Citation Nr: 21077538 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 13-06 346A DATE: December 30, 2021 ORDER Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to September 27, 2010, is denied. Entitlement to a 70 percent, but no higher, rating for PTSD from September 27, 2010, is granted, subject to the regulations governing the payment of monetary awards. Entitlement to a rating in excess of 70 percent for PTSD at any time during the appeal period is denied. Entitlement to an evaluation in excess of 50 percent on an extraschedular basis for PTSD prior to September 27, 2010, and in excess of 70 percent during any time of the appeal period is denied. REMANDED Entitlement to service connection for a respiratory condition is remanded. FINDINGS OF FACT 1. Prior to September 27, 2010, the severity, frequency, and duration of the Veteran's PTSD symptoms more closely approximated to occupational and social impairment with reduced reliability and productivity. 2. From September 27, 2010, the Veteran's PTSD is shown to have been manifested by symptoms causing occupational and social impairment with deficiencies in most areas. 3. At no time during the appeal period has the Veteran's PTSD shown to have been manifested by symptoms causing total occupational and social impairment. 4. A preponderance of the evidence is against a finding that the Veteran has an exceptional disability picture such that the available schedular evaluation for the Veteran's service-connected PTSD is inadequate. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent prior to September 27, 2010, for the Veteran's PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2020). 2. The criteria for a disability rating of 70 percent, but no higher, for the Veteran's PTSD have been met from September 27, 2010, subject to the regulations governing the payment of monetary awards. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, DC 9411 (2020). 3. At no time during the appeal period has the criteria for a disability rating in excess of 70 percent for the Veteran's PTSD been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, DC 9411 (2020). 4. The criteria for entitlement to an evaluation in excess of 50 percent on an extraschedular basis for PTSD prior to September 27, 2010, and in excess of 70 percent during any time of the appeal period have not been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.321, 4.124a, DC 9411 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1965 to May 1967. He received the Combat Infantryman Badge, among other decorations, for this service. These matters are before the Board of Veterans' Appeals (Board) on appeal from a March 2010 and August 2011 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In August 2017, the Board remanded the respiratory claim for further evidentiary development. In May 2019, the Board remanded both matters for further evidentiary development. In May 2018, the Veteran appeared at a Video Conference hearing before a Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the record. In October 2021, the Veteran was informed that the VLJ who conducted the May 2018 hearing was no longer with the Board. The Veteran was offered a hearing with a VLJ who would decide his appeal and informed that if he did not respond the Board would assume that the Veteran did not want another hearing. The Veteran has not responded to the October 2021 Board letter; thus, the Board will assume that the Veteran does not want another hearing. A. Duties to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. 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). Accordingly, appellate review may proceed without prejudice to the Veteran with respect to his claim. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). B. Increased Rating The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. 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. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as deemed appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to the claim. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. With the initial rating assigned following a grant of service connection, separate (staged) ratings may be assigned for separate periods, based on the facts. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. The Veteran's PTSD is rated under DC 9411, 38 C.F.R. § 4.130. A 30 percent rating is warranted 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is 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 is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted when there is 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. 38 C.F.R. § 4.130, DC 9411. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Because "[a]ll non-zero disability levels [in § 4.130] are also associated with objectively-observable symptomatology," and the plain language of this regulation makes it clear that "the veteran's impairment must be 'due to' those symptoms," "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). "[I]n the context of a 70[%] rating, § 4.130 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. at 117. Therefore, although the veteran's symptoms are the "primary consideration" in assigning a disability evaluation under § 4.130, the determination as to whether the veteran is entitled to a 70 percent disability evaluation "also requires an ultimate factual conclusion as to the veteran's level of impairment in 'most areas.'" Id. at 118. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remissions. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation 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. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). 1. Prior to September 27, 2010 The Veteran was afforded a VA examination in August 2009 and the examiner diagnosed PTSD. The Veteran informed the examiner that his wife divorced him 11 years ago and the marriage resulted in three children. The Veteran added that he maintained a relationship with one of his three grown children. The Veteran reported spending the majority of his time in his home and was noted to have "little or no social activities." Concerning employment, the Veteran worked for a telephone company for 18 years until 1986 and then started his own business. His business improved, but the Veteran was injured in October 2008 and worked very little since then and retired in 2009. The examiner described the Veteran as clean and appropriately dressed and his speech was noted to be clear and coherent. Attitude was stated to be cooperative, attentive, and guarded while affect was noted to be appropriate. The Veteran's attention was normal and his mood euthymic. The Veteran was orientated to person, place, and time and thought processes and content were unremarkable. Delusions, hallucinations, panic attacks, and obsessive/ritualistic behavior were absent. Behavior was appropriate and judgment was normal. Suicidal ideations and homicidal ideations were absent, and the Veteran denied a history of suicidal attempts. However, sleep was noted to be impaired due to frequent nightmares. The VA examiner indicated the level of occupational and social impairment caused by the Veteran's PTSD to be occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. After evaluating the evidence of record, the Board finds that symptoms of the Veteran's PTSD prior to September 27, 2010, more nearly approximate to the criteria for a 50 percent rating. The record indicates the Veteran's PTSD was characterized by symptoms of nightmares and sleep impairment. This evidence is most consistent with a finding of occupational and social impairment with reduced reliability and productivity. The Board finds a preponderance of the evidence is against a finding that the Veteran experienced occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. Prior to September 27, 2010, there was no deficiency in judgment, thinking, or mood because the Veteran's thought processes were clear, his behavior was appropriate, delusions and hallucinations were absent, and the Veteran did not exhibit suicidal ideations or homicidal ideations. The Board acknowledges there was evidence of "little or no social activities," but the frequency, duration, and severity of his symptoms did not cause a deficiency in social impairment or family relations because the Veteran maintained a relationship with one of his three grown children. The Board has also considered the Veteran's statements regarding the severity of his psychiatric disorder. The Veteran is competent to report the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.159(a)(2); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Ultimately, however, the opinions and observations of the Veteran do not meet the burden for a higher rating imposed by the rating criteria under 38 C.F.R. § 4.130 with respect to determining the severity of the Veteran's service-connected psychiatric disorder. The Board has considered whether any staged rating is appropriate for the period prior to September 27, 2010, and finds that the frequency, duration, and severity of the Veteran's symptoms were consistent with a 50 percent rating throughout this period. The record does not indicate any significant increase or decrease in the Veteran's symptoms that is not already accounted for by the assigned rating. Accordingly, staged ratings are not warranted. See Fenderson, 12 Vet. App. at 126. In summary, the evidence more nearly approximates that the Veteran's PTSD caused occupational and social impairment with reduced reliability and productivity prior to September 27, 2010, and a preponderance of the evidence is against a finding that the Veteran experienced occupational and social impairment with deficiencies in most areas during this time due to his PTSD. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. Consequently, a rating in excess of 50 percent prior to September 27, 2010, is not warranted. 2. From September 27, 2010 A September 2010 VA treatment note documents that the Veteran presented with suicidal ideations and was admitted for admission on September 27, 2010. The Veteran informed the provider of a plan of cutting his wrists or jumping into traffic because of migraines and feelings of guilt from Vietnam. The Veteran endorsed symptoms of depression, difficulty with sleep, diminished interest, feelings of guilt, decreased energy, trouble concentrating, and changes in appetite. The Veteran reported the increase in his symptoms began after attending a PTSD clinic. The Veteran was afforded a VA examination in April 2011 and the examiner diagnosed the Veteran with PTSD. The Veteran noted he was single for the past 12 years and remained in contact with one of his three children. The Veteran stated he did not leave his home and shopped at night. The Veteran's leisure pursuits included watching TV and sleeping. The Veteran denied suicide attempts. The examiner described the Veteran as appropriately dressed and his speech was noted to be clear. Attitude was stated to be cooperative while affect was noted to be appropriate. The Veteran's attention was normal and his mood hopeless. He was orientated to person and place and time and thought process and content were unremarkable. Delusions, hallucinations, panic attacks, and obsessive/ritualistic behavior were absent. Behavior was appropriate and judgment was normal. Suicidal ideations and homicidal ideations were absent. Impulse control was fair and remote, recent, and immediate memory were normal. The VA examiner indicated the level of occupational and social impairment caused by the Veteran's PTSD to be reduced reliability and productivity. The examiner specified that the Veteran's problems with chronic pain, depression, and anxiety limited social and leisure activities. In an April 2011 notice of disagreement (NOD) the Veteran endorsed symptoms of panic attacks, nightmares, migraines, poor impulse control, and anger. The Veteran added that he could not easily function on a daily basis the majority of the time. In October 2011, the Veteran's provider wrote a letter on his behalf. The provider stated that the Veteran's PTSD symptoms included intense nightmares, high levels of arousal, anxiety (at times unremitting), panic attacks (which caused significant impairment in concentration and focus), sleep impairment, irritability, anger, flashbacks, and frequent and intense nightmares. The provider described these symptoms as severe. The provider indicated that the Veteran suffered from depression, guilt, self-loathing, and constant passive suicidal ideations but no plan. The examiner opined that the Veteran was unlikely to return to a competitive, gainful employment due to chronic PTSD symptoms. The provider stated that the Veteran was isolated from others, led a reclusive lifestyle and rarely left his home other than for treatment appointments. A July 2012 VA treatment note indicates that the Veteran acknowledged passive thoughts of death (wishing he were dead) but denied any active suicidal thinking intent or plan. In October 2012, the Veteran's provider wrote a letter on behalf of the Veteran. The provider stated that the Veteran's PTSD symptoms included frequent and intense nightmares, high levels of arousal, anxiety (at times unremitting), panic attacks (which caused significant impairment in concentration and focus), sleep impairment, irritability, and anger. The provider indicated that the Veteran suffered from depression, guilt, self-loathing, and constant passive suicidal ideations but no plan. The examiner opined that the Veteran was unlikely to return to a competitive, gainful employment due to chronic PTSD symptoms. The provider stated that the Veteran was isolated from others, led a reclusive lifestyle and rarely left his home other than for treatment appointments. A September 2016 VA treatment note indicates the presence of suicidal thoughts. A July 2017 VA treatment note documents that the Veteran's PTSD symptoms resulted in an adjustment in medication that resulted in drowsiness and sedation. The side effects impaired the Veteran's driving abilities, and the Veteran was advised not to drive until his medications stabilized. During the May 2018 Board hearing, the Veteran testified that his psychiatrist increased his medication to treat his PTSD and the result was that he was no longer able to drive a vehicle. The Veteran described his short-term memory as being "shot." The Veteran stated that his nightmares and flashbacks increased to such a point that he could not enter an Asian food store due to the fear of triggering flashbacks from Vietnam. The Veteran added that his symptoms have resulted in increased isolation. The Veteran testified that he attempted suicide twice and he was placed in a unit for 30 days and that his panic attacks have increased. The Veteran specified that he lives alone and avoids going out. He stated that he purchases groceries at 3 a.m. in order to avoid confrontation. A February 2020 VA treatment note documents that the Veteran helped a friend move out and that he planned to participate in a bowling league with his friend. Another February 2020 VA treatment note indicates that the Veteran sent gifts to his grandchildren for Valentine's Day and that he enjoys sending humorous messages to his grandchildren. In August 2020, the Veteran was afforded a VA examination and the examiner diagnosed PTSD. The Veteran informed the examiner that he was divorced since 1998 but maintains contact with one of his three grown children. The Veteran added that he lacked friends. The Veteran noted that he purchased a home in November 2019 and spends most of his time at home completing projects around his house. The Veteran stated he isolates himself from others and avoids driving due to flashbacks. The Veteran described feelings of anger, depression, difficulty feeling happy, loneliness, lack of concentration, and agitation. The Veteran stated he has nightmares three to four times a week and sleeps approximately three hours a night. The examiner described the Veteran as alert and oriented to person, place, time and situation. The Veteran was noted to be irritable, but rapport was adequately established and maintained throughout the evaluation. The examiner stated that the Veteran was generally cooperative during the evaluation and he was not defiant or confrontational but was somewhat irritable. The Veteran's hygiene and grooming were appropriate. The Veteran's mood was described as sad and irritable, and affect was congruent with mood. Thoughts were logical and speech normal. There was no evidence of perceptual disturbances, paranoia, or delusional ideation. Similarly, auditory hallucinations and visual hallucinations were absent. Short-term, long-term memory, concentration, and attention were grossly intact. The Veteran denied suicidal ideation, plan, and/or intent. The examiner reported that the Veteran's symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner stated that the Veteran has difficulty interacting with other people in a socially appropriate manner, has a strained relationship with some family members, and has very limited friends. The examiner opined that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. The evidence indicates that the Veteran's PTSD has been characterized by various symptoms, including anger, difficulty feeling happy, loneliness, lack of concentration, agitation, depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideations. His symptoms have been shown to cause him occupational and social impairment with deficiencies in most areas, as reflected by the currently assigned 70 percent rating. The frequency, duration, and severity of his symptoms have not, however, been shown to result in total occupational and social impairment. The Board acknowledges that the Veteran has been awarded a total disability rating for individual unemployability due to service-connected disabilities, in part based on his service-connected psychiatric disorder. Thus, the evidence more nearly approximates that his psychiatric disorder causes him to have total occupational impairment. A preponderance of the evidence is against a finding, however, that the frequency, duration, and severity of his symptoms also resulted in total social impairment anytime during the appeal period. In analyzing the evidence, the Board has considered, but has not exclusively relied upon, the symptoms associated with a 100 percent rating in the General Formula, and has focused on evaluating the frequency, duration, and severity of all of his symptoms. The Veteran has demonstrated consistently good hygiene. The Veteran has consistently denied delusions or hallucinations. Therefore, the frequency, duration, and severity of these symptoms do not reflect that the Veteran has total social impairment. Further, the Veteran is rarely, if ever, shown to be disoriented to time and place and the record does not reflect grossly inappropriate behavior. Although he experiences some memory loss, this symptom does not more nearly approximate the frequency, duration, and severity of memory loss for names of close relatives, own occupation, or own name. The record reflects that the Veteran is divorced and not in a relationship but appears to be able to maintain a relationship with other family members, such as one of his children and his grandchildren. Although the Veteran separates himself from others for periods of time, the evidence does not show a total lack of connection with family members or others. Additionally, he has also reported being in contact with other veterans. The Board acknowledges that the Veteran isolates himself, but such detachment does not appear to have totally impaired his ability to have social relationships, as reflected by the relationship that he has with his child, his grandchildren, and other veterans. Although the Veteran does not enjoy crowds, his fear of crowds has not prevented him from maintaining some social relationships with family and friends. The Board acknowledges that from September 27, 2020, the Veteran has exhibited suicidal ideations. However, the frequency, duration, and severity of this symptom does not reflect that the Veteran had total social impairment. See Bankhead v. Shulkin, 29 Vet. App. 10 (2017) (noting that the presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas). The Board has also considered the Veteran's statements and other lay evidence regarding the severity of his psychiatric disorder. The Veteran is competent to report the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.159(a)(2); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Ultimately, however, the opinions and observations of the Veteran and other lay evidence does not meet the burden for a higher rating imposed by the rating criteria under 38 C.F.R. § 4.130 with respect to determining the severity of his service-connected psychiatric disorder. The Board has considered whether any staged rating is appropriate and finds that the frequency, duration, and severity of the Veteran's symptoms have been consistent with a 70 percent rating from September 27, 2010. The record does not indicate any significant increase or decrease in the Veteran's symptoms that is not already accounted for by the assigned rating. Accordingly, staged ratings are not warranted. See Fenderson, 12 Vet. App. at 126. Accordingly, because a preponderance of the evidence is against a finding that the Veteran exhibited total social impairment at any time during the appeal period, he does not meet the criteria for a 100 percent rating, which requires total occupational and social impairment. In reaching this conclusion, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Consequently, a rating in excess of 70 percent at any time during the appeal period is not warranted. 3. Extraschedular Consideration of an extraschedular rating requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the veteran's disability picture. If the schedular evaluation does not contemplate the level of disability and symptomatology shown and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008). The first Thun element compares a claimant's symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms. Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). If the veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Director of Compensation Services to determine whether an extraschedular rating is warranted. See Thun, 22 Vet. App. 111. There is no restriction on the Board's ability to review the adjudication of an extraschedular rating once the Director determines that an extraschedular rating is not warranted. Anderson v. Shinseki, 22 Vet. App. 423, 427 (2009). In this case, in May 2019, the Board referred the Veteran's PTSD claim to the Director of Compensation Service for review. In July 2021, the Director of Compensation Service determined that the evidence did not support a higher evaluation on an extraschedular basis. In regard to the first element, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. As explained above, the Veteran's PTSD has been characterized by various symptoms, including anger, difficulty feeling happy, loneliness, lack of concentration, agitation, depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideations. The May 2019 Board decision referred the claim for extraschedular basis on the grounds that the Veteran's PTSD medication caused drowsiness and sedation, which would impair the Veteran's driving abilities and constitute marked interference with employment. However, as explained above, the Board acknowledges that the Veteran has been awarded a total disability rating for individual unemployability due to service-connected disabilities, in part based on his service-connected psychiatric disorder. To the extent to which the symptoms result in occupational impairment, this is contemplated in the schedular rating criteria. Accordingly, the Board concludes that the evidence does not indicate an exceptional or unusual disability picture. As such, the preponderance of the evidence is against the Veteran's claim for an evaluation in excess of 50 percent for service-connected PTSD prior to September 27, 2010, and in excess of 70 percent during any time of the appeal period on an extraschedular basis. In reaching these conclusions, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Service connection for a respiratory condition is remanded. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In June 2020, a VA examiner provided a negative nexus opinion on the Veteran's respiratory claim. The examiner's rationale was that there was no objective evidence of a diagnosis or treatment for an asthma condition in the Veteran's service treatment records (STRs). In June 2021, the Veteran was afforded a VA examination and examiner diagnosed asthma. The examiner offered a negative nexus opinion. The examiner's rationale was that asthma is not a presumptive condition of the chemicals used in the Vietnam Era and that the Veteran's STRs were silent for asthma complaints. The examiner added that asthma can have many factors and triggers. The Board finds these opinions to be inadequate because the examiners' rationale is limited to relying on the absence of documented medical evidence in the Veteran's STRs and ignoring the Veteran's competent lay evidence. Namely, both examiners stated that the Veteran's STRs were silent for any complaints of an asthma condition but failed to consider the Veteran's competent lay evidence that during his duty in Vietnam he was exposed to the smell from dead bodies, feces, and chemicals. See Miller v. Wilkie, 32 Vet. App. 249, 258-60 (2020) (holding that an examination that does not address credible and relevant lay evidence does not include enough detail to inform the Board's decision and, thus, is inadequate). Also, the examiners' premise that the Veteran's STRs are silent for any complaints of a respiratory condition is false because an October 1965 STRs documents a diagnosis of a respiratory infection. Thus, these opinions are of no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that an opinion based upon an inaccurate factual premise has no probative value). The matters are REMANDED for the following actions: 1. Obtain and associate with the claims file VA treatment records from February 2021 to the present. (Continued on the next page) 2. After completing the development above, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any respiratory condition. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including exposure to the smell from dead bodies, feces, and chemicals and/or the in-service diagnosis of an upper respiratory infection. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Patel, 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.