Citation Nr: 21075866 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 18-18 488 DATE: December 21, 2021 ORDER New and material evidence has been received, and the petition to reopen claim of entitlement to service connection for hypertension is granted. From June 29, 2012, entitlement to a rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted. Entitlement to service connection for bilateral hearing loss is granted. From June 29, 2012 to January 28, 2014, entitlement to a total disability rating due to individual unemployability (TDIU) is granted. From June 29, 2012 to January 28, 2014, basic entitlement to Dependents Educational Assistance (DEA) benefits is granted. REMANDED Entitlement to an initial rating in excess of 10 percent for diabetes mellitus type II (diabetes), to include separate ratings for associated neurological disabilities, is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to an effective date earlier than February 24, 2014 for the award of service connection for diabetes is remanded. Entitlement to an effective date earlier than July 25, 2008 for the award of service connection for PTSD is remanded. FINDINGS OF FACT 1. A September 1998 rating decision denied entitlement to service connection for hypertension due to the absence of a current disability. The Veteran did not appeal this decision and new and material evidence was not actually or constructively received within one year of the issuance of the decision. 2. Evidence received more than one year after the September 1998 rating decision reflects the presence of a current hypertension disability. 3. The Veteran filed an increased rating claim for his PTSD on June 29, 2012, and an April 2013 rating decision continued the Veteran's 50 percent rating for PTSD. The Veteran submitted new and material evidence within one year of that decision, and when the claim was readjudicated in December 2014 he filed a timely Notice of Disagreement (NOD) and perfected an appeal. 4. From June 29, 2012, the Veteran's PTSD was manifested by symptoms productive of impairment that more closely approximated occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; but not total occupational and social impairment. 5. The Veteran has a current bilateral hearing loss disability and continuity of symptomatology is established. 6. From June 29, 2012 to January 28, 2014, the Veteran's PTSD symptoms precluded him from securing or following a substantially gainful occupation. 7. From June 29, 2012 to January 28, 2014, the Veteran was permanently and totally disabled due to service-connected disabilities. CONCLUSIONS OF LAW 1. The September 1998 rating decision is final with respect to the denial of entitlement to service connection for hypertension. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence has been received, and the criteria for reopening the claim of entitlement to service connection for hypertension are met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The April 2013 rating decision is not final. 38 C.F.R. § 3.156(b). 4. From June 29, 2012, the criteria for a rating of 70 percent, but no higher, for PTSD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 5. The criteria for entitlement to service connection for bilateral hearing loss are met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303(b), 3.304(d), 3.309(a). 6. From June 29, 2012 to January 28, 2014, the criteria for entitlement to a TDIU are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16. 7. From June 29, 2012 to January 28, 2014, the criteria for basic entitlement to DEA benefits are met. 38 U.S.C. §§ 3501, 3510, 5107, 5110, 5113; 38 C.F.R. §§ 3.102, 3.400, 3.807, 21.3021. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1968 to March 1971, including service in the Republic of Vietnam, with additional Air National Guard service. His decorations include the Combat Infantryman Badge, Bronze Star Medal, and Air Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2010 and December 2014 rating decisions by an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). In February 2019, the Veteran and his former representative agreed to terminate representation. See February 2019 Correspondence; 38 C.F.R. § 14.631(f)(1). As the Veteran has not appointed a new representative, he is unrepresented in this matter. In October 2021, the Veteran testified at a virtual hearing before the undersigned. The issue of entitlement to a TDIU is part and parcel of the increased rating claim on appeal, notwithstanding that the AOJ awarded a TDIU from what it perceived was the date of claim. See Harper v. Wilkie, 30 Vet. App. 356 (2018). The AOJ inexplicably failed to record the Veteran's timely May 2013 substantive appeal that perfected the April 2013 SOC. The Board has recharacterized the appeals concerning new and material evidence to reopen claims of entitlement to service connection for a back disability and hearing loss, as there is no prior final denial of those claims. Thus, the award of service connection for bilateral hearing loss in this decision relates back to the Veteran's July 2009 informal claim. If the Veteran appeals the initial rating for bilateral hearing loss (and the effective date of service connection, if the AOJ assigns a date after July 2009) he may be able to obtain an earlier effective date for the award of a TDIU. The Board has bifurcated certain of the issues on appeal so as to allow a favorable decision without delay. See Locklear v. Shinseki, 24 Vet. App. 311 (2011). The Board acknowledges the Veteran's claim for special monthly compensation (SMC). While this may be part of an increased rating claim, he is not service-connected for his back disability at present, which is shown to give rise to his limitations. See February 2019 VA Form 21-2680. 1. New and material evidence has been received, and the petition to reopen claim of entitlement to service connection for hypertension is granted. Under VA's legacy appeals system, which governs this appeal, a rating decision is final unless it is timely appealed or new and material evidence is received within one year of the issuance of the decision. However, a final claim may be reopened if new and material evidence is submitted. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with the previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 U.S.C. § 5108 (as in effect prior to February 19, 2019); 38 C.F.R. § 3.156. A September 1998 rating decision denied entitlement to service connection for hypertension due to the absence of a current disability. The Veteran did not appeal that decision and the present record does not show that new and material evidence was actually or constructively received within one year of that decision. Thus, it is final for purposes of a reopening determination. See also Dallman v. Wilkie, 33 Vet. App. 101 (2020) (finality decisions in the context of reopening a claim are not "final" so as to limit subsequent awards of an earlier effective date). Since the September 1998 rating decision, additional VA treatment records have been received showing the Veteran's blood pressure readings, as well as showing that he has a clinical diagnosis of hypertension and is prescribed medication for this condition. This evidence is new, and as it relates to the presence of a current hypertension disability it is also material. Thus, as new and material evidence has been received, the claim is reopened. 2. From June 29, 2012, entitlement to a rating of 70 percent, but no higher, for PTSD is granted. At the Board hearing, the Veteran asserted that he is entitled to a higher rating for his PTSD and his appeal as to this issue would be satisfied by the award of 70 percent and TDIU retroactive to the June 29, 2012 date of claim. See Board Hearing Transcript at 10. The Board agrees that this rating is warranted. The Veteran is currently in receipt of a 50 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9411 for PTSD prior to January 28, 2014, and thereafter he is in receipt of a 70 percent rating. The period on appeal is from June 29, 2012, the date of claim, plus the one-year lookback period. In this regard, new and material evidence was received within one year of the April 2013 rating decision that continued the Veteran's 50 percent rating for PTSD. See January 2014 Mental Disorders disability benefits questionnaire (DBQ). Thus, the April 2013 rating decision never became final. See 38 C.F.R. § 3.156(b). At present, the record does not show that new and material evidence was received within one year of the issuance of the unappealed July 2010 rating decision; in the event that the Board's remand directives result in VA securing evidence showing the actual or constructive receipt of new and material evidence within one year of the July 2010 rating decision, the Board will revisit the finality of that decision. Under Diagnostic Code 9411, a 50 percent rating is warranted where PTSD is manifested by occupational and social impairment with reduced reliability and productivity, due to symptoms such as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted where PTSD is manifested by 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); inability to establish and maintain effective relationships. A 100 percent rating is warranted where PTSD is manifested by 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. During the period on appeal, the Veteran presented for psychiatric examinations in November 2012, July 2014, and March 2018. Additionally, in January 2014 he submitted a Mental Disorders DBQ completed by a psychiatrist. The November 2012 VA examiner diagnosed PTSD and stated that the Veteran's level of occupational and social impairment due to mental disorders was best summarized mild or transient symptoms that decrease work efficiency and ability to perform occupational tasks only during periods of significant stress; or symptoms controlled by medication. The examiner noted symptoms including difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including work or a worklike setting (among other symptoms). However, the examiner did not note difficulty concentrating. The January 2014 Mental Disorders DBQ shows diagnoses including in relevant part PTSD and mood disorder not otherwise specified. The examiner said that the Veteran's total level of occupational and social impairment due to mental disorders was reduced reliability and productivity. As the examiner could not apportion this impairment among diagnosed disorders, the Board resolves this reasonable doubt in favor of the Veteran and will attribute all impairment to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). The examiner noted that the report was based wholly upon an interview with the Veteran; the Board observes that the Veteran's candid report of his personal history means this examination report is probative. The examiner noted symptoms including difficulty concentrating, disturbances of motivation and mood, difficulty in establishing and maintaining work and social relationships, inability to establish and maintain effective relationships, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner explained that due to the Veteran's symptoms he has almost no social interactions, his mood is depressed when not on medication, and he is "unable to work." The July 2014 VA examiner diagnosed PTSD and summarized his functioning as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner noted symptoms including difficulty concentrating, difficulty in understanding complex commands, 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 worklike setting, and suicidal ideation. Although the examiner notes that the Veteran's suicidal ideation is passive, the Board notes that this is consistent with a 70 percent rating for PTSD. See Bankhead v. Shulkin, 29 Vet. App. 10 (2017). The examiner stated that the Veteran's PTSD "seems to have gotten worse in the past two years," but it was his opinion that the Veteran was not so impaired that he was unemployable. The March 2018 VA-contracted examiner diagnosed PTSD and summarized the Veteran's impairment as occupational and social impairment with reduced reliability and productivity. The examiner noted symptoms including impaired judgment, difficulty in establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, impaired impulse control, such as unprovoked irritability with periods of violence, and persistent delusions or hallucinations. However, the examiner subsequently noted that the Veteran denied active hallucinations or delusions. Here, the evidence shows that throughout the appeal, the Veteran's PTSD symptoms have more closely approximated occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. In this regard, examiners have consistently noted work and social deficiencies. Examiners noted deficiencies in judgment, mood, concentration. Moreover, the Veteran is divorced and largely isolates and thus is shown to have deficiencies in this area of family relations. Additionally, each examiner of record identified symptoms consistent with the exemplar symptoms listing in the rating schedule associated with a 70 percent disability rating. The Board acknowledges that not all examiners identified this level of occupational and social impairment, and that the July 2014 examiner opined that the Veteran's PTSD "seems to have" worsened during the appeal. However, as the Veteran's level of symptomatology has shown symptoms consistent with the 70 percent level of impairment throughout the appeal, and as deficiencies in most areas are specifically noted throughout the appeal, the Board resolves and reasonable doubt in favor of the Veteran and finds a 70 percent rating is warranted throughout the appeal. In this regard, the lack of symptomatology and impairment noted in 2012 is consistent with different examiners describing the Veteran's level of impairment in different terms. A total schedular rating for PTSD is not warranted. While some symptoms associated with the 100 percent level were shown on some examinations, the Veteran has maintained some social relationships and does not have total social impairment. Moreover, at the Board hearing the Veteran stated that his appeal would be satisfied by an award of 70 percent for PTSD along with TDIU; as discussed below, this award is warranted. The Board acknowledges that remand is warranted to secure outstanding records, including Vet Center records. However, the Veteran explained that his appeal has been satisfied in full, and thus no benefit will flow to the Veteran by remanding the issue of entitlement to a rating in excess of 70 percent for PTSD. Indeed, as the Veteran has limited his appeal and has been awarded the benefit sought, there is no remaining question of law or fact for Board review. 3. Entitlement to service connection for bilateral hearing loss is granted. The Veteran asserts that his hearing loss is due to noise exposure in service, including during combat. See, e.g., Board Hearing Transcript at 23-24. The Board agrees. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection generally requires evidence showing (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection is warranted for certain chronic diseases listed in 38 C.F.R. § 3.309(a), including organic diseases of the nervous system such as sensorineural hearing loss, that are shown to be chronic in service or that began in service and where there is a continuity of symptomatology to the present. 38 C.F.R. § 3.303(b). For VA purposes, a hearing loss disability exists when the auditory threshold is 40 decibels or greater at one of the frequencies of 500, 1000, 2000, 3000, or 4000 hertz, or when the auditory thresholds are 26 decibels or greater at any three of those thresholds, or when speech recognition scores by Maryland CNC testing are less than 94 percent. 38 C.F.R. § 3.385. In December 2009, the Veteran presented for a VA audiology examination. The audiometric results show that the Veteran has bilateral hearing loss for VA purposes, as left ear auditory thresholds were 40 decibels at 3000 hertz and 45 decibels at 4000 hertz and right ear auditory thresholds were 40 decibels at 3000 hertz and 4000 hertz. The Veteran was awarded the Combat Infantryman Badge, among other decorations, and he competently and credibly reported exposure to combat noise. See, e.g., Board Hearing Transcript; September 2009 Lay Statement. Accordingly, an in-service noise injury is conceded. See 38 C.F.R. § 3.304(d). In this regard, there is no evidence to the contrary, as his separation audiogram did not measure auditory thresholds at 3000 hertz and 6000 hertz. See February 1971 Separation Examination Report. The December 2009 VA examiner opined that it was less likely than not that the Veteran's hearing loss was due to in-service noise exposure. The examiner explained that while the Veteran's hearing thresholds worsened in service, he still had normal hearing, and thus hearing loss was most likely due to post-service industrial noise exposure. However, the examiner noted that as the Veteran's hearing thresholds at 3000 hertz and 6000 hertz were not tested at separation, and combat noise exposure is typically represented by a "notch" from 3000 hertz to 6000 hertz, thus "making the presence/absence of hearing loss at those freq[uencies] most often seen [a]ffected by noise exposure indeterminable." See December 2009 VA Audiology Examination Report. The Board appreciates the December 2009 examiner's candor as to the limitations of her opinion. While this opinion has some probative value, it has no probative value as to the presence or progression of hearing loss at 3000 hertz. However, remand to correct this deficiency is unnecessary, as the Veteran competently and credibly reported a progression in hearing loss post-service. See, e.g., Board Hearing Transcript at 24. Accordingly, continuity of symptomatology is shown. Moreover, while there was post-service noise exposure, the examiner's opinion does not address any hearing loss at 3000 hertz and thus there is no intercurrent etiology shown for post-service symptoms. Accordingly, as the present record shows that all the criteria for service connection for bilateral hearing loss are met, the appeal as to this issue is granted. The Board acknowledges that on remand it will attempt to secure the Veteran's National Guard records. However, as the present record weighs in favor of the appeal, it will not defer adjudicating this issue solely to develop negative evidence. 4. From June 29, 2012 to January 28, 2014, entitlement to a TDIU is granted. The Veteran asserts that he should be awarded entitlement to a TDIU from June 29, 2012. The Board agrees. A total disability rating may be assigned, where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as the result of service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. The Veteran is currently in receipt of a 70 percent rating for PTSD throughout the appeal and thus meets the schedular criteria for a TDIU based on that disability alone. As discussed below, a TDIU is warranted based solely on his PTSD. The determination as to whether a veteran can secure or follow a substantially gainful occupation includes an economic component and a noneconomic component. The economic component means that a veteran must not receive income from employment outside of a protected environment that exceeds the poverty threshold for one person. The noneconomic component requires consideration of a veteran's ability to secure or follow substantially gainful employment, including factors such as the veteran's history of education, skill, and training, as well as his or her ability to perform the physical and mental activities required by the occupation in question. See Ray v. Wilkie, 31 Vet. App. 58 (2019). Here, the Veteran reports that he last worked full time in October 2008. See January 2010 VA Form 21-8940. Thus, the economic component of entitlement to a TDIU is met throughout the appeal. As to the noneconomic component, the AOJ has determined that based on the opinion in the January 2014 Mental Disorders DBQ, the Veteran's PTSD has rendered him unable to secure or follow a substantially gainful occupation. The Board adopts this favorable finding as it is not clearly erroneous. As the evidence does not show an increase in impairment from PTSD symptoms between 2012 and 2014, entitlement to a TDIU is warranted from June 29, 2012, the date of claim. 5. From June 29, 2012 to January 28, 2014, basic entitlement to DEA benefits is granted. Although the issue of entitlement to DEA benefits was not explicitly raised, this is an ancillary benefit and the issue of entitlement is raised by the earlier grant of entitlement to a TDIU. Entitlement to DEA benefits is warranted where a veteran has a permanent total service-connected disability, as well as in other circumstances that are not relevant to this matter. 38 U.S.C. §§ 3501, 3510; 38 C.F.R. § 3.807(a)(2). The Veteran has already been found to be permanently and totally disabled as of January 28, 2014. Moreover, he is now in receipt of a total rating as of June 29, 2012, the effective date of entitlement to a TDIU, and the record does not demonstrate an event or deterioration in his condition between June 29, 2012 and January 28, 2014. Accordingly, an effective date of June 29, 2012 is warranted for the award of basic eligibility to DEA benefits. REASONS FOR REMAND 6. Entitlement to an initial rating in excess of 10 percent for diabetes, to include separate ratings for associated neurological disabilities, is remanded. Remand is necessary for an updated examination, as at the Board hearing the Veteran reported symptoms that could represent neurological abnormalities associated with diabetes. See Board Hearing Transcript at 13-14. Additionally, the record indicates that they may be outstanding VA treatment records that have not been secured. See July 14, 2003 VA Treatment Note (indicating that the Veteran was new to the Mather VA from Fresno); September 2009 VA Form 21-4142 (noting he received treatment at the VA hospital in Fresno, as well as Visalia and Mather). In this regard, the AOJ requested pre-2003 records from the VA medical center that he had transferred to, but not the medical center he had transferred from. See February 2019 Exchange of Beneficiary Information. On remand, the Veteran's complete VA treatment records should be secured. Additionally, the Veteran identified the existence of historical private treatment. See September 2009 VA Form 21-4142. On remand, he should be afforded another opportunity to identify his providers. The Veteran's Air National Guard records should also be secured. 7. Entitlement to service connection for hypertension is remanded. Remand is necessary to provide the Veteran an examination and secure a medical opinion. In this regard, while the Veteran's service treatment records note hypertension and he has been prescribed blood pressure medication during the period on appeal, the findings of record do not meet VA's minimum threshold for a current disability of readings predominately at least 160 mm/Hg systolic pressure or 90 mm/Hg diastolic pressure. However, as the Veteran was prescribed medication over portions of the appeal, an opinion should be secured as to whether he would have met the minimum threshold during a portion of the appeal during which he was taking medication. 8. Entitlement to service connection for a low back disability is remanded. Remand is necessary to provide an examination and secure a medical opinion. In this regard, the Veteran has a current diagnosis of a low back disability, and in-service injury is conceded based on his competent and credible testimony as to experiencing back pain while jumping from helicopters and carrying heavy loads in combat. See, e.g., Board Hearing Transcript at 17-18. 9. Entitlement to an effective date earlier than February 24, 2014 for the award of service connection for diabetes is remanded. 10. Entitlement to an effective date earlier than July 25, 2008 for the award of service connection for PTSD is remanded. Initially, the Board observes that while the Veteran appealed the issue of entitlement to an earlier effective date of the increased rating for PTSD, the AOJ characterized the issue on appeal as entitlement to an earlier effective date of service connection. Thus, the latter issue is before the Board. See Percy v. Shinseki, 23 Vet. App. 7 (2009). Action on these issues is deferred pending the completion of the development directed above. The matters are REMANDED for the following action: 1. Secure the Veteran's complete VA treatment records, to include records not found in VA's electronic system. A memo should be completed as to development efforts. The AOJ's attention is invited to the September 2009 VA Form 21-4142 (noting the Veteran received treatment at the VA hospital in Fresno, as well as Visalia and Mather). 2. With any necessary assistance from the Veteran, secure outstanding relevant private treatment records, if any. 3. Secure the records relating to the Veteran's Air National Guard service from 1981 to 1983. 4. Schedule the Veteran for an examination as to the nature and severity of his diabetes and diabetic complications. The claims file should be available to the examiner. All findings should be reported in detail. The examiner should address the following: (a) Assess the severity of the Veteran's diabetes. (b) Diagnose all neurologic abnormalities of the upper and lower extremities. (c) For each disorder diagnosed in subpart (b), opine as to whether it is at least as likely as not (50 percent or greater probability) that such disorder is proximately due to the Veterans' diabetes. (d) For each disorder diagnosed in subpart (b), opine as to whether it is at least as likely as not (50 percent or greater probability) that such disorder has been aggravated (worsened beyond natural progression) by the Veteran's diabetes. In addressing subparts (c) and (d) of this question, the examiner's attention is invited to the Veteran's VA treatment records showing no improvement in his hand tingling following his cervical spine surgery. See January 24, 2019 VA Emergency Room Note. A complete rationale should be provided for all opinions. If no opinion can be provided without resorting to speculation, the examiner should explain why that is so (e.g. insufficient evidence of record, limitations of general medical knowledge, limitations in examiner's own knowledge, etc.). 5. Schedule the Veteran for an examination as to the nature and etiology of his low back disability. The claims file should be available to the examiner. All findings should be reported in detail. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's low back disability had its onset during or is otherwise etiologically related to his active service, to include conceded injury relating to carrying heavy backpack weight while on combat patrol and/or his numerous jumps from helicopters wearing a 50-pound pack while on patrol. The examiner must concede an in-service back injury, given the Veteran's combat service. In addressing this question, the examiner's attention is invited to the Veteran's report of the circumstances of his combat service. See September 2009 Correspondence. A complete rationale should be provided for all opinions. If no opinion can be provided without resorting to speculation, the examiner should explain why that is so (e.g. insufficient evidence of record, limitations of general medical knowledge, limitations in examiner's own knowledge, etc.). 6. Schedule the Veteran for an examination as to the nature and severity of his hypertension. The claims file should be available to the examiner. All necessary testing should be performed. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension has been manifested to a degree of at least 160 mm/Hg systolic pressure or 90 mm/Hg diastolic pressure at any time since July 2009, even if his hypertension subsequently resolved. In addressing this question, the examiner is advised that the relevant question for purposes of establishing initial entitlement to service connection is the level of disability in the absence of medication. Thus, keeping in mind the benefit of doubt afforded to veterans, the examiner should provide an opinion, if possible, as to the Veteran's likely baseline blood pressure readings while taking prescribed blood pressure medication. A complete rationale should be provided for all opinions. If no opinion can be provided without resorting to speculation, the examiner should explain why that is so (e.g. insufficient evidence of record, limitations of general medical knowledge, limitations in examiner's own knowledge, etc.). S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.M. Badaczewski, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.