Citation Nr: 21008603 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 17-25 017 DATE: February 17, 2021 ORDER The appeal for a compensable initial rating for migraine headaches, for the time period prior to February 6, 2017, is denied. A rating of 50 percent, but no higher, for migraine headaches from February 6, 2017, is granted, subject to the laws and regulations governing payment of monetary benefits. Service connection for bruxism (claimed as a dental disorder) is granted. REMANDED The appeal for a compensable, initial rating for bilateral hearing loss, is remanded. The appeal for service connection for a skin disorder is remanded. The appeal for service connection for a left elbow disorder is remanded. The appeal for service connection for a right knee disorder is remanded. The appeal for service connection for a sleep disorder, to include insomnia and sleep apnea, is remanded. The appeal for entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to February 6, 2017, the preponderance of the evidence demonstrates that the Veteran’s service-connected migraine headaches were not manifested by characteristic prostrating attacks. 2. From February 6, 2017, to the present, the Veteran’s service-connected migraine headaches mere manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 3. Bruxism had its onset while on active duty service. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating prior to February 6, 2017, for service-connected migraine headaches are not met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8100 (2020). 2. From February 6, 2017, the criteria for a 50 percent disability rating for service-connected migraine headaches are met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8100 (2020). 3. The criteria for entitlement to service connection bruxism are met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1979 to September 1979 and from February 2012 to January 2013. The Veteran appeared before the undersigned Veterans Law Judge during a videoconference hearing in September 2020. A transcript of the proceeding is of record. The Veteran is represented in this case pursuant to 38 C.F.R. § 14.630. This provision allows for representation by an individual unaccredited by VA for one time only. The Veteran completed the necessary requirements with the filing of a VA Form 21-22a in August 2020, signed by him and the representative, stating that no compensation would be paid or charged for the services. 38 C.F.R. § 14.630(a). With respect to the Veteran’s dental claim, the Board notes that a claim for service connection for a dental disability is considered to be both a claim for compensation and a claim for dental treatment. See Mays v. Brown, 5 Vet. App. 302 (1993). The Veteran testified that he desired dental health treatment through VA in addition to any compensation available. The compensation claim has been adjudicated by the agency of original jurisdiction (AOJ), appealed to the Board, and will be discussed on the merits below. Review of the record indicates that the AOJ referred the Veteran’s request for dental treatment to the VA medical facility near him, but there is no indication that adjudication of that matter has taken place. See June 17, 2015 correspondence to the Veteran. The Board therefore does not have jurisdiction over the Veteran’s request for dental health treatment at this time. The Veteran and his representative are encouraged to follow up with the AOJ for status updates on this referral. Additionally, during the hearing before the Board, the Veteran indicated that he desired a decision addressing a left shoulder claim. The Board notes that in a December 2015 rating decision, the AOJ granted the Veteran’s service-connection claim for his left shoulder disorder. The Veteran did not file a notice of disagreement with respect to the assigned initial disability rating or effective date of the award of service connection for the same. Therefore, there is no question currently before the Board regarding the Veteran’s left shoulder disorder. If the Veteran wishes to file a claim for an increased rating for his service-connected left shoulder disability, he may do so on a form prescribed by the Secretary. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). As in the instant case, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. Id. at 126. Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Historically, service connection for migraine headaches was established in the December 2015 rating decision on appeal, at which time the AOJ assigned a noncompensable initial disability rating pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100, effective May 1, 2015. During the pendency of the appeal, the disability rating was increased to 30 percent, effective February 6, 2017. A 10 percent evaluation is warranted for migraines with characteristic prostrating attacks occurring on an averaging one in 2 months over the last several months. A 30 percent evaluation is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months; and a 50 percent evaluation is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. A 50 percent rating is the maximum rating available under Diagnostic Code 8100. The Rating Schedule does not define “prostrating.” “Prostration” has been defined as “complete physical or mental exhaustion.” MERRIAM-WEBSTER’S NEW COLLEGIATE DICTIONARY 999 (11th ed. 2007). “Prostration” has also been defined as “extreme exhaustion or powerlessness.” DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st ed. 2007). According to Stedman’s Medical Dictionary, 27th Edition (2000), p. 1461, “prostration” is defined as “a marked loss of strength, as in exhaustion.” See Eady v. Shinseki, No. 11-3223, 2013 WL 500460 (Vet. App. Feb. 12, 2013) (The Board adopts the Court’s definition as its own.). Additionally, the terms “productive of severe economic adaptability” have not been clearly defined by regulations or by case law. The United States Court of Appeals for Veteran’s Claims (Court) has noted that “productive of” can either have the meaning of “producing” or “capable of producing.” Pierce v. Principi, 18 Vet. App. 440, 445 (2004). Thus, migraines need not actually “produce” severe economic inadaptability to warrant the 50 percent rating. Id. at 445-46. Further, “economic inadaptability” does not mean unemployability, as such would undermine the purpose of regulations pertaining to a total disability rating based on individual unemployability. Id. at 446; see also 38 C.F.R. § 4.16. The Board notes, however, that the migraines must be, at minimum capable of producing “severe” economic inadaptability. 1. Entitlement to a compensable, initial rating for migraine headaches prior to February 6, 2017. The Veteran was provided with a VA examination in December 2015. At that time, the examiner noted that the Veteran had been diagnosed with migraine headaches and that they began during service. The Veteran reported that the headaches were located frontally with a throbbing, 7-8 out of 10 pain level. The Veteran reported that they were not associated with aura, nausea, or phonophobia but that there was occasional photophobia. He reported that he took medication for treatment as needed. The Veteran reported that his head pain typically lasted less than a day. The Veteran denied any prostrating attacks of migraine headache pain. As discussed below, the Veteran has disputed the February 2017 VA examiner’s notation regarding the frequency of prostrating attacks; however, the Veteran has not disputed the findings of the December 2015 VA examination report. VA treatment records do not indicate worse findings than those described during the December 2015 VA examination. Based on the foregoing, a compensable rating is not warranted prior to February 6, 2017. 2. Entitlement to a rating greater than 30 percent for migraine headaches from February 6, 2017. During the pendency of the appeal, the rating was increased to 30 percent, effective February 6, 2017. See March 2017 rating decision. The increased rating was based upon the results of a February 2017 VA examination which addressed the severity of the Veteran’s migraine headache disorder. The examiner noted the Veteran’s symptoms of pulsating or throbbing head pain, pain on both sides of the head, and nausea, sensitivity to light and sound as well as changes in vision that occurred with the headaches. The Veteran reported that the typical head pain lasted more than two days. Regarding the frequency of the attacks, the examiner was offered the choice to select whether the prostrating attacks occurred once in two months or once every month, or less frequently. The examiner indicated that the attacks occurred once every month. The examiner also indicated that the Veteran did not have very prostrating and prolonged attacks productive of severe economic inadaptability. In the May 2017 Substantive Appeal Form 9, the Veteran reported that the February 2017 VA examination report which noted that he had prostrating attacks once per month, was false and that he actually averaged three to four prostrating attacks per week, sometimes as many as five prostrating attacks per week. Because the examination form did not contain an option for the examiner to indicate attacks that were more frequent than once per month, but perhaps less frequent than “very frequent productive of severe economic inadaptability”, the Board resolves doubt and finds that during this period, the Veteran experienced prostrating attacks three to four times per week on average, with some weeks having five prostrating attacks. During the hearing before the Board, the Veteran reported migraines that occurred once per day and lasted off and on all day. He indicated that at their worst, he would leave work and go home and lie down in a dark place until the headache stopped. Transcript page 19. He also reported that sometimes he would be out of work for a few days depending on the severity of the headaches. He reported that he was ultimately terminated from his job in March 2020. Transcript page 21. He also reported that he believes his headache disability kept him from staying employed. Transcript page 14. Given the Veteran’s sworn testimony that when such attacks occurred, the Veteran had to leave work and go home to rest, the Board resolves doubt and finds that the Veteran had very prostrating and prolonged attacks productive of severe economic inadaptability. As such, the Board finds that a 50 percent rating, but no higher, for migraine headaches, is warranted for the period from February 6, 2017. The 50 percent rating is the maximum schedular rating available under that diagnostic code, and there are no other diagnostic codes that are applicable for rating the Veteran’s service-connected migraine headaches. In sum, the Board finds that a 50 percent rating, from February 6, 2017 to the present, is warranted under Diagnostic Code 8100 for the Veteran’s service-connected migraine headaches. However, the Board finds that the preponderance of the evidence is against an initial compensable rating prior to February 6, 2017. The Board has resolved doubt where necessary but as the preponderance of the evidence is against higher ratings than those noted herein, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. Service Connection Entitlement to service connection for a disorder affecting the Veteran’s teeth, to include bruxism. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. During the pendency of this appeal, a Final Rule prohibiting bruxism as a stand-alone disability was issued in August 2017 and became effective on September 10, 2017. See 82 Fed. Reg. 36080, 36081 (Aug. 3, 2017). The U.S. Supreme Court has held that statutes generally may not be construed to have retroactive effect unless their language requires that result. See Landgraf v. USI Film Products, 511 U.S. 244 (1994) (holding that statutes generally may not be construed to have retroactive effect unless their language requires that result). Although the discussion in Landgraf referred primarily to statutes, the presumption of non-retroactivity applies equally to regulations. See Regions Hosp. v. Shalala, 522 U.S. 448, 456 (1998); see also Vet. Aff. Op. Gen. Couns. Prec. 7-2003, VAOPGCPREC 7-2003, 2003 (holding that “Statutes and regulations... are presumed not to apply in any manner that would produce genuinely retroactive effects, unless the statute or regulation itself provides for such retroactivity.”). In other words, prospectivity is the default rule with respect to changes in statutes and regulations. In this case, the appeal for service connection for a disorder involving the Veteran’s teeth, including bruxism, was pending and certified to the Board prior to the September 10, 2017 effective date of the regulation change, so the new regulatory bar against bruxism does not apply to this Veteran’s claim. Turning to the evidence, it is undisputed that the Veteran has a current bruxism disability, which was diagnosed in February 2013. See September 2018 private disability benefits questionnaire (DBQ) authored by Dr. K.V. Dr. K.V. noted that her dental practice group had treated the Veteran for years prior to his deployment and that his teeth were in excellent condition prior to his deployment to Afghanistan. Dr. K.V. noted that after the Veteran’s deployment, the Veteran had several fractured teeth that either resulted from damage during deployment or bruxism secondary to posttraumatic stress disorder (PTSD). Service connection is already in effect for the Veteran’s PTSD. There is no indication of an injury to the teeth during service; however, service treatment records show that in October 2014, a service dentist noted that the Veteran had fractured teeth which required full coverage crowns to prevent further fractures and recommended that the Veteran wear an occlusal guard to protect teeth against damage caused by clenching or grinding. Bruxism is defined in Dorland’s Illustrated Medical Dictionary as “involuntary, nonfunctional, rhythmic or spasmodic gnashing, grinding, and clenching of teeth (not including chewing movements of the mandible), usually during sleep, sometimes leading to occlusal trauma.” See Dorland’s Illustrated Medical Dictionary, 257 (32nd ed. 2012). The Board finds no reason to question the favorable evidence of record, which indicates that it is at least as likely as not that the Veteran’s bruxism began during service. Accordingly, entitlement to service connection for bruxism is granted based on in-service incurrence under the provisions of 38 C.F.R. § 3.303(a). REASONS FOR REMAND 1. Entitlement to a compensable, initial rating for hearing loss. The Veteran has indicated that prior VA examinations regarding hearing loss may not have resulted in accurate results because the Veteran just did what the technicians told him to do. He has also reported that his hearing has gotten progressively worse since the last examination. For these reasons, the Board finds that the Veteran should be provided a more contemporaneous VA examination to ensure that the record includes sufficient medical evidence to properly evaluate the disability under consideration. See 38 C.F.R. § 5103A; 38 C.F.R. § 3.159; Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). See also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide a veteran with a thorough and contemporaneous medical examination). On remand, the examiner should also review the prior examination reports and indicate whether such reports appear to be accurate representations of the Veteran’s hearing loss disability. 2. Entitlement to service connection for a skin disorder. The Veteran was provided with a VA examination in November 2015 to address his claimed skin disorder. At that time, the VA examiner found that the Veteran did not have a current diagnosis of a skin disorder and thus, did not answer the question of whether any skin disorder was related to service. Since that time, the Veteran submitted a letter from his private, treating dermatologist, Dr. M.H., dated in December 2020, which noted the following skin disorders present during the pendency of the claim: lentigines, nevi, hemangiomas, herpes simplex on his lip, epidermal inclusion cyst on right upper back, basal cell carcinoma on left upper back, seborrheic keratoses, intertrigo, tinea pedis, and hyphae on the feet. The private dermatologist noted that the Veteran had been treated for skin rashes and other symptoms during service. Dr. M.H. noted that the Veteran’s diagnoses are common for men of the Veteran’s age but that it is also possible that his conditions are directly related to the Veteran’s military service and exposure to chemical and biological contaminants while deployed to Afghanistan. As the private dermatologist’s letter demonstrates that the Veteran has current skin disorders and provides an indication that the Veteran’s skin disorders may be related to service, an addendum VA opinion is required. 3. Entitlement to service connection for a left elbow disorder. The Veteran has complained of current left elbow symptoms. In fact, he offered sworn testimony that he cannot lay his elbow on a table and that it feels almost like it is cracked. Transcript page 51. Pain resulting in functional impairment may satisfy the requirement for a current disability in certain circumstances. The United States Court of Appeals for the Federal Circuit held that pain alone, even in the absence of a diagnosis or underlying pathology, can establish a current disability under 38 U.S.C. § 1110 if it results in functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The Veteran has offered testimony that he believes his current left elbow complaints are due to wear and tear during service, to include flying in medical helicopters that did not have seats and performing hoist missions where he would come down a hoist line to rescue someone and cut himself loose, landing on the ground. Transcript pages 53-55. The Veteran’s October 2014 service report of medical history also notes complaints of swollen or painful joints. VA treatment records document the Veteran’s report of pain in both elbows for years in service. See February 2016 VA treatment record. The Veteran’s October 2014 service report of medical history also notes complains of swollen or painful joints. To date, the Veteran has not been provided with a VA examination to address any disorder of the left elbow. As there is an indication of a current disability that may be related to service, a VA examination is required. 4. Entitlement to service connection for a right knee disorder. The Veteran has not been provided with a VA examination specific to the right knee. In December 2015, he was provided with an examination for the left knee disorder, for which service connection was subsequently granted. The December 2015 VA examination report diagnosed a right knee strain but only addressed the left knee in the etiology opinion. VA treatment records document the Veteran’s report of pain in both knees for years in service. See February 2016 VA treatment record. The Veteran’s October 2014 service report of medical history also notes complaints of knee trouble and swollen or painful joints. The Veteran has offered sworn testimony that his joint complaints are due to wear and tear during service, to include flying in medical helicopters and performing hoist missions where he would come down a hoist line to rescue someone and cut himself loose, landing on the ground. Transcript pages 53-55. As the December 2015 VA examination report did not address the etiology of the Veteran’s right knee disorder, and there is an indication that the right knee disorder may be related to service, a remand is required. 5. Entitlement to service connection for a sleep disorder. As an initial matter, the December 2015 rating decision only addressed the claim as it pertained to sleep apnea. However, during the hearing before the Board, the Veteran clarified that he actually sought service connection for a broader sleep disorder. Transcript page 65. Service treatment records dated in December 2012 noted that the Veteran had insomnia and was prescribed medication to treat the same but was only getting three to four hours of sleep per night. An October 2013 private treatment record indicated that the Veteran’s psychiatric disorders resulted in difficulty sleeping. The Veteran asserts that he has a separate sleep disorder caused by his psychiatric disorder or otherwise related to service. Service connection is in effect for PTSD. The Veteran reported to VA in a June 2015 statement in support of the claim for PTSD, that he had an inability to sleep. The December 2015 VA psychiatric examiner included chronic sleep impairment in the list of PTSD symptoms but did not provide any remarks or explanation addressing the Veteran’s assertion that he has a stand-alone sleep disorder apart from his psychiatric disorder. As no VA opinion has been obtained with respect to whether the Veteran has a stand-alone sleep disorder related to service or service-connected disability, a remand is necessary to adequately evaluate the claim. The Board acknowledges that the claim for sleep apnea was denied, in part, because the Veteran failed to attend a VA examination or provide good cause for such failure. However, as the Veteran has clarified that his claim was not specifically for sleep apnea, and he has assured the Board that he is interested in attending a VA examination to address his sleep disorder claim, the Board is satisfied that the Veteran should be provided with an opportunity for a VA examination. 6. Entitlement to a TDIU. During the September 2020 hearing before the Board, the Veteran reported that he had lost his job due to his service-connected disabilities. Moreover, he indicated that he was unemployable due to his service-connected disabilities. See Transcript page 15. Thus, the Board finds that the issue of entitlement to a TDIU has been raised by the record and is part and parcel of the claims for increased ratings. The AOJ has not yet addressed the TDIU claim. As such, the claim for TDIU should be adjudicated by the AOJ on remand. Roberson v. Shinseki, 251 F.3d 1378, 1384 (Fed. Cir. 2001) (“Once a veteran submits evidence of a medical disability and makes a claim for the highest rating possible, and additionally submits evidence of unemployability... VA must consider TDIU.”); see also Rice v. Shinseki, 22 Vet. App. 447, 453 (2009); see 38 C.F.R. § 4.16 (a) (explaining that TDIU may be assigned when a veteran is “unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities”). While on remand, any outstanding VA treatment records should also be obtained. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records dated since April 2017. 2. Afford the Veteran a VA examination to evaluate the current severity of his bilateral hearing loss. The electronic claims folder and a copy of this remand must be made available to the examiner in conjunction with the opinion and/or examination. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner should assess the current severity of the Veteran’s right and left ear hearing loss and discuss the functional impairment of the Veteran’s bilateral hearing loss. The examiner is also asked to consider the Veteran’s sworn testimony that during prior hearing tests, the Veteran did what technicians told him to do, and address whether prior VA audiological evaluations are adequate representations of the severity of the Veteran’s hearing loss. 3. Afford the Veteran a VA examination to address the etiology of his skin disorder(s). The examiner should review the electronic claims file, and the report of examination should include discussion of the Veteran’s documented history and assertions. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner is asked to address the following: a.) Identify all current skin disorders. Consider the diagnoses identified by the Veteran’s private dermatologist, including lentigines, nevi, hemangiomas, herpes simplex on his lip, epidermal inclusion cyst on right upper back, basal cell carcinoma on left upper back, seborrheic keratoses, intertrigo, tinea pedis, and hyphae on the feet. b.) Please determine whether it is it at least as likely as not (i.e., there is a 50 percent or greater probability) that any identified disorder had onset in, or is otherwise related to, service? Consider and address the Veteran’s assertion that he had hazardous biological and chemical exposures during his deployment to Afghanistan. Please also consider and address the Veteran’s contention that his skin problems may be due to exposure to radiofrequency (RF) radiation. Complete rationale is required for any opinion rendered. 4. Afford the Veteran a VA examination to address the etiology of his left elbow disorder. The examiner should review the electronic claims file, and the report of examination should include discussion of the Veteran’s documented history and assertions. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner is asked to address the following: (a.) Identify all current left elbow disorders. The examiner is reminded that the requirement for a current disability is met if the Veteran’s joint pain results in functional impairment, as here where the Veteran reported that he could not sit with elbows on the table due to pain. (b.) For each disorder identified, is it at least as likely as not (i.e., there is a 50 percent or greater probability) that the disorder had onset in, or is otherwise related to, service? (c.) Complete rationale is required for any opinion rendered. 5. Afford the Veteran a VA examination to address the etiology of his right knee disorder. The examiner should review the electronic claims file, and the report of examination should include discussion of the Veteran’s documented history and assertions. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner is asked to address the following: (a.) Identify all right knee disorders. Consider the December 2015 VA examiner’s diagnosis of a right knee strain. (b.) For each disorder identified, is it at least as likely as not (i.e., there is a 50 percent or greater probability) that the disorder had onset in, or is otherwise related to, service? (c.) Complete rationale is required for any opinion rendered. 6. Afford the Veteran a VA examination to address the etiology of his claimed sleep disorder. The examiner should review the electronic claims file, and the report of examination should include discussion of the Veteran’s documented history and assertions. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner is asked to address the following: (a.) Identify all sleep disorders. The examiner should indicate whether the Veteran’s difficulty sleeping is a symptom of his psychiatric disorder, or a stand-alone disorder. (b.) For each stand-alone sleep disorder identified, is it at least as likely as not (i.e., there is a 50 percent or greater probability) that the disorder had onset in, or is otherwise related to, service? (c.) If any stand-alone sleep disorder is less likely than not directly related to service, is it at least as likely as not (i.e., there is a 50 percent or greater probability) that the disorder was caused or aggravated by the Veteran’s service-connected PTSD? Complete rationale is required for any opinion rendered. 7. Then, readjudicate the issues on appeal, to include entitlement to a TDIU. If the benefits sought remain denied, in whole or in part, send the Veteran and his representative a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Donna D. Ebaugh, 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.