2014 to April 23, 2016 the weight of the evidence is against a finding that the Veteran's posttraumatic stress disorder manifested as occupational and social impairment with occasional decrease in work efficiency and intermittent period of inability to perform occupational tasks (though generally functioning satisfactorily with routine behavior, self-care, and conversation normal). 4. For the period from April 24, 2016 to September 19, 2017 the evidence is at least in equipoise as to whether the Veteran's posttraumatic stress disorder most closely approximated occupational and social impairment with occasional decrease in work efficiency and intermittent period of inability to perform occupational tasks (though generally functioning satisfactorily with routine behavior, self-care, and conversation normal). 5. For the period from September 20, 2017 to August 18, 2019 the weight of the evidence is against a finding that the Veteran's posttraumatic stress disorder manifested as occupational and social impairment with occasional decrease in work efficiency and intermittent period of inability to perform occupational tasks (though generally functioning satisfactorily with routine behavior, self-care, and conversation normal). 6. For the period from August 19, 2018 to July 6, 2021 the weight of the evidence is against a finding that the Veteran's PTSD manifested as occupational and social impairment with reduced reliability and productivity. 7. For the period from July 7, 2021 onward the weight of the evidence is against a finding that the Veteran's PTSD manifested as total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a vitamin D deficiency, to include as secondary to diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to a disability rating of 30 percent, but no higher, for posttraumatic stress disorder for the period from April 24, 2016 to September 19, 2017 have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.7, 4.130. 3. The criteria for entitlement to a disability rating for posttraumatic stress disorder in excess of 10 percent from April 24, 2014 to April 23, 2016; in excess of 10 percent from September 20, 2017 to August 18, 2019; in excess of 30 percent from August 19, 2019 to July 6, 2021; and in excess of 70 percent from July 7, 2021 onward have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.7, 4.130. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the Army from January 1971 to January 1974, to include service in the Republic of Vietnam. Exposure to herbicide agents is therefore conceded. 38 C.F.R. § 3.307. These matters originate from a March 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) that, inter alia, denied entitlement to a disability rating in excess of 10 percent for posttraumatic stress disorder (PTSD). These matters were previously before the Board of Veterans' Appeals (Board) in March 2021. In March 2021 the Board directed that the RO obtain updated VA treatment records and obtain VA medical examinations addressing (1) the current severity of the Veteran's PTSD and (2) the nature and etiology of the Veteran's vitamin D deficiency, to include a casual or aggravating relationship with his service-connected diabetes mellitus, type II (DM II). A remand by the Board confers on the Veteran, as a matter of law, the right to substantial compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). Updated VA treatment records were obtained and associated with the claims file in March 2021, June 2021, and July 2021. As discussed further below, VA medical opinions were obtained in July 2021, August 2021, and September 2021. Accordingly, the Board finds that there has been substantial compliance with its March 2021 remand directives as they relate to the Veteran's PTSD and vitamin D deficiency claims. The Board notes that it has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although there is an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as deemed appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. 1. Entitlement to service connection for a vitamin D deficiency, to include as secondary to DM II, is denied. In April 2014 the Veteran filed a claim of service connection for a vitamin D deficiency, claimed as a complication of DM II. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish secondary service connection, a Veteran must provide evidence of (1) a current, non-service-connected disability, (2) a current service-connected disability, and (3) evidence that the non-service-connected disability is either (i) proximately due to or the result of a service-connected disability or (ii) aggravated (increased in severity) beyond its natural progression by a service-connected disability. 38 U.S.C. § 1110; Allen v. Brown, 7 Vet. App. 439, 446 (1995); 38 C.F.R. § 3.310. The record reflects that the Veteran is service-connected for DM II. Further, as noted above, exposure to herbicide agents has been conceded pursuant to 38 C.F.R. § 3.307. An August 2019 VA examiner documented a 2014 diagnosis of vitamin D deficiency. The examiner noted that the 2014 vitamin D deficiency diagnosis was contemporaneous with the Veteran's diagnosis with DM II. The examiner opined that the Veteran's vitamin D deficiency was less likely than not the result of an event, injury, or occurrence in service, stating that vitamin D deficiencies are due to diet. The examiner further stated that there is "no credible medical evidence that exposure to [herbicide agents] results in vitamin D deficiencies." In August 2021 a second VA examiner similarly stated that no medical literature showed a causal relationship between herbicide exposure and vitamin D deficiency. The examiner further stated that there was no medical literature showing a causal relationship between DM II and vitamin D deficiency; rather, the examiner stated that it is the deficiency that may cause DM II. Given the foregoing, the Board finds that the weight of the evidence is against a finding that the Veteran's vitamin D deficiency had its onset in service and/or is etiologically related to his active service, to include being secondary to diabetes mellitus, type II. Accordingly, service connection for a vitamin D deficiency is not warranted on any basis. In reaching the above conclusions, the Board also considered the doctrine of reasonable doubt. 38 U.S.C. § 5107 (b). However, as the preponderance of the evidence is against the claim, the doctrine is not for application. See e.g. Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, service connection for a vitamin D deficiency is denied. 2. Entitlement to a disability rating for PTSD in excess of 10 percent from April 24, 2014 to April 23, 2016 is denied; entitlement to a disability rating of 30 percent, but no higher, for PTSD for the period from April 24, 2016 to September 19, 2017 is granted; entitlement to a disability rating for PTSD in excess of 10 percent from September 20, 2017 to August 18, 2019 is denied; entitlement to a disability rating for PTSD in excess of 30 percent from August 19, 2019 to July 6, 2021 is denied; entitlement to a disability rating for PTSD in excess of 70 percent from July 7, 2021 onward is denied. The Veteran initially appealed a March 2015 denial of his claim for a disability rating in excess of 10 percent for his PTSD. During the pendency of the Veteran's appeal, the RO granted the Veteran increased ratings for PTSD of 30 percent, effective August 19, 2019, and 70 percent, effective July 7, 2021. As the highest possible rating has not been assigned for the periods on appeal, the appeal continues. See AB v. Brown, 6 Vet. App. 35 (1993). Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability; resolving any reasonable doubt regarding the degree of disability in favor of the claimant; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity. See 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.10; see also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Veteran's PTSD is rated under the General Rating Formula for Mental Disorders, which provides for progressively higher disability ratings upon progressively higher showings of levels of occupational and social impairment. 38 C.F.R. § 4.130. A disability rating of 30 percent requires a showing of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A disability rating of 50 percent requires a showing 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 complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A disability rating of 70 percent requires a showing of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A disability rating of 100 percent requires a showing of 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. The list of symptoms that follows each level of impairment is non-exhaustive, meaning that VA is not required to find the presence of all, most, or even some of the enumerated symptoms to assign a particular evaluation. However, because "[a]ll nonzero disability levels [in § 4.130] are also associated with objectively observable symptomatology," and the plain language of the regulation makes it clear that "the veteran's impairment must be 'due to' those symptoms," "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Section 4.130 "requires not only the presence of certain symptoms" but also that those symptoms have caused the level of occupational and social impairment associated with a particular disability evaluation. Therefore, although the veteran's symptoms are the "primary consideration" in assigning a disability evaluation under § 4.130, the determination as to whether the veteran is entitled to a particular evaluation "also requires an ultimate factual conclusion as to the veteran's level of [occupational and social] impairment...." Bankhead v. Shulkin, 29 Vet. App. 10, 18 (2017). The Board notes that entitlement to a disability rating may not be denied on the basis of relief provided by medication except when those effects are specifically contemplated by the applicable rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). The General Rating Formula for Mental Disorders specifically contemplates relief provided by medication: symptoms not severe enough to require continuous medication do not warrant a compensable rating; requiring continuous medication to control symptoms is among the criteria for a compensable rating of 10 percent. 38 C.F.R. § 4.130. The characterization of symptoms at higher levels of evaluation therefore assumes the operative effect, if any, of medications. In evaluating a claim for disability benefits, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. As noted above, the Veteran filed a claim for an increased rating for his PTSD in April 2014, at which time a 10 percent rating was in effect. The next highest disability rating of 30 percent requires a showing of occupational and social impairment 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). The Veteran was afforded a VA examination in March 2015. He reported that he had been dating his girlfriend for approximately one year, describing the relationship as "so far, so good." The Veteran reported having close relationships with two of his three children, and having two close friends in whom he could confide. The examiner acknowledged that the Veteran was service-connected for PTSD, but concluded that they were unable to determine of the Veteran even met the criteria for PTSD at the time of the examination, describing the Veteran as "not cooperative" with the examination. 03/09/2015, C&P Exam, p. 6. The examiner documented the results of two separate assessments designed to identify individuals who were feigning or exaggerating symptoms, or malingering. Both assessments resulted in scores above the cut-off used to identify individuals who were feigning or exaggerating symptoms, or malingering. On April 24, 2017 the Veteran presented to a treating VA mental health provider. He reported having run out of his psychiatric medication "a year or more ago" and that his condition had slowly deteriorated since that time. 04/12/2018, CAPRI, p. 50. The Veteran described intrusive thoughts, insomnia, hypervigilance, and nightmares. Id. The Veteran described awakening from nightmares sweating and with a racing heart, and being unable to return to sleep. Id. The Veteran denied suicidal thinking, and reported "good relations" with his children. The Veteran reported that he enjoyed fishing and helping his brother. Id. at 56. The treating mental health provider performed a mental status examination and characterized the Veteran as "mildly apprehensive", but otherwise normal in presentation, affect, orientation, speech, and thought processes. Id. at 57. The examiner documented intact memory, normal-to-high normal intellectual functioning, and good insight and judgment. Id. In September 2017, the Veteran again presented to the same treating provider and reported "doing well now that he is back on his psychotropics." Id. at 24. The Veteran reported having had only one nightmare in the past week and getting 8 hours of sleep a night. Id. at 24. The Veteran denied suicidal thinking. Id. at 24. The provider again characterized the Veteran as "mildly apprehensive", but otherwise normal in presentation, affect, orientation, speech, and thought processes. Id. at 25. A September 2017 nursing note characterizes the Veteran's mood as "happy/content" and his affect and appearance as "normal" and "calm", respectively. Id. at 27. The Board finds that, for the period from April 24, 2014 to April 23, 2016, the weight of the evidence is against a finding that the Veteran's PTSD manifested as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). Accordingly, the Board concludes that the criteria for a disability rating in excess of 10 percent for the period from April 24, 2014 to April 23, 2016 are not met, and the same is hereby denied. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.7, 4.130. The Board finds that the evidence is at least in equipoise as to whether, for the period from April 24, 2016 (one year prior to the record described above) to September 19, 2017, the Veteran's PTSD symptoms most closely approximated 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: anxiety, suspiciousness, panic attacks (weekly or less often), and chronic sleep impairment. Accordingly, the Board concludes that the criteria for a disability rating of 30 percent, but no higher, for the period from April 24, 2016 to September 19, 2017 are met, and the same is hereby granted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.7, 4.130. Indeed, as he still had good relations with his family and was continuing to enjoy activities such as fishing, and given the findings on clinical examination, a higher level of disability is not deemed warranted as the disability picture most nearly approximated 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). A 10 percent rating is in effect for the period from September 20, 2017 to August 18, 2019. In March 2018 the Veteran again presented to VA treating mental health providers, reporting "great reduction" in nightmares. The Veteran continued to complain of "night sweats", but could not recall for certain whether he had been having a nightmare. 07/31/2019, CAPRI, p. 63. The Veteran reported getting between 7 and 8 hours of sleep. In October 2018 the Veteran reported having anxiety during a recent storm, but denied being depressed. Id. at p. 42. The Veteran denied suicidal thinking and had no audio/visual perceptual disturbances. Id. at 44. With respect to the period from September 20, 2017 to August 18, 2019, the Board finds that the weight of the evidence is against a finding that the Veteran's PTSD manifested as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). In light of the foregoing, the Board concludes that the criteria for a disability rating in excess of 10 percent for the period from September 20, 2017 to August 18, 2019 have not been met, and the same is hereby denied. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.7, 4.130. A 30 percent rating is in effect for the period from August 19, 2019 to July 6, 2021. The Veteran was afforded a VA examination in August 2019. At that time, he the reported nightmares on average of twice a week. The Veteran reported having been with his girlfriend for about 12 years, stating that the relationship was "going well." The Veteran reported a strained relationship with one of his three children, but was close with his four siblings and spent time with two friends. The Veteran stated that he fished as much as he could and attended church regularly. 08/27/2019, C&P Exam, p. 4. The examiner documented symptoms of anxiety, suspiciousness, chronic sleep impairment, and difficulty in adapting to stressful circumstances, including work or a work like setting. Id. at 6. The examiner characterized the Veteran as oriented, talkative, and cooperative; as needing redirection back to questions a number of times; and with no indications of mania, psychosis, or suicidal ideation. Id. at 7. In September 2019 the Veteran reported to a VA mental health provider that he was staying with his mother because she had Alzheimer's disease, and that he would cook for her and take her to appointments. 05/22/2020, CAPRI, p. 16. In September 2020 a VA mental health provider again characterized the Veteran as "mildly apprehensive" but otherwise normal in presentation, affect, orientation, speech, and thought processes. Id. at 17. The Veteran denied suicidal or homicidal thoughts. Id. at 19. In May 2020 a VA mental health treating provider described the Veteran as "doing great." Id. at 2. The Veteran reported regularly sleeping 6 to 7 hours a night. Id. at 2. The VA provider stated that there was "no evidence of destructive ideation directed at himself or others." The VA provider wrote "no evidence of psychotic thought process, thoughts are logical, coherent and linear; no evidence of loosened associations, flight of ideas; no evidence of tangentiality, circumstantiality; no evidence of hallucinations or delusions; no evidence of obsessions nor compulsions." Id. at 2. A December 2020 mental status examination characterized the Veteran as oriented, with euthymic mood and bright affect; having organized thought processes; and no suicidal or homicidal thinking. 03/04/2021, CAPRI, p. 14. In June 2021 the Veteran reported having infrequent nightmares and was doing well with his mood. 07/31/2021, CAPRI, p. 5. The Veteran reported working with a friend on a summer garden. Id. at 5. A VA mental health provider described the Veteran's energy, appetite, and interested activities as "good." Id. at 7, 9. With respect to the period from August 19, 2019 to July 6, 2021, the Board finds that the weight of the evidence is against a finding that the Veteran's PTSD manifested as occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Accordingly, the Board concludes that the criteria for a disability rating in excess of 30 percent for the period from August 19, 2019 to July 6, 2021 are not met, and the same is hereby denied. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.7, 4.130. A 70 percent rating is in effect for the period from July 7, 2021 onward. The Veteran was afforded a VA examination in July 2021. The Veteran reported depressed mood for several hours once or twice a week, and that he used "distractions" of driving or working with fishing gear. 07/07/2021, C&P Exam, p. 1. The Veteran reported sleeping 6 hours a night on average, and waking from nightmares confused, shaking, sweaty, and with a racing heart. Id. at 1. The Veteran reported still being with his long term girlfriend and that the relationship was going well. Id. at 5. The Veteran reported having a good relationship with his children and siblings and that he had friends that he spent time with, but with home he rarely shared his thoughts or feelings. Id. at 5. The Veteran stated that he would go fishing with friends, but engaged in no other activities, and that he used social isolation to manage his PTSD. Id. at 5. The VA examiner documented symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; flattened affect; difficulty in adapting to stressful circumstances, including work or a work like setting. Id. at 7. The examiner characterized the Veteran as showing "occupational and social impairment with reduced reliability and productivity." The Veteran was afforded another VA examination in September 2021. He reported nightmares, poor sleep, exaggerated startle, hypervigilance, social withdrawal, heightened anxiety states, intrusive memories, irritability, disrupted focus, and arousal to/avoidance of cues/triggers. 09/07/2021, C&P Exam, p. 5. The examiner documented symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work like setting; and suicidal ideation. Id. at 7. The September 2021 VA examiner characterized the Veteran as showing "occupational and social impairment with deficiencies in most areas." Id. at 3. With respect to the period from July 7, 2021 onward, the Board finds that the weight of the evidence is against a finding that the Veteran's PTSD manifested as 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. Accordingly, the Board concludes that the criteria for a disability rating in excess of 70 percent for the period from July 7, 2021 onward have not been met, and the same is hereby denied. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.7, 4.130. REASONS FOR REMAND Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. VA will grant a TDIU where the evidence shows that a Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.340. 3.341, 4.16. If there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16. An April 2019 VA nursing telephone note reflects that the Veteran's family called VA health care providers and informed them that he had recently been discharged from a hospital following an emergent abdominal aneurysm surgery. 07/31/2019, CAPRI, p. 27. In September 2019 the Veteran reported having activities such as driving and physical movement restricted as a result of the aneurysm. 05/22/2020, CAPRI, p. 16. A June 2021 urology consult note characterizes the Veteran as status post abdominal aortic aneurysm repair, 06/17/2021, CAPRI, p. 1. VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The Board is unable to exercise its own judgment to determine whether or not, or the extent to which, the Veteran's abdominal aneurysm was the result or a manifestation of any of the Veteran's service-connected disabilities, to include hypertension. Accordingly, the Board concludes that the Veteran's TDIU claim should be remanded to obtain medical treatment records related to the Veteran's abdominal aneurysm, as well as a VA medical opinion that addresses whether the aneurysm was the result or a manifestation of any of the Veteran's service-connected disabilities, to include hypertension, and that identifies any residuals of the abdominal aneurysm or the aneurysm repair surgery. The matters are REMANDED for the following action: 1. Ask the Veteran to execute a VA form 21-4142 for all providers he has seen for his abdominal aneurysm. Obtain medical records from all providers identified by the Veteran in his executed VA Form 21-4142. Ensure that all records obtained pursuant to this remand are associated with the claims file. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any his abdominal aneurysm and/or any residuals thereof. The claims folder, including a copy of this remand, must be made available to the examiner and such review should be noted in the examination report. The examiner should identify and discuss any residuals or disabilities associated with the Veteran's abdominal aneurysm identified during the examination and the pendency of this claim. For each diagnosed disability or residual, please respond to the following: (a.) Whether any such disability or residual associated with the Veteran's abdominal aneurysm is at least as likely as not (1) proximately due to service-connected disability, to include hypertension, or (2) aggravated beyond its natural progression by service-connected disability, to include hypertension. If aggravation is found, the examiner should also state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record and by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sametshaw, Eric C. 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.