Citation Nr: 21075481 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 12-08 296A DATE: December 20, 2021 ORDER Entitlement to an initial 50 percent evaluation posttraumatic stress disorder (PTSD) on the basis of substitution is granted. REMANDED Entitlement to service connection for restless leg syndrome, to include as due to herbicide exposure and/or as secondary to service-connected PTSD, on the basis of substitution is remanded. Entitlement to a compensable evaluation for bilateral hearing loss prior to December 7, 2017, and in excess of 10 percent on and after December 7, 2017, on the basis of substitution is remanded. FINDING OF FACT The Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The criteria for an initial evaluation of 50 percent for PTSD have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service from January 1967 to January 1970, which included service in the Republic of Vietnam from September 1967 to July 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2008, November 2009, and June 2010 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge at the RO in July 2015. A transcript of that hearing has been associated with the claims file. In March 2016, the Board sent the Veteran and his representative a notice letter that a complete transcript of the July 2015 hearing was unavailable. They were provided the opportunity to request an additional hearing; however, no response was received. The Board remanded the case for further development in June 2016. That development was completed, and the case has since been returned to the Board for appellate review. During the pendency of the appeal, in a May 2018 rating decision, the AOJ increased the evaluation for the Veteran's bilateral hearing loss from noncompensable to 10 percent effective from December 7, 2017. However, applicable law mandates that, when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). Thus, the issue remains on appeal. The Veteran subsequently died in July 2019, and the appellant is his surviving spouse. In April 2020, the RO recognized her as a substitute claimant in this case. The Board acknowledges that the appellant has filed a VA Form 10182 for entitlement to dependency and indemnity compensation benefits. However, AMA claims are adjudicated separately from claims under the legacy system. Therefore, that issue will be addressed in a separate Board decision. Law and Analysis Neither the appellant nor her representative has raised any issues with the duty to notify or duty to assist with regard to the issue decided herein. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.1. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board notes that the Veteran appealed the initial assignment of a disability rating, and as such, the severity of the disability is to be considered during the entire period from the initial assignment of the evaluation to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and 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; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In this case, the Veteran's PTSD was assigned a 30 percent evaluation pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Under that diagnostic code, a 30 percent evaluation is contemplated for 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, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability evaluation is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating for PTSD is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, 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); and the inability to establish and maintain effective relationships. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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 symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). "[A] veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). That section "requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Id. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126. In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. For those cases received by the RO prior to August 4, 2014, the rating schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "the DSM-IV"). 38 C.F.R. § 4.130. At the outset, the Board notes that the Veteran's VA medical records show that he has received treatment for PTSD on numerous occasions over the years. Although the Board has 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) (noting that VA must review the entire record, but does not have to discuss each piece of evidence). Thus, while the Board considered all evidence of record, in its decision below, the Board will summarize the relevant evidence as appropriate, and the analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran was entitled to an initial 50 percent evaluation for PTSD. The VA treatment records show that the Veteran was seen for PTSD and depression in June 2009 at which time it was noted that he was taking medication and reported doing well with treatment. He denied feeling depressed, and his sleep, appetite, concentration, and energy were all good. He also reported functioning well at work. It was further noted that he had good eye contact and conversation, a euthymic mood, and an appropriate affect. He did not have suicidal or homicidal ideation, and the treatment provider noted that there was no impairment in his functioning. The Veteran's wife submitted a lay statement regarding his PTSD symptoms in July 2009. She reported that the Veteran had problems with depression, would get into nasty moods, and was argumentative. She stated that he generally kept to himself and had few friends. His wife also noted that he had mood swings and difficulty showing emotion. She indicated that he had punched a wall or window on occasion and had scared her with his behavior. The Veteran was afforded a VA examination in September 2009 during which the examiner noted that he was taking an anti-depressant and that his mood had stabilized on the medication. The Veteran reported being married for 39 years with ups and downs in the relationship since military service. The Veteran indicated that he had good relationships with his children; however, his spouse indicated that he was not necessarily close or affectionate. The Veteran also reported having a few friends, but his wife reported none. The examiner noted that they then agreed that he had talks with people at work, but did not socialize outside of work. The Veteran preferred being alone, and his hobbies included fishing, using the computer, and playing the trumpet. During the examination, the Veteran was fully oriented with normal speech, thought, and attention. He did not have delusions, hallucinations, or inappropriate behavior, and his memory was normal. The examiner indicated that his impulse control was fair and that he had had episodes of violence. The Veteran reported experiencing recurrent and intrusive recollections, distressing dreams, and acting or feeling as if a traumatic event were recurring. He was taking steps to avoid thoughts, feelings, or conversations and/or activities, had markedly diminished interest or participation in significant activities, a feeling of detachment or estrangement from others, a restricted range of affect, and a sense of foreshortened future. He reported difficulties with sleep, hypervigilance, and an exaggerated startle response. The examiner found that the Veteran's symptoms were chronic and moderate in severity and that he had an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. VA medical records dated in January 2010 show that the Veteran requested an increase in his medications in response to an issue with his son. At that time, he was fully oriented with good hygiene and eye contact, and he had no suicidal or homicidal ideation. During a November 2010 VA medical appointment, the Veteran reported having good sleep on medication, as well as a good appetite, energy, concentration, and memory. He denied having any suicidal or homicidal thoughts or intent, and no manic or psychotic symptoms were reported. He was experiencing flashbacks two to three times per month and nightmares once per month. The Veteran indicated that he was easily startled and tried to avoid reminders of war. His insight and judgement were also described as good. VA treatment records dated in January 2011 and February 2011 indicate that the Veteran was having difficulties with intrusive memories, nightmares, discomfort in crowds, depression, and a startle response. He was alert, oriented, and conversational; however, his mood was dull and flat and appeared anxious. He denied experiencing suicidal and homicidal ideation, and there was no no acute emotional distress. VA treatment records dated in August 2011 show that the Veteran again reported having good sleep, appetite, energy, and concentration. He denied any suicidal or homicidal thoughts or intent, and no manic or psychotic symptoms were reported. The Veteran noted that he was experiencing nightmares, was easily startled, and avoided reminders of war. He also reported that his flashbacks and depression were improving. His speech, thought, and appearance were normal, and he had good insight and judgment. In February 2012, the Veteran reported having good sleep and average appetite, energy, and concentration. He denied experiencing suicidal or homicidal ideation. He also reported being easily startled, but he noted that his nightmares were improving and that he had decreased flashbacks. It was further noted that he had normal speech and thought, good insight and judgment, and improving depression. The Veteran's private physician, Dr. D.H. (initials used to protect privacy), indicated that there was no frank depression or suicidal ideation during a September 2012 appointment. It was also noted that he was eating and sleeping fairly well. During an October 2012 VA medical appointment, the Veteran reported having good sleep, energy, and concentration, but that he had a decreased appetite. He denied suicidal or homicidal ideation. The Veteran was continuing to experience improved nightmares and flashbacks, but he was easily startled at times. He also noted improving depression. His speech, thoughts, insight, and judgment were all noted to be good or normal. The Veteran reported similar symptoms in May 2013. At that time, he also denied hallucinations or delusions, obsessive compulsive symptoms, and panic attacks. During a VA appointment in October 2013, the Veteran reported having fair energy and concentration and improving nightmares and flashbacks, but he continued to have a startle response and periods of irritable mood for four days. He also stated that he was having periods of decreased sleep, periods of time where he was more talkative than usual, distractibility, and an increase in goal-directed activity. The Veteran denied having suicidal or homicidal ideation, hallucinations, obsessive compulsive symptoms, and panic attacks. During a December 2013 appointment, the Veteran reported that his mood was "alright." He was observed to be mildly dysthymic and anxious, but reactive. His provider noted that his sentences were goal-directed and that there were no hallucinations or suicidal/homicidal ideation. During an April 2014 VA appointment, the treatment provider noted that the Veteran longstanding PTSD and depressive symptoms with no past psychiatric admissions or suicide attempts. The provider indicated that the Veteran was stable on medication, but had occasional insomnia. The Veteran reported that his PTSD symptoms were chronic, but not debilitating, and included intrusive thoughts and occasional nightmares. He felt that he handled stress well and was able to manage his mood without too much anxiety, despite stressors at work. He was able to manage his mood without too much anxiety. The Veteran's speech, thought, and appearance were normal. His memory was intact, and his judgment and impulse control were adequate. The Veteran denied having suicidal ideation, and his mood was euthymic. In October 2014, the Veteran stated that he was having a bit more difficulty with his PTSD symptoms after an explosion incident at work. He reported that he slept well for the most part with only occasional nightmares. He was also able to enjoy things when good things happened. The Veteran's speech and thought were normal, and his judgment and impulse control were adequate, but his insight was limited. There was no suicidal or homicidal ideation. During an appointment in June 2015, the Veteran reported that his sleep was more problematic due to altering shifts at work. He noted that his PTSD symptoms were manageable and that he was able to enjoy things. He was fully oriented with normal speech and thoughts. His mood was noted to be "ok" and "tired." There was no suicidal ideation, and his cognition was grossly intact. His insight was limited, but his judgment and impulse control were adequate. During the July 2015 hearing, the Veteran testified that his PTSD symptoms had gotten a little bit better since his September 2009 VA examination. He reported experiencing flashbacks once or twice per month. He stated that, if he watched the wrong movie or something similar, his wife would notice a miserable mood in him for the next several days. He also indicated that he felt that he was having anxiety/panic attacks wherein his heart would start pumping and he would start to get ahead of himself approximately two to three times per year, but that it would depend on the situation and trigger. He then stated that, depending on the situation, it could be every day, but clarified that he was not having a panic attack every day and approximated that the attacks were occurring once per month on average. The Veteran also noted issues with hypervigilance and anger. He indicated that he had punched a wall in anger as an example, but had difficulty recalling when the last incident had occurred. He first stated that it did not happen much anymore, as his medication had helped a little, but then stated that it depended on the situation and could have been about a month earlier. In June 2016, the Veteran reported that his mood had improved, and he felt he was managing his stressors well. He stated that his work stressors were unchanged, but manageable, and he reported that he was not overly avoidant of triggers. The provider then noted that his depression had largely resolved. During a December 2016 VA appointment, the medical provider indicated that PTSD symptoms were mild and non-debilitating. The Veteran reported experiencing occasional nightmares and intrusive memories, but overall, he was doing reasonably well. The Veteran was fully oriented with a euthymic mood. His speech and thought process were normal, and his cognition was grossly intact. He had limited insight, but adequate judgment and impulse control. During a June 2017 appointment, the Veteran reported that he was managing his stressors well. He stated that he was not depressed, was staying relatively active, and that his PTSD symptoms were not problematic. He was again noted to be fully oriented with a euthymic mood. His speech and thought process were normal, and his cognition was grossly intact. His insight was limited, but his judgment and impulse control were adequate. In December 2017, the Veteran reported having increased anxiety and depression due to a cancer diagnosis. He was feeling sad and stressed. He reported that his enjoyment was somewhat decreased and that energy was sometimes a struggle. The Veteran's symptoms and evaluation were otherwise similar to his previous appointments. The Veteran was afforded another VA examination in January 2018. He reported that he remained married and characterized the relationship as "good." He also indicated that his relationship with his children was "fine." He noted that he enjoyed fishing and playing guitar, but rarely engaged in social activities. The Veteran stated that his other health problems had caused increased depression. He also reported that he sometimes had anger problems. He stated that he was short-tempered and generally kept to himself, even within his home. He was having periodic nightmares. The examiner noted that the Veteran was actively experiencing a depressed mood, anxiety, and chronic sleep impairment at the time of the examination, but he had had good grooming and hygiene with normal and appropriate mood, thoughts, and speech. The examiner noted that the Veteran had endorsed moderate symptoms and found that he had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. VA treatment records dated in February 2018 documented that the Veteran's PTSD symptoms were chronic, non-debilitating, and unchanged. In August 2018, it was noted that he was grieving the death of his daughter. Although he did not have many friends, he reported feeling supported by his wife and immediate family. The Veteran felt that he was handling stress well, but he reported experiencing intrusive thoughts and occasional nightmares. His affect was blunted, but his speech and thoughts were normal, and there was no suicidal or homicidal ideation. His cognition was grossly intact, and his judgment and impulse control were adequate. In giving the Veteran the benefit of the doubt, the Board finds that the evidence demonstrates that the Veteran's symptoms and impairment more closely approximate the rating criteria for a 50 percent evaluation. Although the VA medical records frequently characterized the Veteran's symptoms as mild and/or non-debilitating in nature, the Board finds that the reported symptoms of social withdrawal, possible panic attacks, and periodic depression reflect a disturbance of motivation and mood and difficulty in establishing and maintaining effective relationships described in the 50 percent criteria. For example, the Board notes that the Veteran reportedly had no social friends and withdrew from his family while in his own home. Moreover, while the Veteran reported managing his stress well during VA medical appointments, he also described panic-like symptoms during the July 2015 hearing. Additionally, the Board notes that the January 2018 VA examiner characterized the Veteran's symptoms as moderate in nature. Thus, resolving any reasonable doubt in his favor, the Board finds that a 50 percent evaluation is warranted. The Board has also considered whether an evaluation in excess of 50 percent is warranted. As previously noted, a 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, 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); and the inability to establish and maintain effective relationships. In this case, the evidence does not show that the Veteran had suicidal ideation; obsessional rituals which interfered with routine activities; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; or neglect of personal appearance and hygiene. Moreover, the Veteran's anxiety and depression during this time period did not rise to the level of severity such that it affected his ability to function independently, appropriately, and effectively. Although the medical records do show that his anxiety and depression affected his mood and motivation, these records also indicate that he was able to work, care for himself, and maintain good hygiene. The Veteran also had appropriate communication, thought processes, and behaviors. Thus, while the Veteran experienced anxiety and/or depression, the Board finds that the evidence of record shows that the severity of such symptoms is more appropriately described as a "disturbance of motivation and mood" under the criteria for a 50 percent evaluation. The severity did not rise to the level of compromising his ability to independently and appropriately function, as contemplated by the criteria for a 70 percent evaluation. The Board also notes that the Veteran reported some anger issues, and lay statements by both the Veteran and his wife indicate that he had punched a wall or window in anger. However, the evidence of record indicates that such incidents did not occur during the appeal period. For example, VA medical records indicate that the Veteran fractured his left hand in 2005 in a fit of rage "years ago." A February 2005 VA treatment record also indicated that the Veteran had hit walls in the past, but was better now since on the medication Nortriptyline, which he had reportedly been taking for 15 years. These records indicate a problem with violent outbursts years prior to the Veteran's claim and the period on appeal. The Board also notes that the medical evidence repeatedly characterized the Veteran's impulse control as adequate. Although the September 2009 VA examiner found the Veteran's impulse control was fair and noted that there had been episodes of violence and the January 2018 VA examiner indicated that irritable behavior and angry outbursts had occurred following his in-service stressor, neither indicated that aggressive or violent outbursts were current. Further, both VA examiners opined that the Veteran's symptoms aligned with criteria for a 30 percent evaluation. The Veteran's VA medical records for the relevant time period do not indicate any instances of aggression or impaired impulse control and instead generally characterized the Veteran's symptoms as mild or non-debilitating. Homicidal ideation was also repeatedly denied by the Veteran throughout the appeal period. During the July 2015 hearing, the Veteran could not recall the last time that he had punched a wall in anger. At first, he indicated that it did not happen much anymore, as his medication helped, but then stated that it could have been a couple months ago. Unfortunately, the hearing transcript was cut off at that point due to technical difficulties. However, the Board also notes that the Veteran's initial statemen, that he did not punch objects anymore since receiving treatment is supported by the concurrent medical records. The Veteran's wife submitted a July 2009 statement recalling instances wherein the Veteran had punched a wall or glass. However, there was no specific date provided for those incidents in the statement and only indicate that they had had occurred after the Veteran returned home from Vietnam. The Board finds that the evidence of record suggests that the Veteran's anger symptoms had improved during the appeal period and that any aggressive or violent outbursts had been managed. Further, there is no evidence of record showing behavior which amounted to sustained impulse control issues or severe symptoms, as are described by the criteria required for a 70 percent evaluation during the relevant time period. With respect to maintaining effective relationships, the Board notes that the Veteran had some difficulty establishing and maintaining effective work and social relationships; however, the evidence does not show an inability to establish and maintain relationships, as contemplated in the criteria for a 70 percent evaluation. Rather, the Veteran remained married throughout the appeal period and was able to maintain relationships with his children and co-workers. The Board acknowledges that his marriage reportedly had ups and downs and that the Veteran was often withdrawn and did not socialize with friends outside of work. However, the Board finds that such impairment more closely aligns with difficulties establishing and maintaining effective work and social relationships as described in the 50 percent criteria and not an inability to establish and maintain effective relationships as described under the 70 percent criteria. Based on the foregoing, the Board finds that the Veteran's symptoms more closely approximate the criteria for a 50 percent disability rating. Overall, the Veteran did not have a level of impairment consistent with occupational and social functioning in most of the areas referenced by the 70 percent evaluation criteria, or total occupational and social impairment to warrant a 100 percent evaluation. Mauerhan, supra, Vazquez-Claudio, supra. The criteria for the next higher rating of 70 percent have not been met or approximated. See 38 C.F.R. § 4.130, Diagnostic Code 9434. The appellant and her representative have not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 368 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND The Veteran was afforded a VA examination in January 2018 in connection with his claim for service connection for restless leg syndrome. The examiner stated that there is insufficient evidence to warrant or confirm a diagnosis of an acute or chronic condition or residuals thereof. However, the examiner did not reconcile that conclusion with the treatment records and Veteran's statements reporting symptomatology. Therefore, the Board finds that an additional VA medical opinion is needed. With regard to the claim for service connection for hearing loss, the Board notes that VA medical records dated in February 2005, April 2010, May 2010, and December 2015 appear to reference audiograms; however, the results of those audiograms are not associated with the claims file. Therefore, the agency of original jurisdiction (AOJ) should attempt to obtain any outstanding records. Accordingly, the case is REMANDED for the following action: 1. The AOJ should obtain any outstanding VA medical records and associate them with the claims file, to include the results of any audiograms performed in February 2005, April 2010, May 2010, and December 2015. 2. The AOJ should obtain a VA medical opinion to determine the nature and etiology of any involuntary movement disorder (claimed as restless leg syndrome) that may have been present. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The examiner should opine as to whether it is at least as likely as not that the Veteran had restless leg syndrome or another involuntary movement disorder that was causally or etiologically related to his military service, to include his herbicide exposure therein (regardless of the fact that any possible disorder may or may not be presumed to be associated with herbicide exposure). In making this determination, the examiner should consider the reported symptomatology, including the January 2018 VA examination report noting sporadic, involuntary jerking movement of one or more extremities, without any specific pattern or association and involuntary spastic contraction of the lower extremities, particularly on the right leg, that resist any passive range of motion. The examiner should also opine as to whether it is at least as likely as not that any disorder that was either caused by or aggravated by the Veteran's service-connected PTSD. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. After completing these actions, the AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Rideout-Davidson, 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.