Citation Nr: 21010426 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 16-15 315A DATE: February 24, 2021 ORDER Entitlement to an initial rating in excess of 70 percent prior to September 4, 2020 is granted and a rating in excess of 70 percent during the entire course of the appeal for posttraumatic stress disorder (PTSD) is denied. Entitlement to an initial rating in excess of 20 percent for right shoulder rotator cuff tendonitis is denied. REMANDED Entitlement to service connection for insomnia is remanded. FINDINGS OF FACTS 1. Throughout the appeal period, the severity, frequency, and duration of the Veteran’s symptoms more closely approximate occupational and social impairment with deficiencies in most areas. Total and occupational social impairment was not shown. 2. The right shoulder disability, at worst, is manifested by range of motion during flares limited to 55 degrees in flexion and abduction; with symptoms of weakness, stiffness, fatigability, occasional locking and popping, constant soreness, guarding of movement, tenderness, painful motion in active and passive motion, lack of endurance after repetitive use, giving way, and effusion. There was no ankylosis or impairment of the humerus. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for a rating in excess of 20 percent for a right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1977 to June 1997. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision. This matter was remanded for additional development in July 2018. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2019). The 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 (2019). 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 (2019). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3 (2019). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2019). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev'd in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). 1. Entitlement to an initial rating in excess of 30 percent prior to September 4, 2020 and in excess of 70 percent thereafter for PTSD The Veteran's PTSD has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under that diagnostic code, a 30 percent rating will be assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating for PTSD will be assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, due to such symptoms as: suicidal ideations; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and the inability to establish and maintain effective relationships. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. However, the symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). "[A] veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The symptoms shall have caused occupational and social impairment in most of the referenced areas. Vazquez-Claudio, 713 F.3d 112. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126. In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126. A June 2013 private treatment letter shows that the Veteran had a history of nervous problems. The Veteran was assessed with sleeping impairments, hypervigilance, irritant, and anxiousness. Private psychiatric treatment notes from numerous sessions in 2014 shows that the Veteran was assessed at various instances with panic attacks with great distress, thoughts of killing himself but would not carry the thoughts out, auditory hallucinations, and anxiety. A June 2014 Certification of Health Care Provider Form for the Veteran’s employer showed that a private psychologist completed the form noting that the psychiatric condition would require treatment and absence from work. An October 2014 private psychiatric assessment report noted that the Veteran was oriented to time, place, and person. He was cooperative, calm, and followed instructions. His mood was noted as appropriate and consistent. Suicidal thoughts or perceptual disturbances were discarded. The Veteran was noted to live with his wife and both of his children. He reported having good relationships in his life, but had authority figure issues. The Veteran was noted to have a history of emotional disturbances and PTSD with delayed expression, panic attacks, and major depressive disorder. The Veteran described himself as a hermit who did not want to go out and big places produced anxiety and he would then have to leave. The Veteran was prescribed medication to treat his psychiatric disability. A February 2015 VA psychiatric initial evaluation note shows that Veteran had been receiving private psychiatric treatment since 2013 for increasing levels of anxiety and depression. The Veteran reported difficulty sleeping and significant weight loss with loss of libido. He reported becoming more isolated and withdrawn, which had led him to barely leave his home. The Veteran also reported symptoms of anxiety with palpitations, chest tightness, and feeling disoriented. The Veteran denied ever experiencing suicidal nor homicidal ideas. He denied ever making a suicidal attempt. He did admit that at some point while under extreme anxiety at work he felt 'like he was being watched, persecuted" No active delusional thoughts were elicited during the evaluation. He denied experiencing perceptual disturbances, current or past symptoms suggestive of mania. Mental health status examination showed anxious mood and intrusive distressing recall/memories. An August 2016 private psychiatric examination report shows that the Veteran reported panic and depression which caused him to lose 40 pounds over the last several weeks. He reported not sleeping, irritability, and poor tolerance. The Veteran reported that his depression affected his daily life, and he was not as active as before and anxiety had continued. Suicidal or homicidal ideations were denied. Mental status examination showed that the Veteran maintained eye contact; speech was logical and coherent; affect was normal; mood of anxiety, worries, and sadness; orientation was to all spheres; difficulty in immediate and recent memory was noted; judgement and insight were normal. The Veteran was diagnosed with depression and PTSD. The private examiner noted that the Veteran was receiving active and regular treatment for his psychiatric disability. VA treatment records shows that the Veteran was admitted and hospitalized from May 1, 2017 to May 5, 2017, and from June 2, 2017 to June 16, 2017 due to his major depressive disorder and PTSD in a VA treatment facility. A May 2017 VA mental health treatment note shows he admitted to psychiatric ward due to exacerbation of depressive symptoms and high levels of anxiety. He also admitted to death wishes without suicidal ideation. A July 2019 VA mental health treatment note shows the Veteran presented stable mood at baseline and actively coping. Main clinical presentation were related to low motivation, energy, isolation, and diminished interest in pleasurable activities. Veteran presented with a good support system. The Veteran was noted to experience chronic symptoms, but is currently stable and showing some efficacy in managing thoughts, feelings and behavior related to the psychiatric disability. Veteran would likely benefit from continued mental health services to maintain stabilization, prevent deterioration, and to work towards increasing the overall quality of life. A September 2019 VA mental health treatment record shows that the Veteran continued with loss of interest in activities and low energy, persistent anxiety; although he continued enjoying of outings with his wife and children. A May 2020 lay statement from the Veteran’s spouse reports that the Veteran has experienced extreme anxiety, depression, and paranoia. She also reported that the family would go to church but the Veteran would leave in the middle of services due to panic attacks. She also reported that he had an estranged relationship with his son due to a violent outburst committed by the Veteran. A September 2020 VA PTSD examination report shows that the Veteran was assessed with total occupational and social impairment due to PTSD. The Veteran reported that his relationship with his wife was well, but that he was distant with his kids. He did not socialize with his kids or anyone else. H reported texting his children, and was irritable and moody. He reported that he had to be careful of what he said or did. The Veteran reported that he did not belong to any clubs or organizations. The Veteran reported that he did participate in church functions and activities. His support system was his wife and daughter. He reported enjoying watching TV and wished he could go to the beach. The examiner noted PTSD symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss; disturbances of motivation and mood; difficulty in adapting to stressful circumstances, including work or work like settings; and impaired impulse control. Behavior observations were noted as normal appearance; speech was normal; psychomotor activity was normal; dysthymic and affect were congruent; thought process was linear, logical, and goal-directed; no indications of derailment or any bizarre behavior; no suicidal or homicidal thoughts; auditory/visual hallucinations were absent; no delusions or paranoia were assessed; no obsessions or compulsions noted; insight and judgment was adequate; sufficient impulse control demonstrated but poor from subjective report; orientation to all three spheres; recent and remote memories appeared to be remote; some difficulties were reported related to impulse episodes. Prior to September 4, 2020, the evidence of record, to include the lay statements, private treatment records, VA treatment records, and VA examination reports, support an initial rating of 70 percent for the Veteran's PTSD. During this period the evidence shows that the Veteran's service-connected PTSD caused symptoms of depression and anxiety; sleep impairments; panic attacks; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances. Additionally, symptoms of anxiety and depression were noted to have caused impairment with his relationships with his immediate family members, and increased social isolation except from his spouse, and daughter. While the Veteran still maintained some limited participation in church activities, no other hobbies or interest were reported, and he barely left his home. The Board finds that collectively, these symptoms are indicative of occupational and social impairment with deficiencies in most areas, to include family relations, judgment, thinking, and mood. There were also suicidal thoughts. The presence or absence of certain symptoms is not necessarily determinative. Those symptoms must ultimately result in the occupational and social impairment in the referenced areas. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The treatment records, private examination reports, and VA examination reports were indicative of occupational and social impairment that approximated the criteria for a 70 percent rating. The findings of the private examiner demonstrated that the Veteran had occupational and social impairment with deficiencies in most areas, such as work. Therefore, the Board finds that an initial rating of 70 percent during the appeal period is warranted. The Board finds that the Veteran is not entitled to a 100 percent rating at any time during the course as the evidence does not indicate that the Veteran experienced total social and occupational impairment. While the Veteran was more isolated and estranged from most of his family, he still resided near his spouse and daughter who were noted to be his support system. Additionally, while limited, he was still able to participate in some church activities, which is evidence that showed he is not totally socially impaired. The Veteran also did not report persistent delusions or hallucinations. There was no evidence of grossly inappropriate behavior and the Veteran continued to maintain good hygiene and grooming. The Veteran denied disorientation to time or place, or memory loss for names of close relatives, own occupation, or name. While the Veteran did admit some thoughts of ending his own life, he reported that he would never follow through with those thoughts. The Board notes that the September 2020 VA examiner reported that the Veteran’s psychiatric disability caused total social and occupational impairment, however, as noted above, he still maintains social connections with his spouse and daughter and participates in church activities outside the home. In fact, the September 2020 VA examiner noted these instances that indicated the Veteran was not totally socially impaired. As the Veteran is not experiencing total impairment of social relationships and does not exhibit many of the characteristics within the criteria for a 100 percent evaluation under the applicable diagnostic code, an increased evaluation is not warranted. 2. Entitlement to an initial rating in excess of 20 percent for a right shoulder disability The Veteran's right shoulder disorder is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201, for limitation of motion of the arm. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 "does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm." Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board notes that the Veteran is right hand dominate. In order for a rating in excess of 20 percent to be assigned, the competent evidence would need to show limitation of motion of the arm to midway between the side and shoulder level or to 25 degrees from the side (Diagnostic Code 5201). A December 2014 VA shoulder and arm examination report that the Veteran was right hand dominant. The examiner diagnosed the Veteran with right rotator cuff tendonitis and degenerative arthritis. The Veteran reported constant right shoulder pain and pain while also doing overhead activities. The Veteran reported flare ups and repetitive use issues impacting his ability to conduct overhead activities with his right shoulder. Range of motion testing showed right shoulder flexion 0 to 90 degrees, abduction 0 to 70 degrees, and external and internal rotation both to 60 degrees. The examiner noted that the limited range on motion contributed to functional loss and objective pain with weight bearing was shown. Pain on palpation was not assessed. Repetitive use testing was conducted with no additional loss of range of motion. The examiner noted that the examination was not conducted immediately after repetitive use over time and the examination results neither supports nor contradicted the Veterans statements describing functional loss. The examiner noted that the exam was not conducted during a flare ups but the Veteran reported flare ups that occurred daily that was severe, and lasted for hours. The examiner noted that the examination result neither supports nor contradicts the Veteran’s statement describing functional loss during flare ups. Muscle strength testing was normal for the right shoulder. Muscle atrophy and ankylosis were not assessed. Rotator cuff condition was suspected as Hawkins’ impingement test was positive, empty-can test was positive, external rotation/infraspinatus strength test was negative, and lift-off subscapularis test was negative. Shoulder instability, dislocation, or labral pathology were not suspected. Conditions or impairments of the humerus were not assessed. Crepitus was not assessed. A January 2016 VA occupational therapy treatment notes shows that the Veteran’s right shoulder range of motion was within function limitations. Flexion was measured to 110 degrees, extension to 50 degrees, and internal rotation to 70 degrees. Muscle strength testing was 4/5. Mild difficulty performing overhead activities and reach lower back was noted. VA treatment records dated from 2016 to 2020 show that the Veteran underwent occupational therapy and physical therapy for treatment for the right shoulder disability. A September 2020 VA shoulder and arm examination report shows that the Veteran was right hand dominant. The examiner diagnosed the Veteran with right rotation cuff tendonitis. The Veteran reported pain mainly in movement and palpation due to inflammation of the right shoulder in the upper external area. The Veteran reported using Motrin 2 times per day. The Veteran reported that he did not experience flare ups that impacted this function of his right shoulder. He did report that the shoulder caused him to be unable to work as he used to or conduct his routine activities he used to do without his wife’s help such as washing the surrounding of his house with hose or doing any type of work. Range of motion testing showed right shoulder flexion 0 to 120 degrees, abduction 0 to 130 degrees, and external and internal rotation both to 45 degrees. The examiner noted that the limited range on motion contributed to functional loss and that the Veteran experienced pain in all planes of motion. Objective evidence of pain to palpation was noted. Crepitus or pain with weight bearing was not assessed. Repetitive use testing was conducted with no additional loss of range of motion. The examiner noted that the examination was conducted immediately after repetitive use over time. The examiner noted that pain significantly limited functional ability with repeated use over a period of time. In terms of loss of range of motion after repetitive use of time were flexion 0 to 120 degrees; abduction 0 to 130 degrees; external and internal rotation 0 to 45 degrees. The examiner noted that the examination was not conducted during a flare up but that pain would significantly limit functional ability with range of motion assessed as flexion 0 to 120 degrees; abduction 0 to 130 degrees; external and internal rotation 0 to 45 degrees. Additional factors contributing to the disability was noted as swelling of the right shoulder area and fragility in the rotator cuff. Muscle strength testing was 4/5 for forward flexion and abduction. Ankylosis was not assessed. Rotator cuff examination showed that the Veteran was unable to perform Hawkins’ impingement test, empty can test, external rotation/infraspinatus strength test, or lift-off subscapularis test. Shoulder instability was not assessed. The Veteran was assessed with moderate acromioclavicular joint degenerative changes. Conditions of the humerus were not assessed. No assistive devices were used by the Veteran. The examiner noted that an MRI taken in 2015 diagnosed rotator cuff tendinopathy. Objective evidence of pain on non-weight bearing or limitation of passive range of motion was not assessed. After a review of the evidence of record, the evidence does not show entitlement to an evaluation higher than 20 percent during the appeal period. In reaching this conclusion, the Board has considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca v. Brown, 8 Vet. App. 202 (1995) and Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, incoordination, repetitive use, pain during flare-ups, and pain during repetitive use over time. A rating in excess of 20 percent for the Veteran's service-connected right shoulder disability is not warranted as the Veteran's symptoms are supported by pathology consistent with the assigned 20 percent rating, and no higher. Even after taking into consideration the Veteran's complaints of pain and reports of flare-ups, examination reports of record showed range of motion of the shoulder to be limited in flexion to 90 degrees and abduction limited to 70 degrees in 2014. A VA physical therapy treatment report shows that the Veteran’s right shoulder was limited to 110 degrees flexion and extension to 50 degrees which does not more nearly approximating limitation of motion of the arm midway between the side and shoulder level, or to 25 degrees from the side of the major or minor extremity. Thus, considering the additional degree of right shoulder impairment with repeated use over time or during flares, the criteria for an evaluation higher than 20 percent are not met. All potentially applicable diagnostic codes have been considered. Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991) (holding that the Board must consider all potentially applicable regulatory provisions). Such a rating is not warranted under other potentially applicable rating criteria as there has been no competent evidence of ankylosis (Diagnostic Code 5200), or recurrent dislocation or malunion of the humerus (Diagnostic Code 5202). Additionally, no malunion, nonunion, or dislocation of the clavicle of scapula has been assessed by VA examiners or in VA treatment records. (Diagnostic Code 5203). Thus, no increased or separate evaluation is for assignment. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 20 percent for the service-connected right shoulder disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to service connection for insomnia is remanded. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Here, in the 2018 remand, the Board requested that if the examiner found there was no separate insomnia diagnosis, then to address the prior diagnoses of record contained in VA treatment records. The examiner found there was no separate sleeping disorder but provided no supporting explanation and did not address the prior diagnoses of record. Accordingly, an addendum is required. The matters are REMANDED for the following action: Obtain an addendum opinion regarding the etiology of the claimed sleep disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. First, the examiner must provide an opinion regarding whether there is a separate sleep disorder, to include insomnia, or if the sleep symptoms are part of his service-connected PTSD. If insomnia is not diagnosed, the examiner must address the prior diagnosis of record. Second, if there is a sleep disorder, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the disorder had onset in, or is otherwise related to, active service. Third, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the disorder is caused or aggravated by the service-connected PTSD. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dworkin, 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.