Citation Nr: 21008672 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 17-24 913 DATE: February 17, 2021 ORDER The petition to reopen a claim for entitlement to service connection for amputation of the left great toe is granted. The petition to reopen a claim for entitlement to service connection for left foot hammer toe deformity, toes two through five, secondary to amputation of the left great toe is granted. Entitlement to an initial 70 percent rating, but no more, for posttraumatic stress disorder (PTSD), nerve problem, prior to March 16, 2016, is granted. Entitlement to a rating in excess of 70 percent for PTSD, nerve problem, between March 16, 2016 and March 9, 2017, is denied. An initial compensable rating for erectile dysfunction associated with prostate cancer is denied. REMANDED Entitlement to a sleep disability, claimed as sleep apnea, to include as secondary to service-connected PTSD and/or herbicide exposure, is remanded. Entitlement to service connection for a skin disability, to include actinic keratosis and chloracne, to include as due to herbicide agent exposure, is remanded. Entitlement to a total disability rating for individual unemployability due to service-connected disabilities (TDIU) is remanded. Entitlement to SMC based on the need for regular aid and attendance is remanded. Whether the June 1981 administrative decision that determined the Veteran’s gunshot wound injury (GSW) to the left foot was not incurred in the line of duty was final is remanded. Entitlement to service connection for amputation of the left great toe is remanded. Entitlement to service connection for left foot hammer toe deformity, toes two through five, secondary to amputation of the left great toe is remanded. FINDINGS OF FACT 1. A January 1983 Board decision upheld the severance of service connection for amputation of the left great toe. 2. Evidence associated with the claims file subsequent to the January 1983 Board decision was not previously submitted and raises a reasonable possibility of substantiating the claim for service connection for amputation of the left great toe. 3. A November 1980 rating decision denied service connection for hammer toe deformity, toes two through five. 4. The evidence associated with the claims file subsequent to the November 1980 rating decision was not previously submitted and raises a reasonable possibility of substantiating the claim for service connection for left foot hammer toe deformity, secondary to amputation of the left great toe. 5. Prior to March 16, 2016, the Board finds that the Veteran’s PTSD, nerve problem, resulted in occupational and social deficiencies in most areas. 6. For the entire appeal period, prior to March 10, 2017, the Board finds that the Veteran’s PTSD, nerve problem, has not resulted in total occupational and social impairment. 7. The Veteran does not have penile deformity. CONCLUSIONS OF LAW 1. The January 1983 Board decision is final. 38 U.S.C. § 7104; 38 C.F.R. § 20.1100. 2. New and material evidence sufficient to reopen the claim of service connection for amputation of the left great toe has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The November 1980 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 4. New and material evidence sufficient to reopen the claim of service connection for service connection for hammer toe deformity, toes two through five, secondary to amputation of the left great toe, has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. Prior to March 16, 2016, the criteria for an initial rating of 70 percent rating, but no higher, for PTSD, nerve problem, have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 6. Prior to March 10, 2017, the criteria for a rating in excess of 70 percent for PTSD, nerve problem, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, DC 9411. 7. The criteria for an initial compensable rating for erectile dysfunction associated with prostate cancer have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.31, 4.115b, DC 7522. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1968 to February 1972. By way of background, in August 2014 the Veteran filed a claim for service connection for PTSD, sleep apnea and a stomach disability. In a May 2015 rating decision, the RO granted service connection for PTSD, assigning a 50 percent rating, and denied service connection for sleep apnea and the stomach disability. The Veteran filed a timely notice of disagreement with the denials of service connection for sleep apnea and the stomach disability, as well as the initially assigned rating for PTSD. In September 2015 the Veteran filed a supplemental claim to reopen a claim of service connection for a left foot disability, and service connection for a skin disability. In a December 2015 rating decision, the RO denied reopening of the left toe amputation and hammertoes and denied service connection for a skin disability. The Veteran perfected appeals on these issues. The Board also notes that the Veteran has additionally perfected an appeal for the issue of entitlement to an increased rating for service-connected erectile dysfunction stemming from an August 2018 rating decision. This case was initially before the Board in February 2019 when the Board denied reopening the Veteran’s claims for service connection for amputation of the left great toe and for a left foot hammer toe deformity, toes two through five. Claims for entitlement to service connection for obstructive sleep apnea, an intestinal disability and a skin disability were remanded. The Board additionally remanded an increased rating claim for the Veteran’s service-connected PTSD. This case was again before the Board in June 2020, when the Board denied entitlement to restoration of a 100 percent disability for prostate cancer. The Board again remanded entitlement to service connection for obstructive sleep apnea, an intestinal disability and a skin disability. The Veteran’s increased rating claim for the Veteran’s service-connected PTSD was again remanded for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999) The Veteran appealed the February 2019 Board decision to the United States Court of Appeals for Veterans Claims (CAVC). In a June 2020 Memorandum Decision, the CAVC set aside the February 2019 decision and remanded the matter considered herein to the Board to determine whether the claims pertaining to the Veteran’s left foot should be reopened. The Court additionally noted that they were dismissing without prejudice the Veteran’s assertions of CUE in the January 1983 and February 2019 Board decisions. Jurisdiction has been returned to the Board. The Veteran’s claims regarding obstructive sleep apnea, and a skin disability have been returned to the Board following development and issuance of an October 2020 supplemental statement of the case. His claim for an increased rating for PTSD has also been returned. After issuance of a statement of the case, the Veteran timely perfected an appeal for this issue. It is unclear why the RO characterized this issue as one including an earlier effective date. The notice of disagreement and the Board remands in both February 2019 and June 2020 clearly noted that the issue appealed was only with respect to the rating assigned. The Board only addresses the ratings assigned for the Veteran’s service-connected PTSD and will not address whether entitlement to an earlier effective date is warranted. The effective date portion of the claim has not been appealed. Additionally, the Board notes that in June 2020, a claim for entitlement to service connection for a gastrointestinal disability, claimed as a stomach disability, was remanded. In a June 2020 rating decision, the RO granted service connection for irritable bowel syndrome with diverticulosis, claimed as stomach problems. This claim is no longer before the Board. A review of the evidence reflects that the issue of a TDIU has been raised by the record. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a TDIU claim is part of an increased rating claim when such claim is reasonably raised by the record. In light of evidence associated with the Veteran’s claims file during the appeal period, the Board finds that the issue of entitlement to a TDIU is reasonably raised by the record and considered to be part of the Veteran’s appeal. The claim for SMC has also been raised by the record and is addressed in the Remand section below. The Board notes that numerous statements have been submitted regarding allegations of clear and unmistakable error (CUE) in a January 1983 Board decision. The issue of whether the January 1983 Board decision should be reversed on the basis of CUE is the subject of a separate decision under a different docket number. That decision will be sent to the Veteran and his representative under a separate cover at a later date. New and Material Evidence 1. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for amputation of the left great toe. 2. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for left foot hammer toe deformity, toes two through five. The evidence of record in January 1983 consisted of the Veteran’s service treatment records, lay statements from the Veteran, and an in-service June 1968 line of duty determination. The Board denied restoration of service connection for amputation of the left great toe as the evidence showed that the disability was not incurred in the line of duty, and the Veteran was absent without leave (AWOL) at the time of his in-service injury. Evidence received since the Board decision includes additional service personnel records, additional lay statements from the Veteran, and treatment records. In the June 2020 CAVC Memorandum Decision, the Court noted that the Veteran for the first time argued that the Board should have considered whether his AWOL period materially interfered with his performance of military duties. The Court also noted that the Veteran’s arguments now aver that the service records added to the file speak to the question of material interference and raise a reasonable possibility that the AWOL period should not bar him from a finding that his left great toe disability was incurred in the line of duty. Based on the June 2020 CAVC Memorandum Decision, the Board finds that the evidence is new because it was not previously submitted to VA decision makers and it is material because it goes to corroborating an element for service connection, specifically, in-service occurrence. The evidence is sufficient to satisfy the low bar of new and material evidence. The claim for service connection for amputation of the left great toe is reopened. With respect to the claim for entitlement to service connection for hammer toe deformity, toes two through five, evidence of record at the time of the November 1980 rating decision consisted of the Veteran’s service treatment records, lay statements from the Veteran, and private treatment records diagnosing hammertoes. The evidence did not establish an in-service injury or a nexus. Evidence received since the rating decision includes additional treatment records, additional service personnel records, and further lay statements from the Veteran. The Court noted that the Veteran had limited his appeal to the theory that hammertoes as secondary to his left great toe disability. The Board finds that the new and material criteria under 38 C.F.R. § 3.156(a) have been satisfied, and the claim for service connection for hammer toe deformity two through five, secondary to amputation of the left great toe, is reopened. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Board should consider only those factors contained in the rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating 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. The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 3. Entitlement to an initial rating in excess of 50 percent for PTSD, nerve problem, prior to March 16, 2016. 4. Entitlement to an initial rating in excess of 70 percent for PTSD, nerve problem, prior to March 10, 2017. The Veteran’s PTSD, nerve problem, is currently rated as 50 percent disabling prior to March 16, 2016, 70 percent disabling between March 16, 2016 and March 9, 2017, and 100 percent since March 10, 2017, in accordance with the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. The Board will address the Veteran’s rating prior to March 10, 2017, as he is already rated at the highest schedular rating (100 percent) since March 10, 2017. Under Diagnostic Code 9411, a 50 percent rating is warranted when there is occupational and social impairment, but with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, 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 task); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. The maximum rating of 100 percent requires 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; and memory loss for names of close relatives, own occupation, or own name. Id. The specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Thus, the analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The classification outlined in the portion of VA’s Schedule for Rating Disabilities that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-5). 38 C.F.R. § 4.130. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996). Effective August 4, 2014, the DSM-IV was superseded by a new fifth edition that significantly changed diagnostic metrics for mental illnesses. In pertinent part, the DSM-5 eliminated the GAF scores used in the DSM-IV. It was recommended that the GAF be dropped from DSM-5 for several reasons, including its lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. A review of the evidence reflects that a rating of 70 percent is warranted throughout the appeal period, prior to March 10, 2017. In an April 2015 VA examination, it was noted that the Veteran had divorced his first wife and had been married eight times. He reported having some friends and having a good relationship with his wife. He reported not really enjoying socializing or being in crowds. The VA examiner noted that the Veteran’s symptoms included depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. The examiner noted that the Veteran’s mood was dysphoric, and affect was congruent with mood, even tearful at times. His speech was noted to be of normal rate, tone and prosody and thought processes were described as logical and goal directed. He denied suicidal/homicidal ideation and his judgment and insight appeared intact. In an August 2015 statement, the Veteran reported the following mental health symptoms: anger, anxiety, chronic sleep problems, depression, difficulty making decisions, emotional numbing, flashbacks, inability to make and keep friends, inappropriate behavior, intrusive thoughts, isolation, memory loss, nervousness, panic attacks, periods of violence, problems with communication, problems at work, problems getting along with people, suspiciousness, and taking medications for mental conditions. In a statement receive in November 2015, the Veteran reported obsessional rituals where he walks the perimeter of his house and checks the locks on the door. He reported that he is obsessed with security. He reported seeing hallucinations of pictures of GI’s and their families and jewelry like wedding rings and bracelets. He reported that he cannot be around other people and does not talk to other people anymore. He reported that he cannot perform his job if he does not have a business relationship with his clients. He reported telling his customers to shut up and stop asking questions. The Veteran reported chronic depression and taking medication for depression. He stated that a lot of times he takes a walk and just sits in the woods. He stated that he has sat in a chair at his house half the night and does not turn the television on and just looks at the screen. He reported sleep problems and is always tired and fatigued. He stated that he gets angry at people for no reason and without being provoked. He reported slamming doors and getting raging mad at his spouse even though she has not done anything wrong. He reported his only relationships were with his wife. He reported not seeing his children or grandchildren often. He stated that he doesn’t really want to be around anyone else. He stated that he cannot establish and maintain relationships with people. At a March 2016 VA examination, the VA examiner noted that the Veteran’s PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. It was noted that the Veteran remains married to his eighth wife and his marriage is a major source of support. He reported having some contact with his daughter and grandchildren. The Veteran denied social interactions with other people. He reported that in December 2015 he stopped his business completely because he could no longer deal with the public without having emotional outbursts of irritability or anger. Symptoms were noted to include: depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, inability to establish and maintain effective relationships, and impaired impulse control. The examiner noted that the Veteran’s mood was dysphoric, and affect was congruent with mood. His speech was noted to be of normal rate, tone and prosody and thought processes were logical and goal directed. He denied active suicidal/homicidal plan or intent and his judgment/ insight appeared intact. The examiner noted that records who increased impairment in the ability to interact with the public, which also affects his ability to work. He noted that the Veteran had stopped almost all social interaction, except with his wife. Following a review of the evidence, prior to March 10, 2017, to include the statements of the Veteran and treatment records, the Board finds that the Veteran’s PTSD, nerve problem, has been most consistent with a 70 percent disability rating, not the 50 percent disability rating currently assigned (prior to March 16, 2016). Although some treatment records appear to reflect milder psychiatric symptomatology, the majority of the treatment records are most consistent with a 70 percent disability rating. Accordingly, and based on these findings, the Board finds that a 70 percent rating is warranted, throughout the period on appeal, prior to March 10, 2017. Nevertheless, the Board finds that a rating in excess of 70 percent is not warranted for any period during the pendency of the claim, prior to March 10, 2017, as the Veteran’s symptomatology does not manifest as total occupational and social impairment, due to such symptoms as (for example only): 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. Id. The evidence supporting a 100 percent rating was not demonstrated until his March 10, 2017 VA examination which resulted in the 100 percent rating awarded since that date. Prior to March 10, 2017, the Veteran’s reported social functioning has been fairly consistent, with social isolation and some interaction. Thus, while limited, he was still able to continue relationships with some people, including some family members. A rating of 100 percent is only warranted for both total social and total occupational impairment due to his PTSD, nerve problem. The Board concludes the criteria for a 100 percent rating for PTSD, nerve problem, have not been met at any point during the period on appeal, prior to March 10, 2017. 38 C.F.R. § 4.130, DC 9411. His own reports at various evaluations regarding how his PTSD, nerve problem, impacted him, overall, would provide additional evidence against this claim, clearly indicating the level of symptomatology cited within the 100 percent rating were not met prior to March 10, 2017. In summary, while the Veteran was significantly socially limited by his service-connected PTSD, nerve problem, prior to March 10, 2017, the evidence fails to show that his impairment was “total” so as to warrant a 100 percent rating, at any point prior to March 10, 2017. Based on the foregoing discussion, the Board finds that Veteran’s PTSD, nerve problem, more nearly approximates the rating criteria for a 70 percent for the entire appeals period prior to March 10, 2017. As such, a rating of 70 percent is granted prior to March 16, 2016, but a rating in excess of 70 percent is not warranted at any time during the period on appeal prior to March 10, 2017. 5. Entitlement to an initial compensable rating for erectile dysfunction associated with prostate cancer. The Veteran’s erectile dysfunction associated with prostate cancer is assigned a noncompensable rating pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7522. There is no diagnostic code which deals with erectile dysfunction exclusively. Diagnostic Code 7522 concerns penis deformity, with loss of erectile power. Under Diagnostic Code 7522, a 20 percent rating is assigned for deformity of the penis with loss of erectile power. No other disability rating is provided. See 38 C.F.R. § 4.115b, Diagnostic Code 7522. In every instance where the minimum schedular evaluation requires residuals and the schedule does not provide for a zero percent rating, a zero percent rating will be assigned when the required symptomatology is not shown. 38 C.F.R. § 4.31. The Veteran is seeking a compensable initial rating for his service-connected erectile dysfunction. The Board observes that, during the pendency of this appeal, the Veteran was granted special monthly compensation under 38 U.S.C. § 1114(k) due to loss of use of a creative organ. In order for a compensable rating to be assigned under Diagnostic Code 7522, deformity of the penis must be demonstrated. The Veteran underwent a VA examination in November 2015. The Veteran was diagnosed with erectile dysfunction. Although a physical exam was declined, the Veteran reported normal anatomy with no penile deformity or abnormality. The Veteran also reported normal anatomy with no testicular deformity or abnormality and no epididymis deformity or abnormality. Similar findings were reported at March 2017 and June 2018 VA examinations. The Veteran submitted a November 2018 Male Reproductive Organ Conditions Disability Benefits Questionnaire (DBQ). It was noted that the Veteran’s penis, testes, and epididymis were normal. A February 2019 Male Reproductive Organ Conditions DBQ submitted did not include an examination of his penis, testes, and epididymis. The evidence is clear throughout the appeal period that although the Veteran experiences loss of erectile power, there is no deformity of the penis. This is a requirement for a higher, 20 percent rating under Diagnostic Code 7522. Thus, the preponderance of the evidence is against a compensable initial rating for the Veteran’s erectile dysfunction. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against a compensable initial rating for erectile dysfunction, there is no reasonable doubt to be resolved, and the doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. REASONS FOR REMAND Unfortunately, another remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran’s claims so that he is afforded every possible consideration. 1. Entitlement to a sleep disorder, claimed as sleep apnea, to include as secondary to service-connected PTSD and/or herbicide exposure. In a March 2020 VA opinion, it was noted that the Veteran did not have sleep apnea. The Board, in June 2020, once again remanded the Veteran’s claim to provide him with a VA examination and additional opinion. An August 2020 VA examiner provided a negative opinion, based primarily on the fact that the Veteran did not have a diagnosis of obstructive sleep apnea. The August 2020 VA examiner cited a March 2020 private sleep study as reflecting a negative diagnosis of obstructive sleep apnea. However, upon review, the Board notes that although the March 2020 private treatment record noted that clinically significant apnea/hypopnea is not identified in this study, it was noted that the Veteran’s sleep efficiency was somewhat poor during the study. Moreover, at the end of the treatment note, under indications, it notes a diagnosis of obstructive sleep apnea. This discrepancy must be addressed. Additionally, it is noted that the Veteran has reported various sleep issues that may or may not all be categorized under sleep apnea. The Board has broadened the claim to include any sleep disability. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In a statement received September 2015, the Veteran noted that he was requesting a claim for sleep apnea or a sleeping disorder, to include as secondary to his service-connected PTSD. He noted that he has difficulty staying asleep and has nightmares and flashbacks. The Veteran reported being prescribed medications. At this juncture, the Board finds that an additional VA medical opinion is necessary. It is unclear from the evidence whether or not the Veteran has a diagnosis of obstructive sleep apnea. Additionally, the evidence reflects that even if the Veteran does not have a diagnosis of obstructive sleep apnea, he may have another sleep disability. The Board finds that an addendum medical opinion is necessary. Finally, the Board notes that in a November 2015 statement from the Veteran’s primary treating physician, it was noted that the Veteran’s sleep apnea is most likely caused by his exposure to Agent Orange. Rationale was not provided. An opinion regarding this contention, that his sleep apnea may be related to his conceded herbicide exposure, has not yet been provided. 2. Entitlement to service connection for a skin disability, to include actinic keratosis and chloracne, to include as due to herbicide agent exposure. In the June 2020 BVA remand, the Board noted that a March 2020 VA examination was inadequate and did not substantially comply with February 2019 remand directives. The Board finds that the VA opinion of August 2020 once again fails to adequately address the questions posed by the Board. This negative etiological opinion did not provide sufficient rationale and the claim must be remanded again for an additional addendum opinion. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998). Additionally, an October 2020 statement from the Veteran reflects that there may be outstanding dermatological VA treatment records that need to be obtained. 3. Entitlement to a TDIU. 4. Entitlement to SMC based on the need for regular aid and attendance. The record reflects that the Veteran has already been awarded a TDIU between February 5, 2016 and February 15, 2016. The most recent code sheet of record (dated June 27, 2020) reflects that the Veteran is at a combined 100 percent disability rating beginning on February 15, 2016, and he is individually rated at 100 percent for his PTSD beginning March 10, 2017. The Court has held that a claim for TDIU is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. Here, the record reflects numerous statements by the Veteran that his service-connected disabilities affect his employability. As noted above, the Veteran has now been granted a 70 percent disability rating for his PTSD beginning August 27, 2014. While the Veteran is in receipt of a 100 percent schedular disability since March 10, 2017 (due to his PTSD) and at a 100% schedular combined rating since February 15, 2016 (due to combined disabilities), the issue remains on appeal as the appeal period begins August 27, 2014. The Board notes that the grant of the increased rating above affects the Veteran’s claim for entitlement to TDIU prior to February 5, 2016. Additionally, the remand of several service connection claims may affect his claim. As such, the Board finds that the claim is inextricably intertwined with the remanded claims. Additionally, the Board notes that a SMC claim is also part and parcel of an increased rating claim, when such a claim is raised by the record. See Akles v. Derwinski, 1 Vet. App. 118 (1991); see also Bradley v. Peake, 22 Vet. App. 280 (2008) (stating that SMC benefits are to be accorded when a veteran becomes eligible without need for a separate claim). The Board has considered a December 2019 statement from the Veteran’s attorney. The Board finds that a claim for SMC pursuant to 38 U.S.C. § 1114 is raised by the record (prior to February 15, 2016) and is thus properly before the Board. The Veteran has already been awarded SMC pursuant to 38 U.S.C. § 1114 since February 15, 2016. The Board notes that the claim for entitlement to SMC under the provisions of 38 U.S.C. § 1114 is inextricably intertwined with the remanded claims. 5. Whether the June 1981 administrative decision that determined the Veteran’s gunshot wound injury to the left foot was not incurred in the line of duty was final. 6. Entitlement to service connection for amputation of the left great toe. 7. Entitlement to service connection for left foot hammer toe deformity, toes two through five, secondary to amputation of the left great toe. In June 1981, an administrative decision was issued which found that the Veteran’s injury of the left foot, secondary to a gunshot wound, incurred on June 19, 1968 was not incurred in the line of duty. It was noted that the Veteran was absent without leave (AWOL) at the time of the accident and the injury was not considered to have been incurred in the line of duty. In a statement received in October 1981, the Veteran disputed that he was AWOL at the time of the accident. The Board interprets this statement as a notice of disagreement (NOD) to the determination made in the administrative decision dated June 1981. 38 C.F.R. § 19.118 (1981). There is no indication that a statement of the case (SOC) has been issued to the Veteran addressing this claim. The Court has held that where a NOD has been filed with regard to an issue, and a SOC has not been issued, the appropriate Board action is to remand the issue to the RO for issuance of a SOC. Manlincon v. West, 12 Vet. App. 238 (1999). This must be accomplished on remand. The claims for entitlement to service connection for amputation of the left great toe and entitlement to service connection for left foot hammer toe deformity, toes two through five, secondary to amputation of the left great toe are inextricably intertwined with the issue of whether the June 1981 administrative decision is final. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1990) (issues are inextricably intertwined when they are so closely tied together that a final Board decision cannot be rendered unless all are adjudicated). The matters are REMANDED for the following actions: 1. Obtain all outstanding dermatological records from the Tennessee Valley Healthcare System. 2. Forward the Veteran’s claims folder to an examiner(s) for an addendum opinion regarding the Veteran’s sleep disability and skin disability. The examiner is requested to review the claims folder, to include this remand. If further examination of the Veteran is found to be necessary, such should be arranged. Following review of the claims file the examiner should provide an opinion on the following: Sleep Disability (a) The examiner must first provide an opinion as to whether there is objective evidence that the Veteran suffers from obstructive sleep apnea. The discrepancy in the March 2020 private examination must be addressed. (b) If the examiner determines that the clinical evidence does not support a diagnosis of obstructive sleep apnea, the examiner should list all diagnosed sleep disabilities, and specifically state whether it is at least as likely as not (a 50 percent probability of greater) that any diagnosed sleep disability, either began during or was otherwise caused by the Veteran’s military service, to include his presumed herbicide exposure. (c) Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s sleep disability was caused by his service-connected PTSD. (d) Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s sleep disability was aggravated by his service-connected PTSD. Skin Disability (e) Whether it is at least as likely as not (a probability of 50 percent or greater) that any skin disability, however diagnosed, had its onset in service or is otherwise medically related to in-service injury or disease, to include presumed herbicide exposure. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. After completing any other development deemed necessary, readjudicate the issues currently on appeal with consideration of all applicable laws and regulations. If any benefit sought on appeal remains denied, issue the Veteran and his attorney a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. 4. Provide the Veteran a statement of the case with respect to the issue of whether the June 1981 administrative decision that determined the Veteran’s gunshot wound injury to the left foot was not incurred in the line of duty was final. The Veteran should be informed of the actions necessary to perfect an appeal on this issue. (Continued on the next page)   Thereafter, this issue is to be returned to the Board only if an adequate and timely substantive appeal is filed. C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. M. Clark, 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.