Citation Nr: 21077184 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 14-21 073A DATE: December 28, 2021 ORDER New and material evidence having been received, the appeal to reopen service connection for obstructive sleep apnea is granted. Service connection for posttraumatic stress disorder (PTSD) with depressive features is granted. Service connection for tinnitus is denied. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) from April 1, 2016, is granted. REMANDED Entitlement to service connection for obstructive sleep apnea is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus type II, is remanded. Entitlement to an initial compensable rating for diabetic nephropathy prior to April 1, 2016, is remanded. Entitlement to a rating in excess of 60 percent for diabetic nephropathy from April 1, 2016, is remanded. Entitlement to a TDIU for the period of appeal prior to April 1, 2016, is remanded. FINDINGS OF FACT 1. Service connection for a sleep disorder was denied in a February 2010 rating decision and the Veteran did not appeal the issue. 2. Evidence received since the February 2010 rating decision is new in that it is not cumulative and was not previously considered by decision makers, and it is material because it raises a reasonable possibility of substantiating the claim for service connection. 3. The evidence is in equipoise on whether the Veteran has diagnoses of PTSD with depressive features that are related to in-service stressors. 4. Tinnitus did not first manifest during active service and has not been continuous since service separation, and any current tinnitus did not manifest to a degree of 10 percent within one year of service separation, and is not related to exposure to acoustic trauma or other injury or event in service. 5. For the period of appeal from April 1, 2016, the Veteran's disabilities meet the schedular criteria for consideration of a TDIU and preclude him from substantial and gainful employment. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen the claim for service connection for obstructive sleep apnea. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 3.159, 20.1103. 2. The criteria for service connection for PTSD with depressive features are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for tinnitus are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. [The criteria for entitlement to a TDIU from April 1, 2016, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from March 1970 to July 1973, including service in Vietnam. In June 2014 and May 2017 substantive appeals, the Veteran requested a hearing before a Veterans Law Judge. A hearing was scheduled for March 2020; however, in January 2020, the Veteran withdrew his hearing request. Accordingly, the hearing request is deemed withdrawn. See 38 C.F.R. § 20.704(d). The Board notes that the Veteran initiated an appeal of service connection for a bilateral eye condition. However, in June 2016, during the pendency of appeal, service connection was granted for glaucoma status post cataract surgery. Because the Veteran was awarded service connection, the issue is no longer on appeal before the Board. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). New and Material Evidence Rating decisions from which an appeal is not perfected become final. 38 U.S.C. § 7105; 38 C.F.R. § § 20.1103. An appeal consists of a timely filed notice of disagreement in writing, and after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § § 20.200. To reopen a claim that has been denied by a final decision, new and material evidence must be received. 38 U.S.C. § 5108. New and material evidence means evidence not previously submitted to agency decisionmakers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened; and which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed, unless it is inherently false or untrue or, if it is in the nature of a statement or other assertion, it is beyond the competence of the person making the assertion. Duran v. Brown, 7 Vet. App. 216, 220 (1994); Justus v. Principi, 3 Vet. App. 510, 513 (1992). 1. New and material evidence to reopen service connection for obstructive sleep apnea. In June 2009, the Veteran initiated a claim for service connection for a sleep disorder as secondary to PTSD, which was denied in a February 2010 rating decision. The Regional Office (RO) noted that there was no evidence of a sleep disorder that was incurred in or aggravated by service, and that PTSD was not service-connected. The Veteran did not appeal the sleep disorder issue and it is final. The Veteran requested to reopen the claim in August 2013. The additional relevant evidence received since the February 2010 rating decision includes VA medical treatment records, statements from family dated in April 2014, and statements from the Veteran. The treatment records indicate that the Veteran was referred for a sleep study in 2011 and has been noted to have a diagnosis of obstructive sleep apnea since at least July 2015. The statements from family members indicate that the Veteran has had a sleep disorder for many years, which has caused many symptoms, and the Veteran indicated that he has had trouble sleeping since leaving service. Presumed credible, the treatment records and lay statements are probative evidence that the Veteran has a sleep disorder that could be related to service. Accordingly, new and material evidence has been received to reopen the claim for service connection for obstructive sleep apnea. Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or an injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disability also may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disability, or if it is aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b). See also Allen v. Brown, 7 Vet. App. 439 (1995). 2. Service connection for PTSD with depressive features. The Veteran contends that he has PTSD due to his compound being overrun in Pleiku, Vietnam, including incoming bombing of living facilities, exposure to all types of body parts, and seeing wounded and killed people. See the August 2009 stressor statement. He also states that he witnessed stressful events in Vietnam on a daily basis, which he tries to not think or talk about. See the February 2020 statement. Service connection for PTSD generally requires medical evidence establishing a diagnosis of the disorder, credible supporting evidence that the claimed in-service stressor(s) actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). The PTSD diagnosis must be made in accordance with the criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Id.; 38 C.F.R. § 4.125(a). If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). Additionally, lay evidence alone may establish an alleged stressor where: 1) the stressor is related to the Veteran's fear of hostile military or terrorist activity; 2) a VA psychiatrist, VA psychologist, or VA-contracted psychiatrist or psychologist, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor; 3) the stressor is consistent with the places, types, and circumstances of the Veteran's service; and 4) there is no clear and convincing evidence to the contrary. 38 C.F.R. § 3.304(f)(3). Fear of hostile military or terrorist activity is defined as occurring when a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. After a review of all the evidence, the Board finds that the Veteran's account of being in Vietnam to be credible and consistent with the circumstances of his service. The Veteran's DD Form 214 and military personnel records confirm that that the Veteran had service in Vietnam from January to December 1971, and he was assigned to the 17th Cavalry Regiment. The claimed in-service stressor is consistent with the places, types, and circumstances of service, and it is related to the threatened death or injury of himself and others from hostile military activity and his response to these events involved a psychological state of fear and helplessness. The question for the Board is whether the Veteran has a current diagnosis of PTSD that is related to the in-service stressor event. There is evidence that the Veteran has a current diagnosis of PTSD. In June 2020, the Veteran had a psychological evaluation. Dr. D.D., a private clinical and forensic psychologist, conducted a review of medical records, clinical history, mental status examination, and PTSD checklist (PCL-C). The Veteran reported that he saw "considerable action" in Vietnam, including enemy attacks from nightly missile attacks and witnessing "his comrade's death and carnage." Dr. D.D. noted that the Veteran had not been diagnosed with PTSD in an April 2014 VA PTSD examination. Dr. D.D. concluded, however, that this evaluation revealed "a clear pattern of PTSD symptoms," and that the Veteran met the DSM-5 criteria for PTSD with depressive features, which was at least as likely as not due to his fear of hostile military activity while in service. The Veteran's PTSD symptoms included nightmares and intrusive thoughts, avoidance of social situations and isolating, inability to remember details of the traumatic event and speaks in general terms, persistent anxiety and depression, irritability, difficulties in concentration, sleep disruption, paranoia, and hypervigilance. His depression, which was associated with his PTSD, resulted in symptoms of depressed mood nearly every day, markedly diminished interest or pleasure in all or most activities, decrease in appetite, insomnia every day, slowed activity, loss of energy, feelings of worthlessness or inappropriate guilt, impaired concentration, and recurrent thoughts of death or suicidal ideation. There is also evidence that the Veteran does not have a diagnosis of PTSD. As noted above, in an April 2014 VA PTSD examination, the examining psychologist found that the Veteran did not meet the criteria for a diagnosis of PTSD or another mental disorder. The examiner noted that the Veteran's reported stressor of a fellow solider being shot while in a helicopter was adequate to support a diagnosis of PTSD; however, the Veteran did not experience intrusion symptoms, persistent avoidance of stimuli associated with the traumatic event, negative alterations in cognitions or mood associated with the traumatic event, or marked alterations in arousal and reactivity associated with the traumatic event. As such, based on chart review and clinical interview, there was not sufficient evidence to meet the diagnostic criteria for PTSD or any other mental health disorder related to military service. The Board finds that the opinions from Dr. D.D. and the April 2014 VA examiner have at least some probative value. Both opinions were rendered by licensed psychologists and were based on physical examination of the Veteran, including conducting clinical testing, and both opinions include at least some rationale. The VA examiner's opinion was rendered after review of the records, including the Veteran's service treatment records (STRs), and it appears from the evaluation report that Dr. D.D. reviewed at least some medical records. Moreover, the Board finds nothing in the record that challenges the qualifications of Dr. D.D. to provide competent medical evidence. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (noting that the credibility and weight to be attached to medical opinions are within the province of the Board). The Board also finds that the Veteran's statements regarding his in-service stressors and symptoms have been generally consistent. The Veteran is competent to describe observable symptoms of PTSD, and he can also report incidents in service that he experienced. The Veteran's statements have also been consistent with the circumstances of his service, as noted above. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). There can be no doubt that further medical inquiry could be undertaken with a view towards development of these claims. Specifically, a medical opinion could be obtained to clarify the contradicting conclusions of Dr. D.D. and the VA examiner regarding the Veteran's diagnoses. The Board considered whether a remand was appropriate to clarify; however, in this case, a remand would only unnecessarily delay adjudication. Specifically, although the VA examiner did not diagnose PTSD, the examiner clearly found the claimed stressor would be adequate to support a diagnosis of PTSD. The private psychologist clearly linked the symptoms to the reported stressor. The private psychologist was aware of the Veteran's history, the criteria necessary to render a diagnosis, and diagnosed the condition using the same format and code utilized by the DSM. See Cohen v. Brown, 10 Vet. App. 128, 140 (1997). Furthermore, as indicated above, the private psychologist linked the PTSD with depressive features to service. Under the "benefit-of-the- doubt" rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993). In this case, the Board finds that there is "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter." As such, this is a situation where the benefit of the doubt rule applies. Ashley, 6 Vet. App. at 59; 38 U.S.C. § 5107; 38 C.F.R. § 3.102. In resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for PTSD with depressive features is warranted. 3. Service connection for tinnitus. The Veteran asserts that he hears ringing in his ears every day. When he wakes up, it sounds like there are birds in his ears and he has to leave rooms when musical instruments are played. He states that he has been experiencing tinnitus since he left service. Diseases of the nervous system, including tinnitus, are listed among the "chronic diseases" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258, 271 (2015). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. The Board finds that service connection for tinnitus is not warranted. VA treatment records indicate that in April 2010, the Veteran reported having left ear hearing loss since last week and some "minimal ringing" of the same ear. He explained that he had been sleeping with a neck massager pillow, which broke, and "some beads probably went into his ear canal." He was sent for an audiology consult, in which he reported that he had sudden onset hearing loss in his left ear about a month ago, accompanied by tinnitus, both of which were getting better. Subsequent VA treatment records are silent for mention of any complaints of tinnitus. In a May 2014 VA hearing loss and tinnitus examination, the Veteran denied having recurrent tinnitus. In sum, it is unclear whether the Veteran has a diagnosis of tinnitus. However, even assuming that the Veteran is experiencing tinnitus, the preponderance of the evidence is against his claim for service connection. As noted above, although the Veteran was in Vietnam and was exposed to missiles and bombings, which is competent evidence of in-service noise to establish an in-service injury of acoustic trauma, his statements regarding the onset of tinnitus lack the credibility necessary to afford them significant probative value, as his statements have been inconsistent. See Caluza v. Brown, 7 Vet. App. 498, 510-11 (1995) (noting that credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements). STRs do not document any complaints, symptoms, or findings of tinnitus, including the July 1973 report of medical history and examination upon separation from service. Although the Veteran has asserted that he has tinnitus due to service, he has also indicated in the May 2014 VA examination that he was not experiencing tinnitus and he reported in the April 2010 VA treatment record that his tinnitus started in the week prior to his appointment. As such, the Veteran's lay assertions alone are not sufficient to establish tinnitus in service and since service. The Board finds that the medical evidence generated at the time of the Veteran's period of active service, including the Veteran's statements and responses on medical questionnaires, to be highly probative. These records were created contemporaneously with the Veteran's period of service and contain information that is inherently more reliable than that recorded at a later time. STRs indicate that the Veteran specifically denied having ear trouble, and that although the July 1973 separation examination noted "hearing loss," the Veteran's hearing was within normal limits bilaterally for VA purposes. The Board finds that the service medical evidence, the Veteran's own statements generated at the time of service, and the lack of complaints, treatment, or diagnosis of tinnitus in the medical evidence of record for approximately 37 after service outweigh the Veteran's statements that he made in connection with his claim for service connection for tinnitus. Finally, there is also no medical evidence that relates any current tinnitus to military service. Because the Veteran denied having tinnitus in the May 2014 VA examination, the examiner did not opine on the etiology of tinnitus. In light of the above, the Board finds that the preponderance of the evidence is against a finding that any tinnitus diagnosis is related to service. As the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). TDIU Total disability meriting a 100 percent schedular rating exists "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15. Where the schedular disability rating is less than 100 percent, a total rating due to individual unemployability nonetheless may be assigned if a veteran is rendered unemployable as a result of service-connected disabilities, provided that certain regulatory requirements are satisfied. See 38 C.F.R. §§ 3.341(a), 4.16(a). Total disability ratings for compensation 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 a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. For purposes of determining whether these threshold minimum rating requirements are met, disabilities affecting both upper or lower extremities or stemming from common etiology or single accident are considered as one, collective disability. "Marginal employment," for example, as a self-employed worker or at odd jobs or while employed at less than half of the usual remuneration, shall not be considered "substantially gainful employment." 38 C.F.R. § 4.16(a). Marginal employment generally shall be deemed to exist when a Veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. 38 C.F.R. §§ 4.16 (a), 4.18. 4. Entitlement to a TDIU from April 1, 2016. In this case, the Veteran's service-connected disabilities consist of glaucoma (70 percent disabling from April 1, 2016); diabetic nephropathy (noncompensable from June 16, 2010, and 60 percent from April 1, 2016); coronary artery disease (30 percent from February 1, 1991); diabetes mellitus type II (20 percent from June 22, 2009); diabetic peripheral neuropathy of the right lower extremity (10 percent from April 1, 2016); diabetic peripheral neuropathy of the left lower extremity (10 percent from April 1, 2016); and coronary artery bypass surgery scar (noncompensable from April 1, 2016). His combined rating has been 70 percent or greater since April 1, 2016. Thus, the percentage requirements of § 4.16(a) are met from April 1, 2016. Resolution of the appeal of this claim therefore turns on whether the service-connected disabilities precluded the Veteran from engaging in substantially gainful employment (i.e., work that is more than marginal, which permits him to earn a "living wage"). See Moore v. Derwinski, 1 Vet. App. 356 (1991). Regarding his education and employment history, the Veteran indicated in a TDIU application submitted in April 2016 that he had completed high school and had some vocational training, which he did not complete. He worked at a tire and rubber company doing factory work from 1974 to July 2007, when he became too disabled to work due to his service-connected diabetes mellitus and heart disease. The Veteran also noted that he completed a blind rehabilitation education or training program in 2013, which lasted 8 weeks. The Board finds that the Veteran's service-connected disabilities preclude him from securing and following substantially gainful employment consistent with his level of education and prior work experience and training. In an April 2016 VA diabetes mellitus examination, the examiner indicated that the Veteran's diabetes would require frequent breaks and a private place with facilities for hand washing and disposal of glucose testing strips. Limitations were also needed for continuous physical exertion, working in extreme temperature or moist areas, working at unprotected heights, and working in isolated areas. The examiner also noted that if the disease progressed and was associated with visual or sensory impairment, then work that required visual acuity, fine dexterity, prolonged walking, and/or heavy labor may need to be limited. In an April 2016 VA heart conditions examination, the examiner indicated that the Veteran's heart disability would prevent him from doing heavy duty/heavy lifting and running, but would not prohibit light or sedentary duty work. In a May 2016 VA eye conditions examination, the examiner found that the Veteran was legally blind due to his service connected glaucoma, as he had a visual acuity of 20/200 or less with use of a correcting lens and a visual field diameter of 20 degrees or less in the better eye. The examiner concluded that the Veteran was unable to hold down employment because of difficulty seeing. In the June 2020 private psychological evaluation, Dr. D.D. concluded that the Veteran's PTSD symptoms of anxiety and depression precluded him from performing occupational duties necessary for competitive employment, and it was unlikely that the Veteran could maintain concentration for more than 40 percent of an 8-hour day, related to others, conform to customary requirements of participation, or maintain a schedule. Dr. D.D. indicated that he considered the Veteran to be "totally psychiatrically disabled." In sum, there is probative evidence that establishes that the Veteran's service-connected disabilities cause significant occupational impairment. Specifically, the April 2016 VA diabetes and heart examiner indicated that the Veteran's diabetes and heart disability prevented him from doing physically demanding work, the May 2016 VA eye examiner indicated that the Veteran's legal blindness prevented him from being employable, and the June 2020 psychiatric evaluation by Dr. D.D. notes that the Veteran was unable to perform occupational duties necessary for competitive employment. As such, the Board finds the Veteran's service-connected disabilities have prevented him from obtaining and maintaining employment since April 1, 2016. Thus, entitlement to a TDIU from April 1, 2016, is warranted. REASONS FOR REMAND 1. Entitlement to service connection for obstructive sleep apnea is remanded. The Veteran asserts that he has had trouble sleeping since leaving service, and that he has been diagnosed with obstructive sleep apnea. See the February 2020 statement. He also contends that his sleep disorder is secondary to PTSD. See the June 2009 application for compensation. VA treatment records currently associated with the claims file indicate that in March 2011, the Veteran was referred for a sleep apnea study at a VA in Little Rock. Subsequent treatment records note that the Veteran had a diagnosis of obstructive sleep apnea syndrome; however, results of the sleep study have not been associated with the claims file. Furthermore, it appears that claims file does not contain VA treatment records dated between March 2011 and December 2015 (except for one treatment record dated in May 2014), and since February 2018. As such, remand is necessary to obtain any relevant treatment records. See 38 C.F.R. § 3.159(c). In addition, the Board finds that a VA medical opinion should be obtained to determine the nature and etiology of the sleep apnea, to include as secondary to the service-connected PTSD. 2. Entitlement to service connection for hypertension is remanded. The Veteran asserts that his hypertension is aggravated by his service-connected diabetes mellitus because "when one starts to go out-of-whack the other does the same." See the February 2020 statement. In relevant VA examinations conducted in September 2009, August 2010, and April 2016, however, the Veteran's hypertension was not found to be due to or aggravated by his service-connected diabetes. Specifically, the September 2009 VA examiner noted that the hypertension was not related to the diabetes because the hypertension predated the onset of diabetes, and that the hypertension was not aggravated by the diabetes because there was no evidence of renal problems, which would accelerate the hypertension. The August 2010 VA examiner noted that the Veteran was diagnosed with hypertension in the mid-1970s, and he was diagnosed with diabetes in the late-1990s; as such, the diabetes was not causative of the hypertension, and aggravation was not found because there was no evidence of renal problems. In February 2011, a VA examiner reviewed the Veteran's claims file and concluded that the diabetes had not aggravated the preexisting hypertension because the Veteran's renal function was good, as demonstrated by a serum creatinine and blood urea nitrogen levels being normal, and it was unlikely that the hypertension would be aggravated without a worsening of the serum creatinine. Finally, the April 2016 VA examiner indicated that the Veteran had preexisting severe hypertension prior to his diagnosis of diabetes, and echocardiograms done in 2010 and 2015 showed mild left ventricular hypertrophy (LVH), which was consistent with longstanding hypertension. Because the LVH was mild, there was no evidence of aggravation of the hypertension. The examiner did not, however, opine on whether the hypertension was related to service on a direct basis. In this regard, the Board notes that STRs are silent for complaints, diagnosis, or treatment for hypertension. In a July 1973 separation examination, however, the Veteran's blood pressure was noted to be 134/88. Furthermore, post-service private treatment records indicate that in March 1978, less than five years after separation from service, the Veteran reported pain across his upper chest off and on for the past several years. He was noted to have hypertension and was taking Diuril. As such, the Board finds that a VA medical opinion should be obtained to determine the nature and etiology of the hypertension. Post-service private treatment records indicate that the Veteran was diagnosed with hypertension in April 1978. In a September 2009 VA examination, the Veteran indicated that he had been diagnosed in the mid-1970s, at which time he was put on medication. He also noted that that he had been diagnosed with diabetes mellitus in the late 1990s, and put on medication. 3. Increased rating for diabetic nephropathy prior to April 1, 2016. 4. Increased rating for diabetic nephropathy from April 1, 2016. Service connection for diabetic nephropathy was granted in a March 2011 rating decision with a noncompensable (zero percent) rating assigned effective June 16, 2010, under Diagnostic Code 7541. In June 2016, during the pendency of the appeal, the RO increased the rating to 60 percent effective April 1, 2016. Disabilities rated under Diagnostic Code 7541, for renal involvement in diabetes mellitus, sickle cell anemia, systemic lupus erythematosus, vasculitis, or other systemic disease processes, are rated as renal dysfunction. Renal dysfunction is evaluated under 38 C.F.R. § 4.115a. Entitlement to a noncompensable rating for renal dysfunction requires albumin and casts with history of acute nephritis; or, hypertension non-compensable under diagnostic code 7101. A 30 percent rating requires albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101. A 60 percent rating requires constant albuminuria with some edema, or definite decrease in kidney function, or hypertension at least 40 percent disabling under diagnostic code 7101. An 80 percent disability rating requires persistent edema and albuminuria with BUN 40 to 80mg percent; or, creatinine 4 to 8mg percent; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is assigned in situations requiring regular dialysis or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg percent; or, creatinine more than 8mg percent; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. Under Diagnostic Code 7101, a 10 percent rating is applicable if diastolic pressure is predominantly 100 or more, or systolic pressure is predominantly 160 or more, or there is a history of diastolic pressure of predominantly 100 or more and continuous medication is required to control blood pressure. A 20 percent rating is warranted if diastolic pressure is predominantly 110 or more or systolic pressure is predominantly 200 or more. A 40 percent rating is warranted where diastolic pressure is predominantly 120 or more. A 60 percent rating is warranted where diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. Here, the Veteran could qualify for an increased rating for the nephropathy based on hypertension. However, the issue of service connection for hypertension is being remanded herein. As such, the Board finds that the issue of entitlement to an increased rating for diabetic nephropathy is intertwined with the issue of service connection for hypertension, and must be remanded. 5. Entitlement to a TDIU for the period of appeal prior to April 1, 2016, is remanded. The Veteran contends that he stopped working in July 2007 due to his service-connected disabilities. See the April 2016 TDIU application. As noted above, a TDIU award of benefits may be granted where the schedular rating is less than total, but when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Here, for the period of appeal prior to April 1, 2016, the Veteran's service-connected disabilities consisted of coronary artery disease status post coronary artery bypass graft, rated as 30 percent disabling from February 1, 1991; and diabetes mellitus type II including diabetic nephropathy, rated as 20 percent disabling from June 22, 2009. His combined rating was 40 percent from June 22, 2009. As such, the Veteran did not meet the schedular requirements for a TDIU on a schedular basis prior to April 1, 2016. A TDIU may be granted alternatively on an extra-schedular basis under § 4.16(b) if it is established that the Veteran is indeed unemployable on account of his service-connected disabilities. However, the Board is precluded from granting a TDIU on an extra-schedular basis in the first instance and must refer the matter to the Director of Compensation Service for the initial adjudication. See 38 C.F.R. § 4.16(b); Barringer v. Peake, 22 Vet. App. 242 (2008). If, and only if, the Director of the Compensation Service or designee determines that an extra-schedular TDIU is not warranted does the Board then have jurisdiction to decide the extra-schedular claim on its merits. Thus, the issue of entitlement to a TDIU prior to April 1, 2016, is being referred to the Director of the Compensation Service for initial adjudication. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he provide sufficient information and, if necessary, authorization to enable the AOJ to obtain any relevant outstanding non-VA treatment records. The AOJ should make an attempt to obtain any treatment records identified by the Veteran that are not currently associated with the claims file. 2. Obtain from the VA healthcare system all outstanding relevant treatment records dated from March 2011 to December 2015, and from February 2018 to present. All records/responses received should be associated with the claims file. If any records sought are not obtained, a written statement to that effect should be incorporated into the record. 3. Obtain a medical opinion on the current nature and likely etiology of the obstructive sleep apnea. The claims folder, including a copy of this REMAND, must be made available to and reviewed by the examiner. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the sleep apnea is causally related to and/or increased in severity by any service-connected disability(s), to include PTSD. A thorough rationale should be provided for all opinions expressed. If the VA examiner determines that further examination is necessary in order to render the requested medical opinion, the AOJ should schedule the Veteran for such an examination. 4. Obtain a medical opinion on the current nature and likely etiology of the hypertension. The claims folder, including a copy of this REMAND, must be made available to and reviewed by the examiner. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the obstructive sleep apnea had its origin during, or is in some way the result of, the Veteran's periods of active military service, to include consideration and discussion of the July 1973 separation examination and the March 1978 post-service treatment record. A thorough rationale should be provided for all opinions expressed. If the VA examiner determines that an examination is necessary in order to render the requested medical opinion, the AOJ should schedule the Veteran for such an examination. 5. Refer the issue of entitlement to TDIU for the period of appeal prior to April 1, 2016, to the Director of Compensation Service for consideration of assignment of an extraschedular rating for a TDIU, pursuant to 38 C.F.R. § 4.16(b). Prior to submission of the claim to the Director of Compensation Service, prepare a full statement as to the Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue of entitlement to TDIU for the period of appeal prior to April 1, 2016. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Nelson 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.