Citation Nr: 21015881 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 15-35 514A DATE: March 18, 2021 ORDER From December 24, 2014 to January 12, 2017, entitlement to an evaluation in excess of 30 percent disabling for post-traumatic stress disorder (PTSD) is denied. From January 13, 2017 to October 2, 2019, entitlement to an evaluation of 50 percent disabling for PTSD, but no higher, is granted. From October 3, 2019, entitlement to an evaluation of 70 disabling for PTSD, but no higher, is granted. Entitlement to service connection for fibromyalgia is denied. Entitlement to service connection for a migraine headache condition is granted. Entitlement to service connection for cervical strain, claimed as neck condition, is denied. REMANDED Entitlement to service connection for obstructive sleep apnea is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). FINDINGS OF FACT 1. From December 24, 2014 to January 12, 2017, the Veteran’s PTSD manifested as occupational and social impairment due to mild or transient symptoms. 2. From January 13, 2017 to October 2, 2019, Veteran’s PTSD manifested as occupational and social impairment with reduced reliability and productivity. 3. From October 2, 2019, the Veteran’s PTSD has manifested as occupational and social impairment with deficiencies in most areas. 4. The preponderance of evidence does not support that the Veteran has fibromyalgia, or any medically unexplained chronic multisymptom illness for which service connection may be granted. 5. The evidence is at least in equipoise that the Veteran’s migraine headaches are a chronic condition which originated in service and have continued to the present time. 6. The preponderance of evidence weighs against a finding that the Veteran’s cervical strain condition was incurred in, caused by, or otherwise due to active service. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for PTSD From December 24, 2014 to January 12, 2017 have not 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 disability rating of 50 percent, but no higher, for PTSD from January 13, 2017 to October 2, 2019 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. 3. The criteria for a disability rating of 70 percent, but no higher, for PTSD from October 3, 2019, 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. 4. The criteria for service connection for fibromyalgia, or any medically unexplained chronic multisymptom illness, are not met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 5. The criteria for service connection for a migraine headache condition are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for cervical strain, claimed as neck condition are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1989 to July 1989, and from November 1989 to July 1992. This appeal comes before the Board of Veterans’ Appeals (Board) from October 2011, April 2015, and March 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2016, the Veteran testified at a video conference hearing in the Cleveland, Ohio RO before the undersigned Veterans Law Judge sitting at the Central Office in Washington, D.C. The Veteran testified in support of his claims for PTSD, fibromyalgia, headaches, and cervical strain. A transcript of the hearing is available in the record. It should be noted that the Veteran’s claim for obstructive sleep apnea, which is being remanded by this decision, was not addressed at the hearing in December 2016. The RO denied that claim by rating decision in March 2017. The VA form 9, substantive appeal submitted in December 2018 indicated that a video hearing was requested. In June 2020 and February 2021, the Veteran’s attorney withdrew the hearing request. In a February 2021 letter, the Veteran’s attorney asked for a 90 day period for a stay of a decision until such time as additional evidence could be gathered and submitted and also indicated no such material would be submitted more than 90 days after the date of the mailing of the letter. A subsequent February 2021 letter indicated that additional evidence was being submitted and that RO consideration was waived. The Veteran’s claims for PTSD, fibromyalgia, headaches and cervical strain have previously been before the Board. The Board remanded those claims each for new medical examinations. Subsequently, the Veteran was afforded new medical examinations, and thus the Board finds its instructions were substantially complied with. Stegall v. West, 11 Vet. App. 268 (1998). 1. From December 24, 2014 to January 12, 2017, entitlement to an evaluation in excess of 30 percent disabling for post-traumatic stress disorder (PTSD) is denied. The Veteran seeks entitlement to an increased evaluation for his service-connected PTSD, which has been evaluated at 30 percent disabling since December 24, 2014. Disability ratings 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 (rating schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability 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. Where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1995). A veteran is presumed to be seeking the maximum possible evaluation. AB v. Brown, 6 Vet. App. 35 (1993). When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods of time based on the facts found – a practice known as “staged” ratings. Under the General Rating Formula, a 0 percent rating is warranted when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational or social functioning, or to require continuous medication. A 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during period of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss. A 50 percent rating is warranted for 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, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. A 70 percent rating 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, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships. A maximum rating of 100 percent is warranted for 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, disorientation to time or place, and memory loss for names of close relatives, own occupation or own name. See 38 C.F.R. § 4.130. It should be noted that the symptoms associated with each rating under the General Rating Formula do not constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the appropriate rating of a psychiatric disorder is not restricted to the symptoms set forth in the General Rating Formula. Id. As the Veteran’s ratings will be staged, each stage will be discussed separately. The Veteran underwent a VA examination for his PTSD in April 2015. The examiner diagnosed the Veteran with PTSD. The Veteran’s symptoms were documented to include anxiety, suspiciousness, and mild memory loss such as forgetting names, directions or recent events. The overall severity of the Veteran’s condition was summarized as occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. See April 2015 VA Examination. Generally, the Veteran’s treatment during this stage on appeal reflect similar symptoms to what was shown by the VA examination. He reported avoiding activities, places and people; difficulty sleeping; being irritable and on guard in December 2015. In September 2016 he reported feeling depressed and frustrated at people, and avoiding crowds. Throughout this stage on appeal, the Veteran denied suicidal or homicidal ideations. See VA Medical Treatment Record. From December 24, 2014 to January 12, 2017, the preponderance of evidence supports that the Veteran’s PTSD manifested as occupational and social impairment due to mild or transient symptoms. Accordingly, the assigned 30 percent evaluation is appropriate during this stage on appeal, beginning on the first date when the evidence showed such impairment. A higher rating is not warranted as the Veteran’s symptoms did not show occupational and social impairment with reduced reliability and productivity during this period. Thus, from December 24, 2014 to January 12, 2017, entitlement to an evaluation in excess of 30 percent disabling for post-traumatic stress disorder (PTSD) is denied. 2. From January 13, 2017 to October 2, 2019, entitlement to an evaluation of 50 percent disabling for PTSD, but no higher, is granted. The Veteran has provided a copy of an examination from January 2017 which is indicated to have been performed by a private licensed psychologist. That psychologist diagnosed the Veteran with PTSD, and annotated symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a worklike setting, and impaired impulse control, such as unprovoked irritability with periods of violence. The psychologist summarized the severity of the Veteran’s condition as occupational and social impairment with reduced reliability and productivity. The psychologist wrote that the Veteran experienced functional impairment predominantly in social areas, but he could function satisfactorily because of the Veteran’s great effort. Thus, the psychologist concluded the Veteran’s actual functional impairment most closely approximated 50 percent impairment. See January 2017 Correspondence. The Veteran also underwent a second VA examination for his PTSD in January 2017. The examiner diagnosed the Veteran’s condition as Other Specified Trauma- and Stressor-Related Disorder, which was noted to be “subthreshold PTSD.” The examiner documented the Veteran’s reports of experiencing anxiety, depression, nightmares and anger. He also reported anhedonia, frequent dysphoric moods, hypersomnia, psychomotor agitation, fatigue, guilt and poor concentration. The Veteran credibly denied current or past suicidal or homicidal ideations. The examiner assessed the overall severity of the Veteran’s condition as 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. See January 2017 VA Medical Treatment Record. Weighing the probative evidence, the Board concludes that a 50 percent evaluation is appropriate from January 13, 2017 to October 2, 2019. Although the VA examiner described the Veteran’s occupational and social impairment similarly to the previous VA examination, the Board is mindful that the Veteran’s symptoms showed worsening due to new symptoms of anhedonia and dysphoric moods. Thus, the Board finds the private psychologist’s assessment of the Veteran’s symptoms during this stage to be more probative. Thus, the evidence preponderates that the Veteran’s condition manifested as occupational and social impairment with reduced reliability and productivity. A higher evaluation during this stage on appeal is not appropriate as the evidence does not show occupational and social impairment with deficiencies in most areas. Accordingly, from January 13, 2017 to October 2, 2019, entitlement to an evaluation of 50 percent disabling for PTSD, but no higher, is granted. 3. From October 3, 2019, entitlement to an evaluation of 70 disabling for PTSD, but no higher, is granted. In October 2019, the Veteran underwent another VA examination for his PTSD. The examiner confirmed the Veteran’s diagnosis of PTSD, and annotated symptoms of depressed mood, anxiety, memory loss, such as forgetting names, directions or recent events, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work like setting, and suicidal ideation. The Board is mindful that this is the first instance in the Veteran’s medical record in which suicidal ideation was listed as one of his mental health symptoms. Thus, the Board observes additional worsening of the Veteran’s condition, first shown at the date of this examination. The examiner summarized the severity of the Veteran’s condition as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. See October 2019 C&P Examination. The Board is mindful that such language is consistent with the language in the rating schedule for a 70 percent evaluation. The preponderance of evidence supports a finding that from October 2, 2019, the Veteran’s condition has manifested as occupational and social impairment with deficiencies in most areas. No evidence of record refutes the VA examiner’s assessment. The Veteran’s condition is shown to have worsened from the date of this examination based on the earliest reports of suicidal ideation in the record. Accordingly, a 70 percent evaluation is warranted. A higher evaluation is not appropriate as the evidence does not show total occupational and social impairment. During the October 2019 hearing, the veteran denied any significant changes in his social or family history since his last exam. He reported that he is married, has 3 sons, and has a small group of friends that he socializes with regularly. He reported that he has difficulty being in large crowds. The Veteran reported that his last employment was about 1 month ago, and he worked as a substitute teacher, and he only worked for 3 days due to his anxiety and PTSD symptoms. He reported that he retired from his previous job as a water operator in 2017, and he had that job for 5 years. He reported that he retired because of irritability and anger management issues with coworkers and management. The weight of the evidence shows that there is not total social impairment. Thus, from October 2, 2019, entitlement to an evaluation of 70 percent, but no higher, for PTSD is granted. Service Connection Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). Generally, service connection requires: (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease; and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999). Service connection may be established for a current disability on the basis of a presumption that certain chronic diseases, to include organic diseases of the nervous system, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (a). For organic diseases of the nervous system, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307 (a)(3). If there is no manifestation within one year of service, service connection for a recognized chronic disease can still be established through continuity of symptomatology. 38 C.F.R. §§ 3.303 (b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (2013). Continuity of symptomatology requires the chronic disease to have manifested in service. 38 C.F.R. § 3.303 (b). In-service manifestation means a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. 4. Entitlement to service connection for fibromyalgia is denied. The Veteran seeks entitlement to service connection for fibromyalgia. Fibromyalgia is among certain conditions given special consideration for service connection for Persian Gulf veterans under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. Military records show the Veteran served in the Persian Gulf in support of Operations Desert Shield and Desert Storm. It should further be noted that the record contains a letter sent to the Veteran in July 1997 from the Office of the Secretary of Defense notifying him that his unit was possibly exposed to a very low level of nerve agents in the Persian Gulf in March 1991. The Veteran has also reported exposure to fumes from oil well fires, and anti-nerve agent medications administered for his deployment. Medical records show the Veteran has consistently reported his exposures to nerve agents and other chemicals to his treating physicians, and such exposures are annotated throughout his medical records and the claim file. For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness (MUCMI); and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service-connection. Under 38 C.F.R. § 3.317, a MUCMI means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). Along with the three examples of a MUCMI provided by section 1117 (a)(2)(B)—chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome—there is a list of signs or symptoms that may be a manifestation of an undiagnosed illness or a MUCMI in 38 C.F.R. § 3.317 (b) that includes fatigue, gastrointestinal signs or symptoms, signs or symptoms involving the respiratory system, muscle pain, joint pain, and sleep disturbances. The term “objective indications of a qualifying chronic disability” includes both “signs,” in a medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117, unlike those for “direct service connection” there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). For purposes of Gulf War undiagnosed illness claims, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(2)(5). The Veteran’s medical record does not reflect a diagnosis, nor history of treatment for fibromyalgia. In June 2009, the Veteran underwent a Gulf War examination by a VA physician. The Veteran reported symptoms of headaches; dizziness; chronic fatigue; tingling and numbness in his hands and feet, including muscle twitches and “sharp reflexes” regardless of whether he was active or not; loose stools; ringing in his ears; and severe forgetfulness. The examiner assessed the Veteran and offered lengthy discussion of the Veteran’s various reports of joint pain, including knee, shoulder and neck pain beyond the reports above. The Veteran was assessed to have left shoulder rotator cuff tendinosis / osteoarthritis and labral tears; right shoulder tendinosis, panlabral tears and osteoarthritis; right knee degenerative joint disease and meniscal degeneration; left knee degenerative joint disease and infraspinatus tendon tear; carpal tunnel syndrome; and a cervical strain. However, the examiner did not diagnose fibromyalgia, writing that “Labs show a normal CBC other than a platelet count slightly low at 127. White count is 4.9, hemoglobin is 14.5. Rheumatoid factor is less than 20. ANA is negative. TSH is normal at 2.8 and chemistry is within normal limits other than a slightly elevated CO2 of 33. ESR is slightly elevated at 28. He does not have the tender points on physical exam seen typically with fibromyalgia.” See June 2009 Compensation and Pension (C&P) Examination. In October 2019, the Veteran underwent a VA examination. The examiner completed a Gulf War General Medical Examination (including burn pits) Disability Benefits Questionnaire, which instructs the examiner to consider the symptoms listed in 38 C.F.R. § 3.317 (b), outlined above. The examiner documented the Veteran’s report of fatigue. However, the examiner’s report does not reflect muscle or joint pain. No diagnosis of fibromyalgia was found. See October 2019 C&P Examination. The Board affords this examination high probative weight based on the examiner’s thorough discussion of each of the Veteran’s complaints and diagnoses. In February 2020, the Veteran underwent a VA examination to assess him for fibromyalgia. The examiner indicated a normal physical examination, with no diagnoses of fibromyalgia, or any undiagnosed illness, or medically unexplained chronic multisymptom illness. See February 2020 C&P Examination. The preponderance of evidence does not support that the Veteran has fibromyalgia, or any medically unexplained chronic multisymptom illness for which service connection may be granted. Although the Veteran has reported symptoms as outlined within 38 C.F.R. § 3.317 (b) as signs and symptoms that may be a manifestation of an undiagnosed illness or a MUCMI, in the Veteran’s case those symptoms have each been attributed to a diagnosed condition. Accordingly, presumptive service connection is not appropriate under 38 U.S.C. § 1117 and 38 C.F.R. § 3.17. Similarly, service connection is not warranted for fibromyalgia on a direct basis, as the first requirement of a disabling condition is not satisfied. See Hickson v. West, 12 Vet. App. 247 (1999). As the preponderance of evidence goes against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107. The claim for service connection for fibromyalgia is denied. 5. Entitlement to service connection for a migraine headache condition is granted. The Veteran seeks entitlement to service connection for migraine headaches. The Veteran has a diagnosis of migraine headaches. See February 2016 C&P Examination. Thus, the first Hickson requirement for direct service connection is satisfied. The Veteran has stated that his chronic headaches date back to the conclusion of the Gulf War in 1991. See July 2009 Correspondence. Service treatment records reflect several reports of headaches in early 1990. In July 1990 the Veteran reported his headaches kept him awake at night. Thus, the second Hickson requirement is satisfied, as the record shows a history of headaches during active service. Turning to the third Hickson requirement for a nexus between the present disabling condition and the in-service incurrence, the evidence of record is conflicting. In May 2012, the Veteran submitted a letter from a private physician regarding his headaches. The headaches were described as lasting one to two hours, with sensitivity to light, accompanying nausea, and difficulty falling asleep. The physician indicated he could not classify the Veteran’s headaches diagnostically, and he suggested a neurology consult. Nonetheless, he indicated that he believed the Veteran’s headaches were due to his military service, and he documented the Veteran’s reports of having first developed headaches during active duty. See February 2012 Medical Treatment Record – Non-Government Facility. In February 2016, the Veteran underwent a VA examination for his headache condition. The examiner diagnosed migraine headaches based on the Veteran’s subjective complaints. The examiner wrote an opinion that the Veteran’s headaches were less likely than not related to military service. The examiner offered rationale that there was no evidence of headaches at the time of the Veteran’s separation from active service. Further, there was no evidence of chronicity of a headache condition, based on physical evaluations from June 2014, October 2014 and August 2015 at which the Veteran did not complain of headaches. See February 2016 C&P Examination. The examiner did not comment on the Veteran’s multiple complaints of headaches during military service shown in his service medical treatment records. Thus, the Board affords the examiner’s opinion low probative value, as it was based on inadequate evaluation of the evidence. The evidence is at least in equipoise that the Veteran’s migraine headache condition was incurred during active service. The Veteran has credibly stated that he has suffered from headaches since military service. The Veteran’s military treatment records reflect some treatment for headaches, but no chronic or migraine headache condition was ever diagnosed, nor noted at the time of the Veteran’s separation. The Veteran’s private physician was unable to diagnostically characterize the headaches as migraines or any other type of headaches, but the physician affirmatively linked the condition to the Veteran’s military service. The Board concludes that the evidence is at least in equipoise to support that the Veteran’s migraine headaches were incurred during military service. The third Hickson prong is satisfied, and the claim for service connection is granted. 6. Entitlement to service connection for cervical strain, claimed as neck condition, is denied. The Veteran seeks service connection for a cervical strain, claimed as a painful neck condition. The Veteran is presently diagnosed with a cervical strain. See October 2019 C&P Examination. The first Hickson requirement is therefore satisfied. The Veteran testified in December 2016 that during his active service, he backed a High Mobility Multipurpose Wheeled Vehicle (Humvee) into another vehicle. He testified that the following morning, he went to sick call and reported a strain on his back and his upper neck, and he was given over-the-counter medications. The Veteran testified that his neck has given him problems since that time, but not continuously. See December 2016 Hearing Transcript. Service treatment records do not reflect such injury or treatment. The Veteran’s service medical records show a complaint for neck pain, during an ophthalmology examination, at which the Veteran reported a headache that also affected the neck and facial area. See March 1990 Service Treatment Record – Medical. However, no further complaints of neck pain are shown in the service treatment records. No record of the vehicle accident is shown in military evidence of record. Nonetheless, the Board finds the Veteran’s statements to be credible and concludes that the second Hickson prong is satisfied to the extent that the Veteran suffered undiagnosed neck pain after a minor motor vehicle accident. Private medical records show that in January 2005, after his discharge from military service, the Veteran suffered an intervening whiplash injury after falling on ice. The injury was diagnosed as an acute cervical whiplash injury with resulting mild upper extremity numbness. By March 2005, the Veteran reported that his whiplash injury had gradually resolved, but he experienced persistent pain in his left shoulder area. See August 2008 Medical Treatment Record – Non-Government Facility. The record contains a letter from a private physician regarding the Veteran’s headaches, but which mentions the Veteran “developed neck pain with an unknown date of onset and he has difficulty looking up or looking down. He also has difficulty driving because it is hard to turn his head.” See May 2012 Medical Treatment Record – Non-Government Facility. The Veteran underwent a VA examination for his neck in October 2019. The examiner indicated review of the Veteran’s claim file and conducted an in-person examination. The examiner documented the Veteran’s report of the Humvee accident which caused him to whip his neck backward and experience pain. The examiner wrote an opinion that it was less likely than not (less than 50 percent probability) that the Veteran’s neck condition was incurred in or caused by the claimed in-service injury. A cervical spine x-ray in 2009 had been negative for such an injury and was an unremarkable study. Review of the Veteran’s medical records showed a cervical strain diagnosis in 2012. Repeat x-rays in 2016 showed loss of normal cervical lordosis, mild to moderate right C3-C4 and C4-C5, and left C3-C4 bony exit neural foraminal encroachment. This indicated that the Veteran had sustained an injury after service, between 2009 and 2016. See October 2019 C&P Examination. The preponderance of evidence weighs against a finding that the Veteran’s cervical strain condition was incurred in, caused by, or otherwise due to active service. Because of the intervening injury the Veteran sustained in 2012, a medical nexus has not been established linking the Veteran’s current disabling condition to his in-service injury. No medical opinion of record has linked the Veteran’s current condition to his in-service injury. Although the Veteran has stated he believes his neck disability was due to his in-service injury, the evidence does not show that the Veteran has the medical training required to render such an opinion. 38 U.S.C. § 1153(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds the VA examiner’s opinion to be more probative. The third Hickson element has therefore not been satisfied, and the claim for service connection must be denied. As the preponderance of evidence weighs against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107. REASONS FOR REMAND 1. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. A review of the evidence of record shows that a private medical opinion submitted by the Veteran has linked the Veteran’s OSA to his service-connected PTSD as well as the Veteran’s obesity. No VA medical examiner has addressed whether the Veteran’s OSA may be secondarily caused or aggravated by his service-connected PTSD. Once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one. Barr v. Nicholson, 2 Vet. App. 303, 311-12 (2007). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). In this case, the October 2019 VA examination reported noted that the Veteran had stopped working one month earlier due to anxiety and PTSD symptoms. As such, the issue of TDIU has been raised by the record. When evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for entitlement to TDIU will be considered to have been raised by the record as “part and parcel” of the underlying claim. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). On remand the Veteran should be provided with notice of the evidence necessary to substantiate a claim for TDIU. Any further development deemed necessary should be conducted. The matters are REMANDED for the following action: 1. Provide the Veteran with appropriate notice of VA's duties to notify and assist, to specifically include notice of how to substantiate a claim for entitlement to TDIU. Additionally, provide him with VA Form 21-8940 and request that he supply the requisite information. 2. Associate with the claims file updated VA treatment records. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s obstructive sleep apnea is at least as likely as not proximately due to service-connected disability or aggravated beyond its natural progression by service-connected disability. The examiner should address the private medical opinion submitted in February 2021 which states that the Veteran’s OSA is secondary to both his PTSD and his obesity. See February 2021 Medical Treatment Record – Non-Government Facility. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Hermsdorfer, 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.