Citation Nr: 21015343 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 05-34 962 DATE: March 17, 2021 ORDER Entitlement to an earlier effective date of December 10, 2010, but no earlier, for the 70 percent evaluation for service-connected posttraumatic stress disorder (PTSD) is granted. Entitlement to an evaluation in excess of 70 percent for service-connected PTSD on or after December 10, 2010 is denied. Entitlement to an evaluation in excess of 10 percent for service-connected digestive disorder, to include gastritis, GERD, and hernia is denied. Entitlement to a separate 10 percent rating for prolapse of the rectum as secondary to service-connected disabilities is granted. Entitlement to compensation under 38 U.S.C. § 1151 for a vision disorder, including presbyopia, claimed as due to prescribed medication for PTSD, is denied. REMAND Entitlement to an evaluation in excess of 30 percent for service-connected hypothyroidism is remanded. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran’s symptoms of PTSD included near-continuous depressed mood and anxiety affecting her ability to function; intrusive thoughts; hypervigilance; suspiciousness and paranoia; impaired impulse control; irritability with angry outbursts with little to no provocation; social isolation; suicidal ideation without intent; chronic sleep impairment; and difficulty establishing and maintaining effective relationships with difficulty adapting to stressful circumstances; without evidence of gross impairment in thought processes, disorientation to time or place, persistent delusions or hallucinations, memory loss, or grossly inappropriate behavior of such severity, frequency, and duration as to more closely approximate total occupational and social impairment. 2. At all times during the pendency of the appeal, the evidence shows that that the Veteran's GERD with gastritis has not manifested adverse symptomatology that equates to persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 3. The medical evidence indicates the Veteran has a separate gastrointestinal disability that manifests with rectal prolapse as secondary to her service-connected disabilities with constipation. 4. In July 2013, the Veteran was given two doses of Venlafaxine (Effexor), and the Veteran reported that she developed mydriasis and paresis of accommodation immediately following this. 5. There is no indication that the Veteran sustained a disability in the form of a vision disorder resulting from taking the PTSD medication as due to carelessness, negligence, lack of proper skill, error in judgment, or some other instance of fault on the part of VA, or because of an event that was not reasonably foreseeable. CONCLUSIONS OF LAW 1. The effective date for the award of an increased rating of 70 percent for PTSD is granted beginning December 10, 2010; the criteria for a rating higher than 70 percent for PTSD on or after that date have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 3.321, 4.1, 4.2, 4.7, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a rating in excess of 10 percent for GERD with gastritis have not been met at any time during the pendency of the appeal. 38 U.S.C. §§ 1101, 5107(b); 38 C.F.R. §§ 3.102, 4.114, DC 7307-7346. 3. The criteria for a separate 10 percent rating for rectal prolapse has been met. 38 U.S.C. §§ 1101, 5107(b); 38 C.F.R. §§ 3.102, 4.114, DC 7334. 4. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for a vision disorder, claimed as due to VA treatment, have not been met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. §§ 3.102, 3.361. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the United States Army and Air Force from June 1989 to June 1997. The issues are on appeal from December 2011 and July 2014 rating decisions. In September 2018, the Board of Veterans’ Appeals (Board) issued a remand to obtain an etiology opinion for the Veteran’s vision disorder claim, and schedule VA examinations for the remaining increased rating claims, and again in July 2020 to request issuance of a supplemental statement of the case (SSOC). The Board finds that post-remand development has been completed to the extent possible, and the matters are again before the Board for appellate review. Stegall v. West, 11 Vet. App. 268, 271 (1998). Thereafter, in an August 2020 rating decision, the RO increased the rating for the Veteran’s service-connected PTSD from 50 percent to 70 percent disabling, effective August 1, 2019. As this does not constitute a full grant, the higher evaluation for PTSD remains on appeal. AB v. Brown, 6 Vet. App. 35, 39 (1993). Since the initial claim on appeal was filed in December 2010, the Board will also review the Veteran’s entire appeal period. The Veteran has not raised any issues with the duty to notify or duty to assist in obtaining documentary evidence. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Thus, the Board need not discuss any potential issues in this regard. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. The Veteran’s entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1. Where the Veteran timely appealed the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the Veteran is entitled to “staged” ratings to compensate him for times since filing his claim when his disability may have been more severe than at other times during the course of his appeal. Fenderson v. West, 12 Vet. App. 119 (1999). The Board has reviewed all the evidence of record. Although the Board has an obligation to provide adequate reasons and bases supporting its decisions, there is no requirement that the Board discuss every piece of evidence in the record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board will summarize the relevant evidence, as deemed appropriate, and the Board’s analysis will focus on what the evidence shows, or fails to show, as to each claim. 1. Entitlement to an evaluation in excess of 50 percent for PTSD prior to August 1, 2019 and in excess of 70 percent thereafter The Veteran is in receipt of a 50 percent rating for PTSD prior to August 1, 2019, and 70 percent thereafter, and asserts her service-connected PTSD should have a 70 percent rating for the entire period on appeal. PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Under such formula, a 50 percent evaluation is warranted for occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks occurring 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 or forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. A 100 percent disability evaluation is warranted where there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the veteran’s capacity for adjustment during periods of remission. See 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. See 38 C.F.R. § 4.126(b). Here, the Veteran is currently assigned an initial rating of 30 percent for PTSD from March 2008 to December 2010. She did file a notice of disagreement with the initial effective date, and the RO issued a December 2009 rating decision changing the effective date for the initial grant to the current date of March 13, 2008. The Veteran was notified of the decisions, but she did not appeal either determination, but instead filed a new claim for an increase that was received December 10, 2010. Therefore, for the period on appeal, she is assigned a rating of 50 percent prior to August 1, 2019, and 70 percent on and after that date. As discussed in more detail below, the Board concludes the 70 percent rating should be assigned from December 10, 2010, the date the increased rating claim was received. The Board further concludes that although the Veteran has generally asserted worsening throughout the appeal period, the evidence does not indicate she meets the criteria for an evaluation higher than 70 percent, nor has she indicated any symptoms warranting a new examination. As noted, the RO, in its August 2020 SSOC, indicated that August 1, 2019, the date of the most recent VA examination, is the date medical evidence first showed the Veteran’s disability had increased in severity. However, after a review of the evidence, the Board finds that the totality of the evidence reasonably shows the Veteran experienced PTSD symptoms more approximating a 70 percent disability rating since she filed her increased rating claim in December 2010, and consistently thereafter. For example, in the January 2011 VA examination, the Veteran reported she was not taking medication, reported she worked part time as a tutor and was married with a daughter. She reported daily depression and anxiety and reported suicidal ideation as occurring weekly; she stated that she has thoughts of driving her vehicle off of the road, but denied any suicidal attempts and stated her family as a deterrent. She reported a past history of panic attacks, but none within the past year. The examiner marked that she had symptoms of avoidance, hypervigilance and obsessive behavior such as checking the locks of the house and leaving lights on at night and carrying a weapon on her. She also reported having an exaggerated startle response and daily depression and anxiety. The examiner stated that the Veteran’s PTSD symptoms were evaluated as being severe and as having a severe detrimental impact on her affective, behavioral, cognitive, social, somatic, and occupational functioning; and that her potential for gainful employment was limited as a result of the severity of her PTSD symptoms. The examiner noted that she had marginal personal hygiene and grooming but was oriented and alert with no evidence of impairment of thought. The examiner noted that her ritualistic behavior was related to her OCD which is unrelated to her PTSD. Her speech was noted to be within normal limits and was coherent and logical, and her memory was intact, and her affect was pleasant. In the November 2015 VA examination, it was noted that she had moderate PTSD and OCD with good/fair insight, and she had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran reported that she is very committed to being with her children and her primary work is being a stay at home mom and home schooling her older daughter, and reported that she has a good relationship with her husband. She reported that the primary problem in their relationship is her need for constant reassurance about things from her past. She reported that she missed a lot of work due to medical appointments and low motivation. She also reported that she often avoided going in due to anxiety that the staff at the school would be angry or disappointed due to her missing so much work. The Veteran reported that her worst symptoms are anxiety, irritability (e.g., “I can snap easily”), lack of motivation and symptoms of Obsessive-Compulsive Disorders. Veteran reported that her lack of motivation and rituals and obsessive thought have the most impact on her functioning such as her need to maintain her compulsions (due to OCD) and her anger (due to PTSD). For example, the Veteran reported that her daughter left a pile of DVDs on the floor. These were to be organized in a particular manner. She reported that this caused her anxiety, things felt out of control and she yelled at her daughter and then picked the box with the remaining DVDs up and dumped them everywhere. In terms of motivation, the Veteran reported trouble getting housework done (e.g., two weeks of laundry piling up) but also noted adequate motivation to cooks meals and take care of her basic self- hygiene. The examiner noted her symptoms include recurrent, involuntary, and intrusive distressing memories of the traumatic event; avoidance; persistent and exaggerated negative beliefs or expectations; persistent negative emotional state; markedly diminished interest or participation in significant activities; irritable behavior and angry outbursts (with little or no provocation); hypervigilance; exaggerated startle response; problems with concentration; depression, anxiety; suspiciousness; weekly panic attacks; circumstantial, circumlocutory or stereotyped speech; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships and in adapting to stressful circumstances, including work or a worklike setting; suicidal ideation; and obsessional rituals which interfere with routine activities. The examiner also marked that the Veteran’s PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, and that the Veteran was noted to be guarded and she appeared disheveled and her hair was unkempt. She was noted to be alert and oriented with normal attention and memory. Her speech was verbose, and her thought processes were circumstantial and tangential with minimal response to redirection. Her mood was dysphoric, and affect was tearful and irritable. She had suicidal ideation weekly, with thoughts of running herself off the road but denied any plans or attempts. She denied delusions or hallucinations. In the August 2019 VA examination, the examiner opined the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. She stated she home schooled her daughter but then the responsibility was too stressful for her and she was often angry at her daughter, so her doctor told her she was not emotionally able to continue home schooling her daughter. She also stated she has problems coping with family members visiting and is anxious for a week prior to the visit and it takes her a couple of weeks to emotionally recover from the visits. The examiner noted that the Veteran has received psychiatric services and counseling since 2014 on a monthly basis and takes medication, but she continues to struggle emotionally and states she trusts very few people and has little socialization outside of her husband, sister, and one friend. She stated she has problems motivating herself to do daily tasks at home and at times it takes her a couple of weeks to fold laundry or to clean the house; she reported that she often gets fatigued and takes naps during the day and is unmotivated to cook and sometimes her husband has to ask her to cook an occasional meal. She stated that there are days she feels so overwhelmed about everything that needs to be done so her husband does most of the cooking and cleaning. She continues to have obsessions/compulsions that can interfere with her daily activities for up to a couple of days at a time, and stated that she continues to have nightmares related to the trauma and her sleep is restless and she seldom feels rested the next day. She reports she has issues with excessive and compulsive shopping and then feels guilty and returns everything. The examiner noted her symptoms include recurrent, involuntary, and intrusive distressing memories and dreams of the traumatic event; intense psychological distress at exposure to cues of trauma; avoidance; persistent negative emotional state; markedly diminished interest or participation in significant activities; detachment; irritable behavior and angry outbursts (with little or no provocation); reckless or self-destructive behavior; hypervigilance; sleep disturbances; depression, anxiety; suspiciousness; weekly panic attacks; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; mild memory loss; flattened affect; circumstantial, circumlocutory or stereotyped speech; impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships and in adapting to stressful circumstances, including work or a worklike setting; suicidal ideation; and obsessional rituals which interfere with routine activities. The examiner noted that the Veteran’s grooming and hygiene were adequate; and she was alert, oriented, cooperative, and provided in-depth response to all questions. Her thought processes were circumstantial and on a couple of occasions tangential, though anxiety and restlessness were noted. Her affect was flat, and she reported she sometimes has suicidal thoughts and has thoughts about driving off the road or jumping off a building; but she denied homicidal thoughts. The examiner noted that though the Veteran has thoughts to injure self or others, there is no imminent threat at the current time. The Veteran’s VA treatment records also show the Veteran consistently reported symptoms consistent with the 70 percent criteria. For example, in a December 2010 mental health consultation, the Veteran reported that she feels hopeless and has thoughts of killing herself and having suicidal ideation when emotionally distressed but denied having any means or plans to act on those thoughts. She reported that she was last seen in September 2010, but her medications were not helping and felt depressed, had low energy, poor motivation and concentration, and a low sex drive. She stated her sleep was poor and she has nightmares of the sexual assault from service. She stated she has not much joy in life and avoids all situations and events and movies and even visiting the state of Massachusetts that remind her of the incident while at West Point. She also was diagnosed with obsessive compulsive disorder and has rituals when her husband leaves, and she washes her hands continuously and arranges her silverware and clothes in certain orders or she gets upset. She denied having any auditory or visual hallucinations, but it was noted that she has had them in the past. She stated that the hallucinations include obsessive thoughts and thinks she has ringing in her ears but denied any visual hallucinations. She stated she has thoughts of being better off dead but denied suicidal or homicidal plans or intent. It was noted that she was neatly dressed and groomed and was noted to be pleasant and cooperative. She was alert and oriented with no abnormal involuntary movements. Her eye contact was good, and her speech was fluent, and her thoughts were linear, logical, and goal directed. Her mood was depressed but her affect was appropriate. There was no evidence of delusional or paranoid thinking other than her obsessive thoughts about family safety. Her judgment seemed fair and her memory was grossly intact. In another consultation that month, it was noted she had recurrent intrusive thoughts; distress to trauma cues; avoidance; increased arousal with difficulty sleeping; irritable outbursts of anger; trouble concentrating; hypervigilance; nightmares; guilt and shame; significant anxiety; paranoia such that she carries knives and mace on her; avoids crowds and enclosed spaces; diminished interest in activities; worthlessness feelings; thoughts of death or suicide; low energy and low motivation; depression; poor impulsivity; instability; and chronic suicidal ideation. She had no manic symptoms or psychotic symptoms. The examiner marked that her symptoms are causing clinical problems with social, occupational and other functioning and noted she had a moderate risk for self-injury that is chronic but not acute and was deemed to not be an imminent risk to herself or others. In January 2011 she reported sleep disturbances, suicidal ideation such as driving her car off a bridge, nightmares, anxiety, obsessive rituals, intrusive thoughts, flashbacks and some paranoia such that she thinks the government and her neighbors might be spying on her. In February 2011, she underwent a suicide assessment and reported thoughts of suicide, with sleep disturbances, impulsivity, poor self-control, anxiety, and agitation. She was determined to have a moderate risk of suicide that appear to be chronic but has a history of reaching out to her husband and doctors for help when having these thoughts. The doctor noted that she had fair hygiene and grooming with appropriate appearance. Her mood and affect were anxious, and her speech was hesitant with no hallucinations or delusions. It was noted that she had ongoing trust and safety issues, with shame and self-blame and avoidance, and has suicidal ideation with social isolation. She has re-experiencing symptoms, PTSD symptoms, depression and hopelessness, with maladaptive thoughts and beliefs. In a follow up, it was noted that she was assessed for suicidal and homicidal ideation after reporting ideation recently stating that she had thoughts about plans such as stepping out in front of a truck, jumping off of a bridge, or driving into a tree. The examiner noted the Veteran denied these thoughts after resuming her medication and she stated that her mood had improved since restarting Fluoxetine, though she still struggles with low energy and motivation, and denied feeling worthless or having suicidal or homicidal ideation. She reported occasional nightmares and flashbacks and reported daily anxiety. The examiner noted her grooming and hygiene to be fair, and stated she was cooperative with good eye contact. Her speech was regular in rate, rhythm and volume, and her mood was noted to be better with an anxious affect. Her thoughts were logical and goal-oriented, and she did not have suicidal or homicidal ideation. She denied auditory or visual hallucinations and her judgment was noted to be fair. In the January 2012 notice of disagreement, the Veteran stated that her nightmares and night sweats are a nightly thing; she had anxiety that causes her to have angry outbursts daily over things people normally would not be agitated over; and that her depression has worsened with increased feelings of suicidal ideation, hopelessness, and loss of motivation. In October 2013, she reported having nightmares, avoidance, constantly being on guard and watchful, easily startled, and felt numb or detached from others. In December 2013, she reported having constant anxiety and discussed how her home needed to be organized a certain way. She reported that for several years, she “pulls” on her hair such as her eyebrows and that she one time almost pulled out one of her entire eyebrows. She reported nightmares, hypervigilance, avoidance, paranoia that someone will come hurt her or her children, that she has a constant gray cloud in her life; sad mood, anhedonia, difficulty concentrating, fatigue/low energy; and passive suicidal ideation. She stated that she has nightmares of her trauma, avoids watching the news or television in general so that she does not see anything about an assault or child abuse, and explained that if she is exposed to cues, she thinks obsessively about whether people who harmed her in the past will find her and hurt her or her children. She stated that she dislikes crowds or being “boxed in” (i.e., in traffic), and she described herself as always on guard, easily startled, and “hypervigilant” with irritability. In March 2014, she was noted to be alert, oriented and casually groomed, and her mood was guarded, with a restricted affect with fleeting eye contact. Conversation was coherent and relevant with normal tempo and volume. She reported anxiety and that her sleep is disrupted at times. Her thought processes were noted to be organized without hallucinations or delusions and she denied suicidal ideation or thoughts of self-injury. The Veteran continued to have monthly therapy and take medications with improvements to her mood during these sessions, and records indicated that her anxiety decreased, and her anger management improved with medication usage. However, a May 2016 letter from the Veteran's VA psychiatrist, Dr. J.F., stated that the Veteran has ongoing nightmares and recurrent intrusive recollections with difficulty interacting with others, and that she has fluctuations in mood. He stated that despite her education and training, she is unable to hold a job, even homeschooling, as problems with concentration, intrusive recollections, anxiety, and flashbacks interfered with her attempts. Dr. J.F. further stated that the Veteran's OCD was worsened by the severity of her PTSD. Further, June 2017 treatment records showed her medication dosage was increased after she reported feeling more irritable with increased obsessional thoughts. In correspondence from December 2017, she discussed how stressful situations cause her to want to kill herself, and that she is unable to sleep, has nightmares and night sweats, and chest pains. She also mentioned her depression, anxiety, OCD, and anger and wanting to avoid others. In a follow-up letter in January 2018, she discussed her attempt at a part-time job, but that the added responsibility took a toll on her PTSD so she had to quit. She stated that when she first started the job, her PTSD worsened right away due to the added responsibility and change in her typical routine and that her PTSD got so bad that she could no longer keep working. In VA treatment records from January 2018, it was noted she had severe PTSD and has a great deal of difficulty interacting with groups of people. She reported more intrusive thoughts and feeling angry and having avoidance which often presents as rage. She was noted to be uncomfortable in public situations including functions with her children. She stated she has severe nightmares and avoids anything related to the military. She has severe anxiety and her symptoms oscillate negatively based on environmental triggers. The doctor stated that she would not be able to function in any type of work environment and she would not be able to sustain employment. It was noted that she has struggled with suicidal ideation since her time in the military; her concentration is limited due to intrusive recollections; she has mood swings; and that this is a chronic condition that will require close supervision, psychotherapy and medication management. The January 2018 psychiatrist further stated that the Veteran’s symptoms suggestive of OCD are “better understood in the context of posttraumatic stress disorder. She does not have any fear of contamination or need for symmetry. She does not have any the classical subtypes. The ruminating thoughts are more driven by anxiety and depression. This is consistent with the primary diagnosis PTSD and recurrent major depression.” In sum, the record shows that the Veteran has had consistent treatment sessions with ongoing medication prescriptions, with VA psychiatrists consistently noting the Veteran’s mood improving through therapy and medication use, but that she also consistently reported suicidal ideation, depression, irritability, hypervigilance, inability to have a job, problems with concentration, intrusive recollections, anxiety, and flashbacks. Further, although her OCD is a separate diagnosis from her PTSD, the Veteran’s VA psychiatrists stated that her PTSD symptoms have exacerbated and worsened her OCD symptoms. Further, although her appearance and hygiene were mostly noted to be appropriate, at times it was also noted to be fair or unkempt, and she reported that there were days to weeks where she was unable to handle basic daily activities and her husband had to do the cooking and cleaning. Further, the Veteran stated in May 2016 that she rarely wore anything other than sweats but would dress nicer when she has to leave the house to go to the doctors or when she did go to church – though this also causes her anxiety and panic attacks if she gets attention for dressing nice. Accordingly, after a review of the evidence of the record, the Board finds that the preponderance of the evidence indicates that a 70 percent evaluation effective December 10, 2010, the date the increased rating claim was received, is appropriate. The claim is granted to this extent only. However, a higher rating is not warranted. There is no evidence in the claims file that the Veteran’s symptoms more closely approximate the criteria for a 100 percent disability rating. At no point did she demonstrate symptoms comparable to grossly inappropriate behavior, persistent danger of hurting herself or others, intermittent inability to perform activities of daily living, disorientation to time or place, and memory loss for names of close relatives or own name. Further, none of the VA examiners noted that she had disorientation to time or place, grossly inappropriate behavior, persistent danger of hurting herself or others, or neglect of personal hygiene. After considering the evidence, the Board finds against a 100 percent rating as there is no evidence of symptoms resulting in the social and occupational impairment contemplated by a total rating. For example, VA medical records showed the Veteran has stated she had suicidal thoughts but no attempts, and that she has a relationship with her children and husband and there is no indication of persistent harm to self or others. While she is socially isolated, she does not have total social impairment. Although the Veteran reported she had thoughts of suicide in lay statements as well as reporting suicidal thoughts during ongoing treatment sessions, suicidal ideation is contemplated by the 70 percent disability rating. There is no suggestion she was in persistent danger of hurting herself, as she consistently reported that she had no plans of such. Further, VAMC records consistently noted her as pleasant, cooperative, well appearing, with normal speech but a depressed and anxious mood. Her attention was noted as intact and she was fully oriented. It was reported she had normal to fair hygiene and her judgment and cognition were normal, and she denied hallucinations and any homicidal ideation. As such, a total 100 percent rating at any point on appeal is denied. In summary, the Board finds effective December 10, 2010, the criteria for a 70 percent disability rating, but no higher, were met. However, the criteria for a 100 percent rating have not been met. In reaching this decision, the Board considered the doctrine of reasonable doubt and has resolved any doubt in the Veteran’s favor by making the 70 percent rating effective in 2010 rather than 2019. However, the preponderance of the evidence is against any further increased ratings. 2. Increased Ratings for GERD/Gastritis and Separate Rating for Gastrointestinal Disorder of Rectum Prolapse Here, the Veteran is currently service connected for hypothyroidism rated at 30 percent since December 9, 2008; for internal hemorrhoids associated with hyperthyroidism rated at 20 percent since January 26, 2012; and for gastritis/GERD rated at 10 percent since April 5, 2007 (a higher rating for hypothyroidism is discussed in the remand portion below). The Board notes that the Veteran’s service-connected hemorrhoids have been assigned the maximum schedular rating available under Diagnostic Code (DC) 7336 and gastritis/GERD/ is evaluated under DC 7346. The Board reiterates that the severity of a digestive system disability is ascertained, for VA rating purposes, by application of the criteria set forth in VA’s Schedule for Rating Disabilities at 38 C.F.R. § 4.114. Ratings under DCs 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. See 38 C.F.R. § 4.114. However, separate ratings may be assigned for different manifestations of the same disability, providing that “none of the symptomatology for any one of [the] conditions is duplicative of or overlapping with the symptomatology of the other two conditions,” and that such combined ratings do not constitute pyramiding, which is prohibited by 38 C.F.R. § 4.14. Esteban v. Brown, 6 Vet. App. 259 (1994). If the symptoms are “‘distinct and separate,’ then the appellant is entitled to separate disability ratings for the various conditions.” Murray v. Shinseki, 24 Vet. App. 420, 423 (2011) (quoting Esteban, 6 Vet. App. at 262). First, as for the Veteran’s GERD/gastritis, she contends that it is more severely disabling than represented by the rating assigned at all times during the appeal. As noted above, the Veteran’s GERD with gastritis is rated as 10 percent disabling under 38 C.F.R. § 4.114, DC 7307-7346. Diagnostic Code 7307 provides the following ratings for hypertrophic gastritis. A 10 percent rating is warranted for chronic hypertrophic gastritis with small nodular lesions and symptoms. A 30 percent rating is warranted for chronic hypertrophic gastritis with multiple small eroded or ulcerated areas and symptoms. A 60 percent rating is warranted for chronic hypertrophic gastritis with severe hemorrhages, or with large ulcerated or eroded areas. See 38 C.F.R. § 4.114, DC 7307. GERD is not specifically listed in the rating schedule, but is evaluated as analogous to hiatal hernia. See 38 C.F.R. § 4.20 (when an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous). Diagnostic Code 7346 provides a compensable, 10 percent rating, if the GERD’s symptoms equate to a hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. See 38 C.F.R. § 4.114. A 30 percent rating is warranted if symptomatology equates to a hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The Veteran was afforded VA examinations for her GERD with gastritis in March 2011, September 2015 and July 2019. In the 2011 examination, it was noted she had a history of nausea, vomiting, constipation, heartburn, hemorrhoids, and hematuria. In the 2015 VA examination, it was noted that she had delayed motility of barium meal; reflex disturbances; abdominal distention; constipation with mild discomfort; esophageal reflux with nausea and abdominal pain. In the 2019 examination, she stated that she had stomach pains and burning of the chest and a feeling like something is stuck in her throat, and that she took medication which didn’t help much, and she tried dietary changes and that helped. The examiner noted she had recurring episodes of symptoms that are not severe; abdominal pronounced pain; recurrent nausea; but she does not have hypertrophic gastritis, anemia, weight loss, vomiting, melena, or hematemesis. The records indicate that she has anemia; diverticulitis, irritable bowel syndrome and peritoneal adhesions, and that she has had impairment of sphincter control and anal fissures (she also had rectum prolapse– see below). In a December 2010, the Veteran's husband submitted a statement that she suffered from bouts of indigestion, acid reflux, dry heaving, vomiting, stomach discomforts, and nausea. Private records noted her constipation and rectum issues, and as noted immediately below, she is being granted a separate rating for those symptoms. However, none of the examinations or any other medical evidence of record, VA or private, contain evidence of chronic hypertrophic gastritis with multiple small eroded or ulcerated areas and symptoms or persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. In fact, the 2019 examination indicated some improvement was shown, though permanency is not established. Therefore, a rating in excess of 10 percent is not warranted under either DC 7307 or 7346, which are both potentially applicable. As such, the Board finds that the Veteran’s disability picture more closely resembles the 10 percent disability rating but no higher. In so finding, the Board acknowledges that the Veteran has exhibited some symptoms of the 30 percent disability rating. However, the Veteran’s disability picture does not meet the 30 percent rating requirements. Although the Veteran has had persistent recurrent epigastric distress with pyrosis and regurgitation, the Veteran’s statements and VA examinations do not show her symptoms have resulted in considerable impairment of health. When there is an approximate balance between positive and negative evidence the benefit of the doubt doctrine must apply in favor of the Veteran. But when the preponderance of the evidence weighs against the claims of the Veteran, the claim will be denied on its merits. In this case the preponderance of the evidence is against the claim of the Veteran, therefore the benefit of the doubt doctrine is inapplicable. 38 U.S.C. § 5107; Gilbert v, 1 Vet. App. 49. The Veteran’s claim for an evaluation in excess of 10 percent for GERD with gastritis is denied. As noted above, although the claim for a higher rating for the Veteran’s GERD under DC 7307-7346 is being denied, during the period on appeal, the Board notes that the Veteran has a separate and distinct disability of rectal prolapse under DC 7334, which was noted to be due to her constipation from her service-connected disabilities. Murray, 24 Vet. App. 420, 423 (quoting Esteban, 6 Vet. App. at 262). Under the applicable diagnostic criteria, a 10 percent rating is assigned for mild prolapse with constant slight or occasional moderate leakage. A 30 percent rating is assigned for moderate prolapse which is persistent to frequently recurring. Finally, a 50 percent rating is assigned for severe (or complete) prolapse, which is persistent. See 38 C.F.R. § 4.114, DC 7334. First, the Veteran’s records first indicated a diagnosis of rectal prolapse in 2011 and again in the November 2015 VA examination. As such, throughout the appellate period, the Veteran has had a current diagnosis of rectal prolapse. For example, in 2009, medical reports received from private physicians show a history of rectal bleeding caused by constipation. A colonoscopy in October revealed a few diverticula in the sigmoid colon and hemorrhoids. A September 2011 private medical record included a diagnosis for rectal prolapse. Further, the November 2015 VA examination provided a diagnosis for a prolapsed rectum. In the January 2011 VA examination, it was noted she had rectal bleeding with constipation with internal hemorrhoids and diverticulosis and gastroparesis. October 2013 VA records showed she had diagnoses for diverticulosis, internal hemorrhoids, rectal prolapse with weakened pelvic floor, and GERD and gastroparesis. December 2013 records noted she had a significant weakened pelvic floor and a prolapsed rectum. Her records showed that she attended ongoing physical therapy sessions for her rectal prolapse to strengthen her weakened pelvic floor. More recent VA records showed in August 2019 that she had ongoing diagnosis for rectal prolapse. The October 2019 proctology consultation noted she had rectal bleeding and it was noted she had a history for rectal prolapse with physical therapy. She stated she still has constipation occasionally as well as abdominal cramping. She also takes nitroglycerin for fissures. In the November 2015 VA examination, she was diagnosed with internal hemorrhoids, rectal prolapse, anal fissure, and partial prudential neuropathy per defecography. The examiner noted that the severity of her rectal prolapse was mild with constant slight or occasional moderate leakage. The July 2019 VA examination also showed that the examiner opined that the Veteran’s hypothyroidism had progressed with an increase in dose of medication, and that “the constipation has caused some complication such as anal fissures and prolapsed rectum.” In addition, July 2011 private records showed that she reported occasional bowel or bladder leaking. She reported sneezing causes urine loss about 5-6 times a day and 1-2 times at night. She stated she also has trouble controlling flatulence about 3 times a day with trouble initiating defection when constipated. It was noted that she had anal pain much more suggestive of a fissure than any other source and perineal descent (aka prolapse). It was noted that she had hemorrhoids and that her symptoms included bleeding from the anus, pain in the rectum, hemorrhoids, itching around the anus, stomach/abdominal pain, irritable bowel disease, constipation, diverticulitis, and a history of colon polyps. In the January 2012 NOD, she reported the prolapsed rectum due to constipation, and in a March 2013 statement, she said that due to hypothyroidism, her constipation issues have resulted in a weakened pelvic floor and prolapsed rectum. In an October 2014 statement, she stated that due to constipation issues, she now has a weakened pelvic floor and prolapsed rectum. In the August 2015 Form-9, she reported that her constipation has caused her to have a weakened pelvic floor and prolapsed rectum, and that she does daily physical therapy exercises for it. In the May 2016 statement, she reiterated the aforementioned statements that she currently has issues related to constipation, such as prolapsed rectum, weakened pelvic floor, and anal fissures. Accordingly, based on the lay and medical evidence as discussed, the Board finds the evidence indicates that the Veteran’s rectal prolapse is due to her service-connected hypothyroidism constipation. Therefore, a separate 10 percent rating for symptoms of mild rectal leakage under DC 7334 is warranted. Finally, the Board has considered the Veteran’s contentions with regard to her claim for higher ratings for her GERD/gastritis. Although the Board does not doubt the sincerity of the Veteran’s belief that her disabilities are more severely disabling than reflected in the current ratings, as a lay person without the appropriate medical training or expertise, she simply is not competent to provide a probative opinion on a medical matter, such as the severity of her current disability as evaluated in the context of the rating criteria. Bostain v. West, 11 Vet. App. 124, 127 (1998). The statements from the Veteran clearly articulate the symptoms and troubles she experiences; however, even with consideration of these problems, the Board finds that a higher initial rating for GERD/gastritis and a higher rating for rectal prolapse is not warranted under the pertinent criteria for either disability. Therefore, a higher rating than 10 percent for GERD, to include gastritis, is denied, but a separate 10 percent rating for rectal prolapse as due to service-connected disabilities is warranted. Entitlement to compensation under 38 U.S.C. § 1151 for a vision disorder The Veteran asserts that in July 2013, she took a dose of Effexor prescribed to ber by VA for her service-connected PTSD, and she started to experience difficulty reading in addition to pupil dilation. She has stated that her near vision never returned to normal after that, and she now has to wear bifocals constantly, experiences vertigo and dizziness wearing bifocals, and started experiencing dry eyes after taking the Effexor. The law provides that compensation may be paid for a qualifying additional disability that is (1) not the result of the Veteran’s willful misconduct; (2) was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by VA either by a VA employee or in a VA facility; and (3) the proximate cause of the disability was (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination or (B) an event not reasonably foreseeable. See 38 U.S.C. § 1151. First, there must be evidence of additional disability, as shown by comparing the veteran’s condition before and after the VA medical care in question. See 38 C.F.R. § 3.361(b). To determine whether a veteran has an additional disability, VA compares the Veteran’s condition immediately before the beginning of the hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy (CWT) program upon which the claim is based to the Veteran’s condition after such care, treatment, examination, services, or program has stopped. VA considers each body part or system separately. The additional disability must not be the result of the Veteran’s willful misconduct. See 38 U.S.C. § 1151(a); 38 C.F.R. § 3.301(c)(3). Second, the additional disability must be caused by hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy program furnished the veteran by VA. See 38 C.F.R. § 3.361(c). Merely showing that a veteran received care, treatment, or examination and that the veteran has an additional disability does not establish cause. See 38 C.F.R. § 3.361(c)(1). In order for additional disability to be compensable under 38 U.S.C. § 1151, the additional disability must have been actually caused by, and not merely coincidental to, hospital care, medical or surgical treatment, or medical examination furnished by a VA employee or in a VA facility. See 38 C.F.R. § 3.361(c)(1); Loving v. Nicholson, 19 Vet. App. 96, 99-100 (2005); Sweitzer v. Brown, 5 Vet. App. 503, 505 (1993). That is, the additional disability must have been the result of injury that was part of the natural sequence of cause and effect flowing directly from the actual provision of “hospital care, medical or surgical treatment, or examination” furnished by VA and such additional disability must be directly caused by that VA activity. Loving, 19 Vet. App. at 101. Third, the proximate cause of the disability, as opposed to a remote contributing cause, must be (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (2) an event that was not reasonably foreseeable. See 38 U.S.C. § 1151(a)(1); 38 C.F.R. § 3.361(d). Whether the proximate cause of the additional disability was an event not reasonably foreseeable is to be determined based on what a reasonable health care provider would have foreseen. See 38 C.F.R. § 3.361(d)(2). The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with informed consent. See 38 C.F.R. § 3.361(d)(2). Thus, 38 U.S.C. § 1151 contains two causation elements – an additional disability must not only be “caused by” the hospital care or medical treatment received from VA, but also must be “proximate[ly] cause[d]” by the VA’s “fault” or an unforeseen “event.” See 38 U.S.C. § 1151(a)(1). Here, as noted, on July 22, 2013, the Veteran was prescribed Effexor. Thereafter, on July 29, 2013, the Veteran reported to VA that she had stopped taking the medication about 4-5 days prior as she started having blurred vision after taking two dosages of Effexor. She stated that she did not have vision issues prior to this. Thereafter, in August 2013, the Veteran had an eye examination and was diagnosed with mydriasis and accommodation paresis. In response to this claim, the Veteran had a VA examination in June 2014. The examiner, an ophthalmologist, listed the diagnoses as mydriasis and accommodation paralysis, as well as early presbyopia. Her corrected and uncorrected distance and near visual acuity was noted to be 20/40 or better in both eyes. All other testing was noted to be normal. The examiner noted that the Veteran should avoid any topical or systemic meds which would cause mydriasis and/or accommodation paresis. Thereafter, also in June 2014, a VA medical opinion was provided by a clinical psychologist. She acknowledged that the Veteran’s reported symptoms and previous diagnosis of mydriasis and/or paresis accommodation were most likely a rare side effect of Effexor /Venlafaxine, which was prescribed to treat the Veteran’s PTSD. Specifically, the examiner stated: The side effect profile of Effexor/Venlafaxine includes abnormal accommodation (in 6-9% of persons taking the medication), Blurred vision (4-6%), and mydriasis (2%). This side effect is dose dependent and would be expected to be a greater possibility at higher doses of the medication. Research has shown that the vision effects, if they occur at all, are temporary and remit or go away after the medication is discontinued. Given this medical evidence, it is possible that the Veteran was in the minority of individuals taking Effexor/Venlafaxine who experienced a visual side effect as a result of taking this medication. The examiner then noted the August 2013 diagnosis of mydriasis (dilation of the pupil) and accommodation paresis, and stated that these “could be consistent with a low probability, but possible, temporary side effect from Effexor” but noted the Veteran stopped taking the medication. The examiner further stated that the 2014 examination showed that the Veteran was not diagnosed with mydriasis or accommodation paresis, but with presbyopia. She cited to the American Optometric Association that presbyopia refers to a normal, age-related vision change and that “presbyopia may seem to occur suddenly, but the actual loss of flexibility takes place over a number of years. Presbyopia usually becomes noticeable in the early to mid-40s. Presbyopia is a natural part of the aging process of the eye. It is not a disease, and it cannot be prevented.” As such, she opined that presbyopia was not related to or caused by taking Effexor/Venlafaxine; instead, it was a natural part of the aging process of the eye that she “would have experienced whether or not she had ever been prescribed Effexor.” Finally, the 2014 examiner opined the current vision loss of presbyopia “is not a result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA.” The examiner again reiterated that presbyopia is an age-related decline in vision that is part of the normal aging process. She stated that “there is no medical or scientific evidence that presbyopia is caused by or a result of any medication or medication side effects. Presbyopia is not preventable. Therefore, there is no “additional disability” related to vision that the Veteran is currently diagnosed with that is in any way related to her service-connected PTSD or to her being prescribed venlafaxine/Effexor by the VA.” In the 2018 Board remand, it was noted that the 2014 examiner did not specifically note whether the diagnosis of mydriasis and/or paresis accommodation had resolved or not. Therefore, a new examination was requested. Following remand, a November 2019 examination noted the diagnoses of bilateral presbyopia and keratoconjunctivitis sicca. The Veteran stated that she took one dose of Effexor for PTSD in 2013, and she started to experience difficulty reading in addition to pupil dilation. The near vision never returned to normal after that, and she now has to wear bifocals constantly. She stated that she also experiences vertigo and dizziness wearing bifocals and that she also started experiencing dry eyes after taking the Effexor. After examination, it was noted that her uncorrected distance and near visual acuity was noted to be 20/40 and her corrected distance and near visual acuity was 20/20 or better in both eyes. It was noted that she had Lacrimal System Conditions, including Dry Eye Syndrome, but that there is no decrease in visual acuity or other visual impairment, and she treats it with over the counter artificial tear drops. The 2019 examiner, after a review of the full medical record, noted the Veteran’s dry eyes and pain due to dryness, but opined that it is less likely than not that the Veteran’s presbyopia and Keratoconjunctivitis Sicca was caused by or became worse as a result of the VA treatment. The rationale was that these conditions are more likely due to aging of the age and not medication side effects. The examiner also noted that the Veteran had a history of presbyopia per STRs in 1995, and noted the August 2013 eye examination immediately after the July 2013 incident noted her visual acuity and reading glass prescription was consistent for her age and the diagnosis of presbyopia worsened as a result of the aging process and not due to side effects of Effexor. The examiner further opined that “it is less likely than not the diagnosed eye condition was caused by carelessness, negligence, lack of skill, error in judgment or a similar instance of fault on the part of VA.” The rationale was that the Veteran’s eye conditions “are at least as likely than not due to the natural aging process of the eyes…[and] medical records show [Veteran] had long history of Presbyopia.” Therefore, the examiner opined that “it is less likely than not the current eye condition was due to an event not reasonably foreseeable. There were no identified eye conditions that were due to an event not reasonably foreseeable. The [Veteran’s] reported blurred vision has resolved.” In sum, the examiner again stated that the Veteran’s diagnosis of presbyopia “worsened as a result of the aging process and not due to side effects of Effexor.” In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In this case, the examiner was aware of the Veteran’s medical history, provided a fully articulated opinion, accepted the Veteran’s statements of the 2013 incident, cited to medical literature, and furnished a reasoned analysis for her conclusions. The Board therefore attaches significant probative value to this opinion. There is no other competent medical opinion to the contrary. Additionally, although the Veteran believes her vision disorders began due to the 2013 incident, the Board notes that the VA medical records show that she reported blurred vision over a year before in March 2012 and was referred for an eye consultation. Thereafter, in a May 2012 eye examination for possible glaucoma, it was noted that her visual acuity was 20/20 with correction. It was determined she did not have glaucoma, but was given a diagnosis for myopia and presbyopia and she was given a prescription for glasses. In addition, during the July 22, 2013 mental health consultation, after she was prescribed Venlafaxine, the doctor specifically stated that she “was explained the risks and benefits of the proposed treatments and gives fully informed verbal consent to the medications.” In the August 2013 VA eye consultation to follow up to her claims of blurred vision from the medication, it was noted that her visual acuity was 20/20 and 20/40 at near without correction. She was diagnosed with presbyopia and low myopia and given a prescription for progressive lenses and readers for near. The doctor noted that the visual acuity and reading glass prescription “is consistent for her age.” In addition, the Veteran herself reported to the eye doctor that “she researched the medication on webMD and states she did not immediately see anything listed about vision changes on the side effect profile” but states “she had to do a little digging” and found that people have complained of vision changes while on the medication “but it does not say whether or not it is permanent.” The examiner therefore researched side effect and noted that UpToDate does list “ocular side effects of abnormal accomodation (6-9%), abnormal or blurred vision (4-6%) and mydriasis (2%)” but that none of these are listed as permanent. In addition, the examiner noted that under warning/precautions in UpToDate it lists: “May cause mydriasis; use caution in patients with increased intraocular pressure or at risk for acute narrow-angle glaucoma.” The Veteran’s doctor specifically stated that the Veteran “was not found to have glaucoma at last visit with ophto May 4, 2012.” Therefore, the Board concludes there is no evidence the Veteran suffered an additional disability following taking medication prescribed in July 2013 that was not otherwise resolved. The Board is aware and takes note of the Veteran’s contentions; however, the most probative evidence of record are the June 2014 and November 2019 VA examiners’ opinions. The VA examiners took the Veteran’s entire health history leading up to the 2013 incident and thereafter into account, they provided competent and credible opinions consistent with the medical evidence of record, and their opinions included a detailed rationale based on the evidence of record. There is no other medical opinion to the contrary. As there is no vision disorder arising from VA care in 2013, there is no justification for awarding compensation under 38 U.S.C. § 1151. Additionally, as noted above, while there may be a small percentage of ocular side effects, none of the conditions were listed as permanent, and the 2014 examiner specifically stated that “research has shown that the vision effects, if they occur at all, are temporary and remit or go away after the medication is discontinued” – which the Veteran reported she immediately stopped after the second dosage. Further, medical records show that the Veteran does not have a current diagnosis for blurred vision and her current vision disorders are unrelated to the medication; and the expert opinions are that while there is a small possibility of visual defects as a side effect from the medication, any residuals are temporary and in this particular case, the Veteran’s alleged blurred vision has since resolved following the July 2013 incident. The Board is sympathetic to the Veteran’s situation and acknowledges that she suffered symptoms when she took the PTSD medication. However, again, while the medical opinion finds that the Veteran’s medication might have caused a temporary change in vision, there has been no additional residual visual defects due to this incident. The Board has, however, as part of the remand below, requested consideration of the possibility of whether the Veteran’s hypothyroidism caused or aggravated the current eye conditions. In sum, the preponderance of the evidence is against a determination that any VA treatment led to any residual visual disabilities as a result of any alleged careless improper, or negligent treatment. Accordingly, the claim must be denied. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure due process and proper development regarding the Veteran’s claim for a higher rating for her hypothyroidism. First, the Veteran asserts that her symptoms warrant at least a 60 percent rating for hypothyroidism throughout the period on appeal. The Board notes that ratings for hypothyroidism fall under the criteria for 38 C.F.R. § 4.119, DC 7903 prior to the regulatory amendment effective December 10, 2017, as well as the current criteria effective since that date. Because the Veteran’s appeal was pending at the time of the amendment, she is entitled to application of the criteria that are most favorable to his claim. However, a higher rating may not be awarded under the criteria effective December 10, 2017, prior to that effective date. The old DC 7903 criteria, effective prior to December 10, 2017, provided 10, 30, 60, or 100 percent ratings for hypothyroidism. A 100 percent rating was assigned if there was cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. A 60 percent rating was assigned if there was muscular weakness, mental disturbance, and weight gain. A 30 percent rating was assigned if there was fatigability, constipation, and mental sluggishness. A 10 percent rating was assigned if there was fatigability or continuous medication required for control. See 38 C.F.R. § 4.119, DC 7903 (2005 & 2017). The current DC 7903 criteria, effective since December 10, 2017, provide for 30 or 100 percent ratings for hypothyroidism. A 30 percent is assigned for hypothyroidism without myxedema; and a 100 percent is assigned for hypothyroidism manifesting as myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion) and mental disturbance (including, but not limited to dementia, slowing of thought and depression). Here, the Board notes that the most recent VA examination in July 2019 did not adequately address the Veteran’s consistent reports of symptoms of sleepiness, depression, slowing of thought, poor memory, difficulty swallowing, constipation, muscle pain – to include her diagnosis for fibromyalgia, and intolerance to cold, which could support a rating higher than 30 percent under the old and new criteria. Additionally, the Board notes that the Veteran has asserted that the examination did not adequately reflect her symptoms. In a November 2020 statement, the Veteran argued that her hypothyroidism symptoms include constipation, fatigability, cold intolerance, weight gain, muscular weakness, mental disturbances, sleepiness, bradycardia, and continuous medication required for control. She also stated that she has recently had a low resting heart rate and this is being followed by her primary care doctor, and stated her doctors have told her that they have noted atrophying of her muscles, especially in her arms and feet. Therefore, a new VA examination should be obtained to determine the current nature and severity of the Veteran’s hypothyroidism, including whether her reported symptoms are due to that condition or due to separate disabilities. The matters are REMANDED for the following action: 1. Obtain VA medical records from October 2019 to present and associate them with the claims file. 2. DO NOT schedule the following until the VA medical records have been obtained. 3. Schedule the Veteran for examination(s) with an examiner to determine the current nature and severity of her hypothyroidism. A copy of the file, to include a copy of this remand, The examiner should identify whether there is myxedema, cold intolerance, muscular weakness, cardiovascular involvement (to include hypotension, bradycardia of less than 60 beats per minute, or pericardial effusion), mental disturbance (to include dementia, slowing of thought or mental sluggishness, or depression), sleepiness or fatigability, weight gain, or constipation. The examiner should consider the Veteran’s lay reports, to include in her November 2020 statement, as well as reports during the 2011, 2015, and 2019 VA examinations and her ongoing medical treatment. She also stated in September 2020 that she has had weight gain due to the condition, such that she gained 20 pounds in 6 weeks and has had difficulty losing the weight. She also states that she has a resting heart rate of 54 bpm, sometimes as slow as 49 bpm, according to her smart watch. She stated this is due to the hypothyroidism and causes dizziness, fatigue, and shortness of breath, as well as short term memory loss issues and occasional chest tightening problems; she stated she told the VA examiner that she has weakness in her muscles that goes through her legs when standing up and has started doing resistance exercises to help without much of a difference. She stated the loss of strength is noticeable in her legs and arms but was not mentioned in the VA report even though she reported it to the examiner. As such, the examiner must note the Veteran’s assertions and discuss whether the symptoms are related to the thyroid condition. If the examiner determines any of the Veteran’s symptoms and/or findings are due to conditions other than her thyroid disorder, this should be explained. For example, she is service-connected for a mental health condition and for gastritis/GERD, which could potentially have overlapping symptomatology. The examiner is asked to explain the reasons behind any opinions and conclusions expressed. 4. Thereafter, the AOJ should adjudicate the claim for an increased rating for hypothyroidism under both the old and new criteria. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G.Hoy, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.