Citation Nr: 21005678 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 18-27 151 DATE: February 2, 2021 ORDER Entitlement to service connection for sleep apnea is denied. Entitlement to a rating higher than 30 percent for irritable bowel syndrome is denied. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to a rating higher than 30 percent for posttraumatic stress disorder (PTSD) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s sleep apnea had its onset during or is related to service, or that it was caused or aggravated by a service-connected disability. 2. The Veteran did not submit a Notice of Disagreement or new and material evidence within one year of the December 2008 rating decision that awarded service connection for irritable bowel syndrome, initially rated as 10 percent disabling; thus, the December 2008 rating decision is final. 3. The current claim for an increased rating for irritable bowel syndrome was submitted on October 27, 2016. 4. The current 30 percent rating for the Veteran’s irritable bowel syndrome is the maximum schedular rating for irritable bowel syndrome, and it adequately contemplates the Veteran’s symptoms of abdominal cramps, diarrhea, and bloating. He has not experienced fecal leakage, and there are no other applicable diagnostic codes which would allow for a separate or higher rating. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. 2. The criteria for a disability rating in excess of 30 percent for irritable bowel syndrome are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.114; Diagnostic Code 7319. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1988 to October 1992. This case comes to the Board of Veterans’ Appeals (Board) from a February 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office. In September 2019, the Board denied the claims of entitlement to service connection for bilateral hearing loss and memory loss, and for a rating higher than 30 percent for irritable bowel syndrome. It also granted a claim for service connection for tinnitus and remanded the claims for service connection for sleep apnea and for a rating higher than 30 percent for PTSD for further development. The Veteran appealed the claim to the Court of Appeals for Veterans Claims (Court), and a Joint Motion for Partial Remand was issued in August 2020 which vacated the Board’s denials of the claims for service connection for bilateral hearing loss and for a rating higher than 30 percent for irritable bowel syndrome. Sleep Apnea The Veteran requests service connection for sleep apnea, including as secondary to his service-connected PTSD. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). This permits service connection not only for a disability caused by a service-connected disability, but also for the degree of disability resulting from aggravation of a disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). While the evidence shows that the Veteran has a current disability, unfortunately the preponderance of the evidence does not demonstrate that this disability was incurred in service or is secondary to a service-connected disability. The Veteran’s service treatment records do not appear to show any complaints or treatment for sleep apnea. The Board acknowledges that some of the copies of the Veteran’s service treatment records are of very poor quality and are very hard to read. The Veteran has not, however, actually asserted that he was ever treated for or diagnosed with sleep apnea in service, and the earliest treatment records showing reports of possible sleep apnea are from 2004, when he reported feeling tired all of the time, and a May 2006 sleep study that found mild sleep apnea. The Veteran attended a VA examination in February 2017. He reported that he had been diagnosed with obstructive sleep apnea in 2005 after a history of observed apneic spells, daytime drowsiness, and loud snoring. He now used a CPAP machine which was helpful, but had mild daytime drowsiness. The examiner wrote that sleep apnea was a disease of unknown etiology, but was more common in men, patients who were obese, and those who smoked or had nasal allergies. The examiner wrote that there was some evidence that sleep apnea was more common in those with PTSD, but the exact relationship was not clear, and it was therefore less likely than not that sleep apnea was secondary to PTSD. The Veteran submitted a sleep apnea Disability Benefits Questionnaire in August 2018. The completing physician wrote that the Veteran had sleep apnea that started shortly before and after getting out of the military. She wrote that the Veteran had sleep studies in May 2006 and May 2014, and that the Veteran had a hard time staying awake throughout the day, had fatigue, and would stop breathing while asleep at night. The Veteran attended a VA mental health examination in July 2019 with a psychologist. He wrote that, based on the Veteran’s history, it was less likely than not that his sleep apnea was related to PTSD. An addendum medical opinion was obtained in July 2019, in order to clarify the relationship between sleep apnea and PTSD. The VA physician examiner wrote that there was a 2014 review of literature exploring the possible relationships between PTSD and sleep-disorder breathing, such as sleep apnea, but it found that “no conclusions can be drawn from the data currently available on the potential relationship between [sleep disordered breathing] and PTSD.” He wrote that another review from 2015 also found an association, though inconsistent, between PTSD and sleep disordered breathing, but without clarity as to whether sleep apnea predisposes to PTSD or the other way around. He wrote that another report had reviewed prior studies showing high co-morbidity between sleep apnea and PTSD and found a moderate to high risk of selection bias, which would overestimate the relationship. Because of the lack of scientific evidence supporting a causal role for PTSD in the development of sleep apnea, the examiner opined that the Veteran’s sleep apnea was less likely than not caused by his PTSD. The July 2019 VA examiner also wrote that there were insufficient records to determine the onset of the Veteran’s condition, and he could not establish a baseline for the disorder. He also found that sleep apnea was not at least as likely as not aggravated by PTSD, explaining that the current state of research on any relationship between PTSD and sleep apnea was preliminary, and they did not support a causal relationship or aggravation of sleep apnea. He wrote that sleep apnea and PTSD both caused disturbed sleep, but through different and independent mechanisms. He explained that just because both conditions disturb sleep, does not mean they interact with each other or aggravate each other. He further explained that sometimes physicians will put forth the logical fallacy that the conditions “aggravate” each other, when in fact the conditions both merely aggravate sleep, and an aggravation of the symptom, which is disturbed sleep, is not synonymous with the aggravation of the disease that it causing the symptoms, which is sleep apnea. In September 2019, the Board remanded this issue in order to obtain an additional medical opinion addressing direct service connection for sleep apnea, because the Veteran now indicated that he experienced symptoms in or shortly after service, noting that he complained of chronic fatigue in 1994. The examiner was also asked to address the medical literature submitted by the Veteran’s representative in August 2019. An additional medical opinion was obtained in January 2020. The examiner found that the Veteran’s service treatment records were silent for any diagnosis of sleep apnea. He wrote that complaints of trouble sleeping, snoring, gasping for air, and daytime sleepiness cannot be used in retrospect to infer a historical diagnosis of sleep apnea, as that would be engaging in pure speculation, and only a sleep study done in real time can make a diagnosis of sleep apnea. He concluded that it was less likely than not that the disorder was incurred in or caused by service. The examiner also reviewed the new evidence submitted by the Veteran’s representative, but explained that this evidence did not actually claim that PTSD caused sleep apnea, but only that there was a “connection” between them, and that this did not meet the standard for a 50 percent or greater probability of proximate cause. He specifically discussed the 2016 article cited by the representative and the studies discussed within the article, and explained how these studies considered interaction between the disorders, but did not actually find a causal relationship. He explained that a higher prevalence of sleep apnea is not the same as causation, and did not establish any causal association, and that the article did not in fact actually make a conclusion regarding causation. The Board finds that the preponderance of the evidence therefore clearly establishes that the Veteran’s sleep apnea is not related to his active duty service and has not been caused or aggravated by his PTSD. The February 2017 VA examiner found that the Veteran’s sleep apnea was not secondary to PTSD, and then subsequent addendum medical opinions were provided by a VA physician who explained in great detail why the preponderance of the evidence did not establish that PTSD caused or aggravated the Veteran’s PTSD. The addendum opinions very clearly addressed the medical literature and explained why they showed only increased correlation of the disorders, but not causation. There are no other medical opinions which contradict the opinions of the VA examiners. The Board also acknowledges that the Veteran submitted a Disability Benefits Questionnaire in August 2018. While the physician wrote that the Veteran had sleep apnea that started shortly before and after getting out of the military, this is clearly contradicted by the VA treatment records. The examiner does not appear to have based that statement on any actual review of the records, and it is unsupported by the other evidence of record. The records show that the Veteran had reported feeling tired and fatigued prior to 2006, but that only in 2006 did he attend his first sleep study and was first diagnosed with mild obstructive sleep apnea. As was explained by the January 2020 VA addendum opinion, symptoms such as daytime tiredness do not establish a diagnosis of sleep apnea, and the Board is not able to afford her opinion any probative weight. There is no other competent and probative medical evidence relating the Veteran’s sleep apnea to service or to PTSD, and the Veteran has not presented any other evidence or arguments regarding why he believes service connection for sleep apnea is warranted. The Board acknowledges that the Veteran’s assertions that he believes his sleep apnea was caused or aggravated by his PTSD. While the Veteran is competent to report his symptom as he experiences them, as a lay person, he is not competent to opine on a complex etiology such as the medical causes or medically aggravating factors of sleep apnea. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board has considered the Veteran’s assertions, but in the absence of any probative medical evidence supporting this assertion, his lay statements alone are not sufficient to find such a nexus, and his statements are outweighed by the more probative opinions of the VA examiners. The preponderance of the evidence of record is against finding that the Veteran’s sleep apnea was incurred in or otherwise the result of his active service or was caused or aggravated by a service-connected disability. The claim is denied. The preponderance of the evidence is against the claim, and the benefit of the doubt doctrine does not apply. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Irritable Bowel Syndrome The Veteran requests a rating higher than 30 percent for his irritable bowel syndrome. The relevant period on appeal is from up to one year prior to the date of the Veteran’s claim for increase in October 2016. At the outset, the Board addresses the Veteran’s contention that the period on appeal should extent back to February 5, 2008. The August 2020 Joint Motion for Partial Remand found that the Board had assumed that the appeal period went back to one year prior to the submission of a request for increase in October 2016, but had failed to consider whether the Veteran’s November 2009 submission requesting reconsideration of the December 2008 rating decision could have constituted a Notice of Disagreement to that decision. The Veteran and his attorney submitted a brief in August 2020 arguing that the Veteran’s November 2009 submission did express dissatisfaction and disagreement with the initial rating and effective date assigned. They wrote that he also submitted new and material evidence within one year of the December 2008 rating decision, including statements from the Veteran and his wife regarding the severity of his condition and his spouse’s statement about the severity of his condition and his treatment. They argue that the Veteran’s wife also wrote that VA doctors had told her that IBS and constant diarrhea were the same thing, and the presence of constant diarrhea would indicate that the severity of the Veteran’s condition would more closely approximate a 30 percent rating. The Board has considered this argument, but does not find that the November 2009 submission constitutes a Notice of Disagreement or that the December 2008 rating decision remains pending. The Veteran did submit a letter dated in November 2009 and received in December 2009, within one year of the date the December 2008 rating decision was mailed. The Veteran’s November 2009 letter stated, “I would like to request that my Compensation be readjusted to 30% or more from your last judgement dated December 16, 2008.” He also wrote that he believed that his irritable bowel syndrome had been present since 1992, but that his previous claim had been denied. He wrote that he asked that “you reconsider your judgment of 10% and render a judgement of 30% or more.” He wrote that medication helped sometimes, but not always, and that his condition made family trips more difficult. The laws in effect at the time of the December 2008 rating decision required that a Notice of Disagreement be a written communication from a claimant or his representative expressing dissatisfaction or disagreement with an adjudicative determination and a desire to contest the result. 38 C.F.R. § 20.201 (2008). The Board has carefully considered the wording of the Veteran’s November 2009 letter, but does not find that it constitutes a Notice of Disagreement. The Veteran wrote that he wanted his rating to be “readjusted” and that he wanted VA to “reconsider” the 10 percent evaluation. The Board finds the plain meaning of these words to indicate that he wished to have a readjudication of the issue. The letter identified no specific error in the December 2008 rating decision and did not indicate a desire to appeal that decision. The Board also notes that the Veteran’s request for VA to “reconsider” the decision has been a common term requested by veterans for a readjudication of a claim. VA regulations generally allow for “reconsideration” in very few instances, including when VA receives service department records which were not available during the prior adjudication. See 38 C.F.R. § 3.156(c). Nevertheless, Regional Offices will often accept such requests as either a claim for an increased rating or for readjudication of original claims based on the evidence at the time of the initial rating. The term does not, however, indicate an initiation of a Board appeal, and is not accepted as an attempt to submit a Notice of Disagreement. The Veteran also argues that new and material evidence had been received within one year of the December 2008 rating decision, specifically the November 2009 letter from his spouse. See 38 C.F.R. § 3.156(b) (2009) (New and material evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending.). The Veteran’s spouse submitted a letter describing her husband’s symptoms from PTSD and irritable bowel syndrome. She wrote that her husband could not be far form a bathroom and that his doctor stated that the Veteran’s irritable bowel and constant diarrhea were the same thing. VA treatment records which were already of record and considered for the December 2008 rating decision indicate that the Veteran had a history of chronic diarrhea. The December 2008 rating decision in fact specifically mentions the Veteran’s history of chronic diarrhea. The Board therefore does not find that the letter from the Veteran’s spouse contains any information that is actually “new,” as this symptom was already established. Furthermore, even if her assertions were to be considered new and material evidence, this evidence was then considered in the subsequent July 2010 rating decision. The Veteran received a notification letter in December 2009 that his November 2009 letter had been accepted as a claim for an increased rating. The Veteran was afforded a new VA examination in February 2010, and a rating decision was issued in July 2010, continuing the 10 percent evaluation. The Veteran did not submit a Notice of Disagreement with the July 2010 rating decision or new and material evidence within one year of this decision, and it is final. See 38 U.S.C. § 7105. A subsequent rating decision issued in August 2012 increased the Veteran’s rating for irritable bowel syndrome to 30 percent, effective February 24, 2012. The Veteran did not appeal either the rating or the effective date assigned in this decision, and he did not submit new and material evidence within one year. The August 2012 rating decision is also final. See id. The Board therefore finds that there are no prior decisions which remain pending, and the current claim on appeal was submitted on October 25, 2016. The current appeal period to be considered therefore spans from October 25, 2015, one year prior to the claim, to the present. Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. A February 2017 VA examination found the Veteran's intestinal condition to be manifest by irritable bowel syndrome, which “is mainly characterized by diarrhea.” He reported having diarrhea every other day, and experiencing 4 to 5 loose stools on those days. The Veteran also reported having abdominal cramps and bloating. He had no other episodes of bowel disturbance, no weight loss, no malnutrition. He was able to perform his work at the prison where he was employed with no impact on his ability to work. The Veteran’s VA treatment records show that he receives ongoing treatment for irritable bowel disorder and diarrhea. In July 2017, the Veteran denied any bowel/bladder incontinence. In March 2019, it was noted that he was taking medication and doing well. The records make no mention of the Veteran experiencing any fecal or urinary leakage. For the entire period on appeal, the Veteran’s irritable bowel syndrome has been rated at 30 percent under Diagnostic Code 7319. A 30 percent rating is assigned for severe irritable colon syndrome, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. This rating, 30 percent, is the maximum rating available for irritable bowel syndrome. The Board finds that these criteria very accurately describe the Veteran’s symptoms, which is frequent diarrhea and abdominal distress. Based on the evidence of record, the Board concludes that the Veteran’s symptoms are fully encompassed by the criteria for a maximum 30 percent rating under Diagnostic 7319, and he is not entitled to any higher rating or separate ratings under any other diagnostic codes. The Veteran, through his attorney, has also argued that he should be awarded an additional rating under Diagnostic Code 7332, for impairment of sphincter control. They argue that 38 C.F.R. § 4.114 does not explicitly prohibit separate ratings, and cited Southall-Norman v. McDonald, 28 Vet. App. 346, 354-56 (2016) which found that separate ratings for hemorrhoids and impairment of sphincter control should be considered in a case where the veteran was service connected for hemorrhoids, but also had fecal leakage. The Board has considered all other applicable diagnostic codes, but does not find that the Veteran could be awarded a higher rating by applying a different diagnostic code, or that an additional, separate rating can be assigned without violating the rule against pyramiding. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (VA may not assign multiple ratings for duplicative or overlapping symptomatology.). The Board notes that diseases of the digestive system and abdomen, while differing in the site of pathology, produce a common disability picture characterized by varying degrees of abdominal distress or pain, anemia, and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated by the instructions under the title “Diseases of the Digestive System,” do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. See 38 C.F.R. § 4.113. Thus, ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Therefore, under the regulation, a determination must be made regarding the predominant disability picture. Hiatal hernia is evaluated under Diagnostic Code 7346. A 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is assigned when two or more of those symptoms are present with less severity. A 60 percent rating is authorized for hernia with symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. Here, the Veteran is not service-connected for a hiatal hernia, and his disorder does not manifest to symptoms comparable to those listed here. While symptoms of “cramping” are noted, there is no evidence of vomiting, arm or shoulder pain, regurgitation, material weight loss, hematemesis or melena with moderate anemia; or other symptom combinations productive of /considerable severe impairment of health. There also is no showing of ulcerative colitis to warrant a higher rating under Diagnostic Code 7323. A 10 percent rating is assigned for moderate ulcerative colitis; a 30 percent rating is assigned for moderately severe ulcerative colitis, and a 60 percent rating is assigned for severe ulcerative colitis with numerous attacks a year and malnutrition. 38 C.F.R. § 4.114, Diagnostic Code 7323. The Veteran has never been diagnosed with ulcerative colitis, and he is not found to have separate symptomatology which are comparable to a condition of ulcerative colitis. Diagnostic Code 7332 evaluates rectum and anus impairment of sphincter control. A 10 percent rating is assigned for constant slight, or occasional moderate leakage. A 30 percent rating is assigned for occasional involuntary bowel movements, necessitating wearing of a pad. A 60 percent rating is assigned for extensive leakage and fairly frequent involuntary bowel movements. A 100 percent rating is assigned only if there is evidence of complete loss of anal sphincter control or extensive bowel leakage and fairly frequent involuntary bowel movements and this is neither alleged nor shown in this instance. 38 C.F.R. § 4.114, Diagnostic Code 7332. The Board has seriously considered the Veteran’s assertions that a separate rating should be assigned under Diagnostic Code 7332, but unlike the case in Southall-Norman, the Veteran has not been shown to have a distinct, separate condition of fecal leakage related to his irritable bowel syndrome. At no time has the Veteran actually asserted that he had fecal leakage, it was not found at the VA examination, and it has never been noted in his VA treatment records. The Veteran’s prior attorney noted incidents in 2010 and 2012 when the Veteran had soiled his underpants, but these incidents occurred well before the current appeal period, and there is no indication of any fecal leakage occurring since 2015. While the attorney wrote in that the Veteran’s statement in November 2016 that his symptoms were “unimproved” must indicate that he has sphincter impairment, the Board does not find that such a general statement indicates that this very specific symptom is present. The Veteran did not make any mention of this to the February 2017 VA examiner, and in fact specifically denied fecal incontinence to his medical provider in July 2017. The Board therefore finds no evidence that a separate sphincter impairment disorder is present, and a separate rating under Diagnostic Code 7332 is not warranted. In short, the Board has considered evaluating the service-connected irritable bowel syndrome under other possibly applicable diagnostic codes for the digestive system found at 38 C.F.R. § 4.114, but finds that the Veteran’s symptoms are fully encompassed by the rating assigned under Diagnostic Code 7319, and no other diagnostic code is applicable which would allow for a higher or separate rating. The claim for an increased rating is denied. The Board has again considered the doctrine of reasonable doubt, but the preponderance of the evidence is against the claim. Extraschedular Consideration for Irritable Bowel Syndrome Because the Veteran has argued that his symptoms are not adequately compensated by the rating schedule, the Board has also considered whether referral for an extraschedular rating is warranted. Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board may consider whether the case should be referred to the Director of VA’s Compensation and Pension Service for a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe a disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff’d sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board notes the Veteran’s frequency of diarrhea and incontinence are factors contemplated in the rating criteria. Further, with regard to the effect on employment, the February 2017 VA examination indicated that the Veteran’s irritable bowel syndrome did not impact his ability to work, and that it was moderate in severity. In addition, there is no evidence of hospitalization due to his irritable bowel syndrome. The simple fact that his symptoms do not establish a rating as high as the Veteran desires does not mean it does not include the type of real-world impairment experienced by the Veteran. The fact that he must frequently use the bathroom and avoids long trips does not place his symptomatology outside of that contemplated by the rating schedule, or make application of the rating schedule impracticable in this case. Accordingly, the Board determines that the Veteran’s difficulty due to irritable bowel syndrome has been considered under the criteria set forth in the rating schedule and finds that the schedular rating criteria adequately contemplate his symptomatology. Comparing the Veteran’s current disability level and symptomatology to the Rating Schedule, the degree of the disability before the Board, including the effect on his daily life and impairment of earning capacity, is contemplated by the Rating Schedule and the assigned schedule rating is, therefore, adequate and no referral for an extraschedular rating is required under 38 C.F.R. § 3.321(b)(1). REASONS FOR REMAND Bilateral Hearing Loss In an August 2020 Joint Motion for Partial Remand, it was found that the Board failed to ensure that the duty to assist was satisfied in its prior decision, because January 2017 and June 2018 audiograms were mentioned in the Veteran’s VA treatment records, but had not been obtained. This issue is therefore remanded so that these relevant records can be obtained and reviewed. The Joint Motion for Partial Remand also noted that the Board denied the claim on the basis of no current disability, but the January 2017 VA examination revealed speech recognition levels of 92 percent in the right ear, which could qualify as a disability in that ear pursuant to 38 C.F.R. § 3.385. If it is not clear from the obtained records, the VA audiologist who performed the January 2017 evaluation must be asked to clarify which word list was used for the speech recognition test, in order to determine if the test is sufficient to establish a hearing loss disability under 38 C.F.R. § 3.385. PTSD The Veteran has also requested a rating higher than 30 percent for his service-connected PTSD. The Veteran attended a VA examination with psychologist J.T. in June 2019. He found the Veteran to present normally, and although he had symptoms of depressed mood, anxiety, suspiciousness, sleep impairment, disturbances of motivation and mood, and difficulty with relationships, his overall severity of symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform tasks. This is generally the standard for assigning a 30 percent evaluation. The Veteran last attended a VA examination in September 2019 with VA psychologist V.K. The examiner found that the Veteran had both PTSD and depressive disorder, and that he had impairment in most major areas of functioning, problems with motivation and mood, paranoia, altercations, severe depression, and relationship problems. She concluded that the Veteran had occupational and social impairment with deficiencies in most areas, which is generally the standard for an evaluation of 70 percent. An addendum medical opinion was then requested to reconcile the findings in the 2019 PTSD examinations. The addendum opinion was provided in January 2020 from psychologist M.P. based on review of the Veteran’s 2017 and 2019 VA examinations, the 2019 Disability Benefits Questionnaire. She wrote that the Veteran had no history of inpatient psychiatric treatment, lived at home with a supporting wife, and was employed, with no suicidal ideation or hallucinations. She concluded that the Veteran’s current level of functioning was most consistent with the June 2019 VA examination. While the Board appreciates the attempt to obtain a reconciling medical opinion, it is unclear to the Board how psychologist M.P. could conclude that the June 2019 VA examination was the most accurate, even though she did not interview the Veteran or review his VA treatment records. The September 2019 VA examination was also conducted by a fully qualified VA psychologist, and in fact her evaluation is far more detailed and comprehensive than the June 2019 VA examination. The Board finds that the current severity of the Veteran’s symptoms remains unclear, and a new VA examination should be afforded to the Veteran to address the current severity of his symptoms and provide a retrospective opinion on his overall severity of his symptoms since 2015. The matters are REMANDED for the following action: 1. Obtain all VA treatment records since December 2019, and complete audiological testing results from the Veteran’s VA audio evaluations in January 27, 2017 and June 15, 2018. 2. If the VA audiological testing results from the January 27, 2017 evaluation do not indicate whether the Maryland CNC word list was used for speech recognition testing, contact the audiologist who performed the examination and ask her what word list was used. 3. Schedule the Veteran for an examination with a psychiatrist or psychologist to address the severity of his PTSD and psychiatric symptoms. The examination may be held via telehealth during social distancing restrictions and an opinion can be provided based on other medical evidence of record.  The examiner must be provided access to the Veteran’s entire claims file and must specify in the report that the claims file has been reviewed.   The examiner should perform a complete psychiatric evaluation of the Veteran, including discussion of whether the Veteran has psychiatric symptoms separate from his symptoms from PTSD, and whether these symptoms can be differentiated.   The examiner is also asked to review the Veteran’s past VA examinations, including the February 2017, June 2019, and September 2019 examinations. Why did these examiners come to such different conclusions regarding the severity of the Veteran’s psychiatric disorder? Please discuss the overall severity of the Veteran’s psychiatric symptoms since October 2015. If it is not possible to provide such a retrospective opinion, please explain why. (Continued on the next page) A complete and fully explanatory rationale must be provided for any opinion offered.  If any opinion cannot be rendered without resorting to speculation, the examiner must explain why.  DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mary E. Rude, 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.