Citation Nr: 21021904 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 16-15 112 DATE: April 14, 2021 ORDER Entitlement to a 100 percent initial disability rating for post-traumatic stress disorder (PTSD) from September 25, 1996, is granted. Entitlement to an effective date prior to September 25, 1996, for the grant of service connection for PTSD is denied. Entitlement to an effective date prior to September 25, 1996, for entitlement to total disability based on individual unemployability (TDIU) is denied. Entitlement to service connection for hypothyroidism, to include as secondary to herbicide agent exposure, is granted. REMANDED Entitlement to service connection for diabetes mellitus, to include as secondary to herbicide agent exposure, is remanded. Entitlement to service connection for a bilateral eye condition, to include as due to herbicide agent exposure or secondary to diabetes mellitus, is remanded. Entitlement to service connection for erectile dysfunction (ED), to include as due to herbicide agent exposure or secondary to a service-connected disability, is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran’s PTSD has been characterized by either total occupational and social impairment or symptomatology that caused attitudes of all contacts except the most intimate to be so adversely affected as to result in virtual isolation from the community; or totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavior processes associated with almost all daily activities such as fantasy, confusion, panic, and explosions of aggressive energy resulting in a profound retreat from mature behavior; or demonstrable inability to obtain or retain employment. 2. The Department of Veterans Affairs (VA) received a claim for service connection for nervousness in March 1974, which was ultimately denied in a March 1976 Board of Veterans’ Appeals (Board) decision, which became final. 3. VA received a claim for service connection for PTSD in March 1972, which was ultimately denied in a December 1983 Board decision, which became final. 4. VA received a June 1984 claim for service connection for PTSD. VA denied the Veteran’s claim to reopen in a May 1985 determination. The Veteran did not submit new and material evidence or a notice of disagreement within the appeal period, and the decision became final. 5. VA received a May 1989 claim for service connection for PTSD. VA denied the claim in a May 1994 rating decision. The Veteran did not submit new and material evidence or a notice of disagreement within the appeal period, and the decision became final. 6. The Veteran’s most recent claim for service connection for PTSD was received on September 25, 1996. 7. No claim for TDIU was reasonably raised by the record or informally or formally filed prior to September 25, 1996; no communication received prior to September 25, 1996, could be construed as an informal or formal claim of entitlement to TDIU. 8. The Veteran has a current diagnosis of hypothyroidism. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 100 percent disability rating for PTSD from September 25, 1996, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2020), 4.130, Diagnostic Code 9411 (2008), 4.132, Diagnostic Code 9411 (1995). 2. The criteria for entitlement to an effective date prior to September 25, 1996, for the grant of service connection for PTSD have not been met. 38 U.S.C. §§ 5108, 5110, 7104; 38 C.F.R. § 3.400. 3. The criteria for entitlement to an effective date prior to September 25, 1996, for TDIU have not been met. 38 U.S.C. §§ 5108, 5110, 7104; 38 C.F.R. § 3.400. 4. The criteria for entitlement to service connection for hypothyroidism have been satisfied. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1967 to January 1969, including service in the Republic of Vietnam. This matter comes before the Board on appeal from April 2013, May 2014, and December 2016 rating decisions by a VA Regional Office (RO). In January 2019, the Veteran testified before the undersigned at a hearing. A transcript of his testimony has been associated with the claims file. As set forth in the most recent May 2019 Board decision, the issues of entitlement to service connection for diabetes mellitus, hypothyroidism, ED, and a bilateral eye condition (claimed as cataracts and glaucoma) were previously remanded for additional development. In July 2020, the RO issued a supplemental statement of the case (SSOC) denying the issues once more. These matters now return to the Board. The Board also notes that in its May 2019 remand decision, the Board instructed the RO to issue a statement of the case (SOC) with respect to the Veteran’s claim for entitlement an earlier effective date for PTSD based on clear and unmistakable error, or CUE, in a prior rating decision that denied entitlement to service connection for a psychiatric condition. See Manlincon v. West, 12 Vet. App. 238 (1999). Additionally, the Board remanded the issues of entitlement to an effective date prior to September 25, 1996, for entitlement to service connection for PTSD and TDIU on a non-CUE basis and of an increased rating for PTSD prior to March 31, 2014, as inextricably intertwined with the CUE issue. In July 2020, the RO issued an SOC denying entitlement to an earlier effective date based on CUE in a prior rating decision in addition to a July 2020 SSOC denying the other issues. However, the Veteran did not file a substantive appeal with respect to the CUE issue. As such, the CUE issue is not presently before the Board. Last, as a preliminary matter, the Board notes that, in light of confusion as to whether the Veteran wanted a private attorney or Disabled American Veterans to represent him in his claim, the Board sent him a letter asking him to clarify who was representing him and to send proper authorization forms. The letter indicated that if the Veteran did not respond within 30 days to indicate who was representing him, the Board will assume that he wished to proceed unrepresented in his appeal. To date, the Veteran has not responded to this correspondence. As the 30 days to respond have elapsed, the Board will assume he is now proceeding pro se in this matter. 1. Increased Rating for PTSD The Veteran contends that he is entitled to an increased disability rating for PTSD. At the outset, the Board notes that the appeal period spans back to September 25, 1996, when the Veteran’s most recent claim for service connection for PTSD was received. The record also reflects that the Veteran was awarded a 100 percent disability rating for PTSD from March 31, 2014. As such, the Board will focus on the evidence of record from the period beginning September 25, 1996, but prior to March 31, 2014. At the same time, the Board also notes that the Veteran’s entire history has been considered. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 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. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Where, as here, entitlement to service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each piece of evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). VA is responsible for determining whether the evidence supports the claim or is relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). First, the Board will review the evidence of record shortly before or during the period on appeal. In a letter received in August 1996, shortly before the period on appeal began, Dr. J.S. indicated that he had treated the Veteran at the West Mental Health Center between 1979 and 1981. After ending his employment at that clinic, Dr. J.S. indicated that he had treated the Veteran for psychiatric and other medical conditions at some point between 1985 and 1995, although the exact dates of treatment were unclear. Dr. J.S. stated that the Veteran frequently has trouble falling asleep, has “always been depressed,” and that at some point after being treated at the West Mental Health Center, he occasionally had to be bathed and dressed and literally forced into socialization during festive occasions like Christmas. It was unclear from the letter whether this had occurred recently. A private treatment record from October 1996 noted that the Veteran was responding well to Prozac, although it made him sleepy. See October 17, 1996, Progress Notes. In a March 1998 VA health questionnaire, the Veteran reported being bothered by repeated, disturbing memories, thoughts or images, and feeling cut off or distant from people. He was feeling bothered by feeling down, depressed, or hopeless, and was often bothered by little interest or pleasure in doing things. In an April 1998 VA mental health note, he reported insomnia and anergia, as well as crying spells, memory problems, sadness, isolation, and feelings of numbness. He had some passive suicidal ideation without an intent or plan. He complained of nightmares, flashbacks, and an increased startle response, and voiced feelings of abandonment. On his mental status examination, he was calm and appropriate, but very tearful, with an extremely constricted affect and psychomotor retardation. In May, August, and November 1998 VA mental health notes, he once again complained of a lack of energy, poor sleep, crying spells, guilty feelings, memory problems, sadness, feelings of isolation, and numbness, although the symptoms were somewhat improved. He again endorsed some passive suicidal ideation, as well as nightmares, flashbacks, an increased startle response, and feelings of abandonment. His affect was very restricted, but not tearful, with psychomotor retardation. Similar symptoms were reported in February 1999. In a March 1999 VA mental health note, he reported that he had “rage attacks,” although denied violence. He was having fewer crying spells than before but was still having some passive suicidal ideation. He denied any nightmares, flashbacks, or increased startle responses, but still felt abandoned by people. His affect was constricted with a very quiet voice, with some spontaneous tearfulness and psychomotor retardation. He reported similar symptoms in a May 1999 VA mental health note. In a May 1999 letter from Dr. M.V., a staff psychiatrist at the Decatur VA Medical Center, Dr. M.V. stated that the Veteran had disabling symptoms including intense, unrelenting dysphoria, nightmares, flashbacks, feelings of numbness, rage attacks, and cognitive and psychomotor slowing. He had been complying with his medications but continued to suffer from severe symptoms. His affect in the past few treatment sessions he had with Dr. M.V. was constricted and hopeless. He felt abandoned by others and his family had split up several years ago. Dr. M.V. opined in the letter that he was totally disabled as a result of PTSD, with impaired thought processes and communications, chronic danger of hurting himself, and intermittent inability to perform activities of daily living. He also had deficiencies in many other areas, such as work, family relations, judgment, thinking, and mood, with suicidal ideation and near-continuous depression, which affected his ability to function independently, appropriately, and effectively. Additionally, he had extreme difficulty adapting to stressful circumstances, including work or a worklike setting. An August 1999 VA progress note reflected that he was being followed for depression and PTSD and that he was fearful, as on previous visits. He also reported some suicidal thoughts. In a separate August 1999 VA mental health note, he complained of difficulty sleeping. On his mental status examination, there was dysphoria, but no psychomotor acceleration or retardation and no florid signs or symptoms of psychosis. In a September 2000 VA mental health note, he reported that he was depressed, irritable, and verbally abusive to his sister, with whom he was staying. He reported sudden anxiety attacks with restlessness, shortness of breath, and tachycardia. His mood and affect were depressed, and he endorsed suicidal ideation. He also displayed possibly paranoid thinking and guarded behavior. At an August 2002 VA examination for skin diseases, he reported not sleeping well. The VA examiner noted that he was soft-spoken and inhibited to a degree that made taking his medical history difficult initially, although he was ultimately cooperative and answered questions appropriately. At a separate August 2002 VA examination for PTSD, the VA examiner noted that the Veteran was initially diagnosed with schizophrenia in 1982 after being treated by a mental health clinic in Fulton County. This diagnosis was later changed to PTSD by Dr. M.V. during treatment with VA. The Veteran denied suicidal or homicidal ideation except for passive suicidal thoughts. He reported being divorced and unemployed. For the past 20 or 30 years, he had been living on Social Security disability income, which he indicated that he received partially due to his “nerves.” He complained of insomnia, irritability, and losing his temper easily. He also reported that anxiety and panic attacks had developed about a year ago. He also admitted that he had violent thoughts towards other people and that he wanted to hurt his family, although he denied those thoughts at the examination. Additionally, he indicated that he had previously been verbally and physically abusive, and still had outbursts of anger where he broke things around him. He reported avoiding crowds and preferring to be alone. He did not have any friends. On his mental status examination, the examiner noted that he was neatly and cleanly dressed and fairly cooperative, although he kept his eyes down and did not say much. He exhibited some psychomotor retardation, as well as slow speech with a low tone and some hesitancy. His affect was “rather flat,” although he also cried several times during the interview, and his mood was depressed and anxious. He admitted to some suicidal thoughts and violent thoughts, although without intent. His thinking was coherent, albeit somewhat tangential, with “meager” thought content and paranoid thoughts. He also reported hearing voices that expressed derogatory statements about himself. In addition, he had “rather poor” concentration and displayed obsessive thinking. Insight and judgment were poor. In a May 2003 letter from C.H., a social worker, C.H. opined that the Veteran met the criteria for a disability rating between 70 and 100 percent due to his mental and emotional problems. He reported constant, day-to-day periods of lability wherein he experienced mood swings, somatic complaints, and associated paranoia. He also had “marked, extreme levels of deficiencies” in his ability to maintain pace or persistency, concentrate, function socially, and perform activities of daily living. He displayed affective disorders including continued and constant loss of interest in almost all activities, an appetite disturbance, sleep disturbance, psychomotor agitation, chronic fatigue, changes in bowel habits, excessive moodiness, pains throughout his body, difficulty breathing, nervousness and jitteriness, suicidal thoughts, difficulty concentrating, hallucinations, paranoid ideations, and avoidant behaviors. At a separate May 2004 VA examination for PTSD, the Veteran reported that he used to have an active social life but was now unable to participate in recreational activities due to multiple health problems. He was able to dress himself, take care of himself, take care of his personal hygiene, eat independently, eat his own meals, and watch TV. His affect was flat and tearful. In a December 2006 VA treatment note, he reported that he did not sleep well and that his energy was low. He also endorsed thoughts of hopelessness and worthlessness and some passive suicidal ideation. In addition, he reported anxiety and panic attacks, as well as mood swings, anger issues, and paranoia. He denied auditory or visual hallucinations and manic symptoms, but also reported that he had chocked his wife in the past. His speech was slow and soft, mood was down, and affect was restricted and sad. His thought processes were coherent and goal-oriented, although he had some paranoia. In a February 2007 VA treatment note, his affect was blunted and guarded, although insight and judgment were fair. He had slow speech, poor eye contact, vague thought processes, and paranoid thought content. He reported having “quite a bit” of loss of interest in things that he used to enjoy, difficulty concentrating, and being “super alert.” Additionally, he felt “extremely” distant or cut off from others and emotionally numb, and he reported having angry outbursts. In an April 2007 VA mental health note, he reported that he had stopped taking his medications because they were not helping to alleviate his symptoms. His affect was blunted, and he was guarded and paranoid with tight associations. There were no fixed delusions or auditory hallucinations at that time, but his insight and judgment were poor. In an October 2007 physical conducted by Dr. R.S., the Veteran reported feeling worthless, depressed, and nervous for the past 30 years. He reported living at home with his fiancée and their son. His affect was appropriate, and his thought processes were logical. Similarly, in a November 2007 consultation with Dr. K.V., he reported a decreased appetite, with a longstanding history of PTSD, anxiety, depression, and nervousness. In treatment records from Midtown Neurology, Dr. L.F. noted that the Veteran was alert, although he seemed to require some effort to stay awake, and that he had fluent speech. With respect to his memory, he was aware of details of his personal history. See January 2008, November 2007 Progress Notes. In a June 2008 survey of symptoms taken for Dr. D.H. at Henry Family and Sports Chiropractic Clinic, the Veteran endorsed symptoms such as apprehension, morbid fears, a poor appetite, a tendency to cry without reason, irritability, depression, acoustic hallucinations, anxiety, an inability to concentrate, confusion, fatigue, nervousness, and insomnia. In an October 2012 report from the Emory Winship Cancer Institute, Dr. A.N. noted that the Veteran reported a loss of interest in activities, fatigue, increased irritability, excessive restless, feeling depressed, and feeling sad and tearful. Although he was not currently suicidal, he endorsed a 40-year history of anxiety, depression, and suicidal thoughts. In a May 2013 letter, Dr. E.H. reported that the Veteran had a long history of PTSD and depression, which produced debilitating symptoms. She opined that stressful situations were detrimental to his wellbeing and would increase the severity of his condition. Due to the intensity of his symptoms, she reported, he had difficulty adapting to stressful circumstances in his life, which was not favorable for his medical or emotional health. The Board now turns to the applicable law. During the pendency of his claim, the regulations regarding disability ratings for PTSD have undergone several changes. First, the regulations in effect when the claim was filed were revised a short time later, effective November 7, 1996. Thereafter, the regulations were revised once more, effective April 24, 2009. In this regard, the Federal Circuit Court of Appeals has held that the Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. See Kuzma v. Principi, 341 F.3d. 1327 (Fed. Cir. 2013). However, the Board is not precluded from applying prior versions of the new diagnostic codes if the prior versions were in effect during the pendency of the appeal, as is the case here. Prior to November 7, 1996, mental disorders were rated pursuant to 38 C.F.R. § 4.132, Schedule of ratings – mental disorders. VA’s then-extant Schedule for Rating Disabilities provided a general rating formula for psychoneurotic disorders, including PTSD, based on the degree of incapacity or impairment. 38 C.F.R. § 4.132, Diagnostic Code 9411 (1995). A 70 percent disability rating was assignable where the ability to establish and maintain effective or favorable relationships with people was severely impaired, with psychoneurotic symptoms of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. Id. A 100 percent disability rating, on the other hand, was warranted where the attitudes of all except the most intimate were so adversely affected as to result in virtual isolation in the community; or when there were totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality, disturbed thought or behavior processes associated with almost all daily activities, such as fantasy, confusion, panic, and explosions of aggressive energy, which resulted in profound retreat from mature behavior; or when the veteran was demonstrably unable to obtain or retain employment. Id. 38 C.F.R. § 4.130 provided that the severity of a psychiatric disability would be evaluated based on actual symptomatology as it affected social and industrial adaptability. See 38 C.F.R. § 4.130 (1995). As set forth in the regulation, it was important for the rating board to neither under-evaluate an emotionally sick veteran with a good work record, nor over-evaluate his condition on the basis of a poor work record not supported by the psychiatric disability picture. Id. Ratings were to be assigned that represented the impairment of social and industrial adaptability. Id. Shortly after the Veteran filed the instant claim, the regulations underwent significant changes that became effective on November 7, 1996. From that date, PTSD and various other mental disorders were rated under the General Rating Formula for Mental Disorders found in 38 C.F.R. § 4.130 (2008). Pursuant to the version of the General Rating Formula for Mental Disorders that was in effect from November 7, 1996, to April 23, 2009, a 70 percent rating was warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating was warranted for total occupational and social impairment, due to symptoms such as gross impairment of 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 minimum personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Finally, the regulations were revised once more, effective April 24, 2009. Under the currently applicable regulations governing the General Rating Formula for Mental Disorders in 38 C.F.R. § 4.130, the 70 percent rating were unchanged from the criteria in effective from November 7, 1996. However, the 100 percent rating criteria were changed so that a 100 percent disability rating was also warranted for symptoms of gross impairment of thought processes or communication or persistent delusions or hallucinations, in addition to the symptoms listed in the version of the regulation in effect immediately prior to April 24, 2009. For simplicity’s sake, the Board will discuss the Veteran’s symptoms and the applicable law during three separate periods: first, the period beginning September 25, 1996, to November 6, 1996; from November 7, 1996, to April 23, 2009; and from April 24, 2009, to March 30, 2014. Ultimately, the Board finds that a 100 percent disability rating is warranted for PTSD throughout the period on appeal. September 25, 1996, to November 6, 1996 There is a relatively small amount of evidence from this narrow portion of the period on appeal. However, when considered in the context of the Veteran’s entire medical history, including evidence generated just before his claim was filed, the evidence generally indicates that the Veteran’s disability picture more closely approximates a 100 percent disability rating. For instance, the evidence indicates that the Veteran was virtually isolated from his community and that he was unable to obtain or retain employment at least in part because of his service-connected PTSD symptoms. The August 1996 letter from Dr. J.S. does not indicate the precise dates of the occasions when the Veteran had to be forced to bathe or interact with others. Nonetheless, when viewed in the light most favorable to the Veteran, this evidence suggests that he had become virtually isolated from his community, this evidence suggests that the Veteran had become virtually isolated from his community and that his symptoms caused him to retreat from mature behavior, such as socializing or bathing himself. The Board also notes that the evidence from throughout the record reflects that the Veteran receives disability benefits from the Social Security Administration (SSA). Unfortunately, it appears that not all of the relevant SSA records are available. See September 2002 SSA Response (indicating that the Veteran had been considered disabled for SSA purposes from September 15, 1973, and had received continuous disability benefits from that date, but that his medical records could not be located and SSA was thus unable to comply with VA requests for copies of his medical records). However, the claims file contains an SSA Report of Continuing Disability Interview from May 1987, which indicates that he was unable to work due to spinal problems, for which he is also entitled to service connection, as well as a “nervous problem.” Affording him the benefit of the doubt, the Board finds that the evidence indicates that the Veteran’s nervous condition has rendered him unable to obtain or maintain employment, consistent with a 100 percent disability rating. From November 7, 1996, to April 23, 2009 The Board also notes that a 100 percent disability rating is warranted prior to April 24, 2009, under both the previous rating criteria and the rating criteria in effect from November 7, 1996, to April 23, 2009. To that end, the evidence during this portion of the appeal period continues to show that he was unable to obtain or maintain employment at least in part due to PTSD, that he was virtually isolated from his community, and that he had psychoneurotic symptoms bordering on a gross repudiation of reality or disturbed behavior such as confusion, panic, and explosive anger. The evidence also suggests that he was a persistent danger to himself or others and that he was intermittently unable to perform activities of daily living. Such a finding is supported by the evidence from this portion of the appeal period. For instance, as set forth above, the Veteran consistently reported to VA treatment providers between April 1998 and November 1999 that he suffered from feelings of isolation and abandonment, while those treatment providers also noted psychomotor retardation. In March 1999 treatment records, his treatment provider noted “rage attacks,” while in the May 1999 letter from Dr. M.V., Dr. M.V. indicated that the Veteran was “totally disabled” due to his PTSD. Dr. M.V. based this assessment on symptoms such as his rage attacks, cognitive and psychomotor slowing, intermittent inability to perform activities. He also opined that the Veteran was a persistent danger to himself or others. Likewise, in September 2000 VA records, he reported that he had been verbally abusive to his sister, while the treatment provider noted paranoid thought content. Additionally, the August 2002 VA examiner noted that he had no friends, lost his temper easily, had engaged in prior instances of physical and verbal abuse, suffered from outbursts of anger, had paranoid thoughts, heard voices, and displayed poor insight and judgment. These observations are consistent with a May 2003 letter from C.H., who also reported that the Veteran had marked levels of deficiency in various areas due to paranoia, hallucinations, avoidant behaviors, and psychomotor slowness. Similarly, December 2006 VA treatment records reflect that he suffered from “anger issues” and paranoia and that he had previously choked his wife. Moreover, he reported in February 2007 that he felt extremely cut off from others and had angry outbursts, while his April 2007 VA treatment records reflect paranoid thoughts and poor insight and judgment. Last, in his June 2008 survey of symptoms for Dr. D.H., he endorsed various symptoms such as hallucination and confusion. Ultimately, taken in the light most favorable to the Veteran, this evidence demonstrates markedly severe psychiatric symptoms, including disturbed or paranoid thought content, hallucinations and confusion, reports of past verbal and physical abuse, and psychomotor retardation. Indeed, letters from various treatment providers, such as Dr. M.V. and C.H. consistently report that he is totally disabled due to his PTSD symptoms due to such symptoms. The other evidence of record, such as contemporaneous VA mental health treatment notes and his VA examination reports, bolsters their opinions. As such, resolving all reasonable doubt in the Veteran’s favor, the Board finds their opinions highly probative. Under either applicable rating criteria, his disability picture thus more closely approximates a 100 percent disability rating. From April 24, 2009, to March 30, 2014 Last, the Board has considered the evidence of record during the period of appeal after the current rating criteria went into effective, but prior to the effective date of his existing a 100 percent disability rating. Under any of the three sets of applicable regulations, the Board finds that a 100 percent disability rating is warranted during this period on appeal. Generally, the evidence from on or after April 24, 2009, reflects symptoms that are the same as or a continuation of the symptoms noted in evidence generated earlier in the appeal period. For instance, in the May 2013 letter from Dr. E.H., she notes that the Veteran has a long history of debilitating symptoms, while Dr. A.N. noted his 40-year history of suicidal thoughts in 2012. Moreover, when compared to the evidence of record generated after the effective date for the 100 percent disability assigned by the RO previously, his symptoms appear largely the same. To that end, he underwent an April 2014 VA examination, where the VA examiner noted a history of anger, irritability, angry outbursts, and isolation. Although he was “not as paranoid as he was before,” when he “felt people were out to get him” and “were against him,” he still had these feelings sometimes. He also reported crying spells two or three times a week, a depressed mood, anxiety, avoiding crowds, hypervigilance, mistrust, suspiciousness, social isolation, flashbacks, and panic attacks a few times a month. He also reported a loss of interest in activities, emotional numbness, feelings of detachment and estrangement, a restricted range of affect, difficulty socializing and trusting others, and paranoid delusions. The examiner also noted that he was very soft-spoken and hard to understand, as well as that he displayed symptoms of psychomotor retardation, poor eye contact, and barely audible speech. These symptoms, which were noted approximately one month after the 100 percent disability rating assigned by the RO became effective, are nearly identical to the symptoms described in evidence generated prior to March 31, 2014. For example, his prior treatment records and examination reports are replete with instances of paranoid thoughts, psychomotor retardation, isolation from others, restricted affect, and angry outbursts. As such, resolving all reasonable doubt in his favor, the Board finds that a 100 percent rating is warranted during this portion of the period on appeal as well. Ultimately, having reviewed the entire record, including evidence generated since filing his claim in September 1996, the Board finds that the Veteran is entitled to a 100 percent disability rating from September 25, 1996. 2. Earlier Effective Date for PTSD Generally, the Veteran asserts that he is entitled to an earlier effective date for establishing service connection for PTSD. Essentially, he has argued that he has filed numerous prior claims for PTSD and that he is entitled to an effective date prior to September 25, 1996, as a result. By way of procedural background, the record reflects that the Veteran first filed a claim for service connection for nervousness in March 1974. This claim was denied in a May 1974 rating decision. Subsequently, the Veteran appealed this decision, but the Board ultimately denied entitlement to service connection in a March 1976 decision. The Veteran did not appeal the decision to the Court, and the Board decision became final. Subsequently, he filed a new claim for PTSD in October 1981, which was denied in March 1982 rating decision. Once more, this rating decision was ultimately appealed to the Board, which denied the claim in a December 1983 decision. He did not appeal this decision to the Court either. Thereafter, the Veteran filed a new claim for PTSD in June 1984. In a May 1985 notification letter, however, the RO informed the Veteran that his claim had previously been denied and that he would need to submit new and material evidence not previously submitted in order to reopen his claim. He did not respond to this letter and no new documents were associated with the claims file until May 1989, when he filed a new claim for a nervous condition. This claim was denied in a May 1994 rating decision. The Veteran did not submit new and material evidence within one year of this rating decision, nor did he submit a notice of disagreement within the appeal period. As such, it became final. In September 1996, he filed a new claim for PTSD, which was ultimately granted. Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increased compensation will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5100; 38 C.F.R. § 3.400. If a claim for disability compensation is received within one year after separation from service, the effective date of entitlement is the day following separation or the date entitlement arose. 38 C.F.R. § 3.400(b)(2). Otherwise, it is the date of receipt of claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. For claims received prior to March 24, 2015, a “claim” is defined as a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. §§ 3.1(p), 3.155(a) (2014); Brannon v. West, 12 Vet. App. 32, 34-5 (1998). Any communication or action indicating an intent to apply for one or more VA benefits, including statements from a Veteran’s duly authorized representative, may be considered an informal claim. 38 C.F.R. § 3.155(a) (2015). Such informal claims must identify the benefit sought. Id. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. Id. If received within one year from the date it was sent to the claimant, it will be considered as filed as of the date of receipt of the informal claim. Id. Effective March 24, 2015, VA amended various regulations governing how to file a claim. The amended regulations require that all claims governed by VA’s adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57,660 (Sept. 25, 2014). At the time that these amendments were made, VA also deleted a regulation that allowed various documents to be considered informal claims. More specifically, prior to March 25, 2015, a report of examination or hospitalization could be accepted as an informal claim for benefits in claims for an increased disability rating or to reopen a claim after a final disallowance. See 79 Fed. Reg. 57,660, 57,675 (Sept. 25, 2014) (removing then-current 38 C.F.R. § 3.157(b)). Additionally, veterans generally have one year from the mailing date of the notice of a rating decision to file a notice of disagreement with that decision. 38 C.F.R. § 3.156(b) provides that new and material evidence received prior to the expiration of this period will be considered to have been filed in connection with a claim that was pending at the beginning of the appeal period. In Beraud v. McDonald, the Federal Circuit Court of Appeals held that, when new evidence is submitted within the one-year period of appeal following the issuance of a rating decision, the claim remains pending until VA provides a determination that directly responds to that new submission under 38 C.F.R. § 3.156(b). 766 F.3d 1402, 1407 (Fed. Cir. 2014). Here, the Board has carefully reviewed the Veteran’s claim file. However, the record indicates that the earliest effective date permissible by law has already been assigned. To that end, the Veteran’s prior claims for service connection for a mental health disability, however characterized, had all become final. No new and material evidence was received within one year of any rating decision for purposes of 38 C.F.R. § 3.156(b) such that finality of that rating decision would have been vitiated, and no formal or informal claims were pending prior to September 25, 1996. First, the Board notes that a Board decision becomes final on the date stamped on the face of the decision, unless the case is further appealed to the Court or a motion for reconsideration is granted. 38 C.F.R. § 20.1100. The Veteran did not appeal either the March 1976 or December 1983 Board decisions to the Court, nor has he submitted motions for reconsideration of those Board decisions. As such, those decisions on his March 1974 and March 1982 claims, respectively, became final. Additionally, the May 1985 and May 1994 RO determinations became final. To that end, the RO issued a May 1985 determination that the Veteran had not submitted new and material evidence to reopen his claim for PTSD after he submitted a June 1984 informal claim. The Veteran did not submit a notice of disagreement with this decision within one year of its issuance; moreover, no new and material evidence was submitted during that time. As such, the claim did not remain pending. Moreover, the Veteran did not submit a notice of disagreement within one year of the May 1994 rating decision denying entitlement to service connection for a nervous condition, and no new and material evidence was submitted within one year of the rating decision. As a result, this claim became final as well. The Board has considered whether the Veteran filed any other formal or informal claims for service connection prior to September 25, 1996. However, the record does not indicate that any other formal or informal claims were received prior to the September 25, 1996, claim for service connection that was ultimately granted. As such, the Board has already assigned the earliest effective date allowable by law. The pertinent legal authority governing effective dates is clear and specific, and the Board is bound by that authority. Although the Board acknowledges the Veteran’s contention that because he has been pursuing various claims for PTSD since shortly after his discharge from service, these claims had been finally adjudicated. As provided by law, the effective date of an evaluation and award of compensation based on a claim reopened after final disallowance is the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5100; 38 C.F.R. § 3.400. As such, the preponderance of the evidence is against the assignment of an effective date for the grant of service connection for PTSD earlier than September 25, 1996. 3. Earlier Effective Date for TDIU At the time his case reached the Board on appeal, the Veteran was entitled to TDIU from September 25, 1996. As set forth above, no earlier effective date is warranted for the Veteran’s claim for PTSD, because no formal or informal claim for service connection for PTSD was still pending prior to September 25, 1996. Moreover, the Veteran was not entitled to service connection for any disability prior to September 25, 1996. As such, TDIU could not have been raised by the record pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), prior to his September 25, 1996, claim at the earliest. Moreover, the record does not indicate that the Veteran filed either an informal or formal claim for TDIU that was pending prior to September 25, 1996. Consequently, an earlier effective date for TDIU is not warranted. 4. Service Connection for Hypothyroidism The Veteran has also claimed that he is entitled to service connection for hypothyroidism, to include as due to herbicide agent exposure. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Additionally, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he served in the Republic of Vietnam during the Vietnam era. 38 C.F.R. § 3.307(a)(6)(iii). In addition, if a veteran was exposed to an herbicide agent during active service, certain diseases shall be service connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service. 38 C.F.R. § 3.307(e). Pursuant to the National Defense Authorization Act for Fiscal Year 2021, hypothyroidism was added to the list of diseases presumptively associated with exposure to herbicide agents. 38 U.S.C. § 1116(a)(2). The Veteran’s service in Vietnam, and hence his presumed exposure to herbicide agents, is not in question, as set forth above. As he has a current diagnosis of hypothyroidism and was presumed to be exposed to herbicide agents during his service in the Vietnam, the Board finds that service connection for hypothyroidism is thus warranted on a presumptive basis. REASONS FOR REMAND 1. Diabetes mellitus The Veteran has also claimed entitlement to service connection for diabetes mellitus, to include as due to herbicide agent exposure. The Veteran’s exposure to herbicide agents is conceded as a result of his service in the Republic of Vietnam. Additionally, the Veteran has reported that a private treatment provider diagnosed him with diabetes mellitus, which he treats with herbal medicines. At this juncture, however, it is unclear whether the Veteran has a current diagnosis of diabetes mellitus during the period on appeal, or whether he instead has prediabetes or impaired glucose tolerance. To that end, the Board remanded this claim in May 2019 for him to undergo a VA examination that would clarify his diagnosis. In the March 2020 VA examination report, the VA examiner opined that the currently available treatment records did not support a diagnosis of diabetes. Relevantly, he noted that the existing medical records indicated that the Veteran had been diagnosed with impaired glucose tolerance in February 2013, but that his glucose levels and A1C levels at that time did not meet the diagnostic criteria for diabetes mellitus. He indicated that the diagnostic criteria for diabetes mellitus were A1C levels of 6.5 percent or greater, or glucose tolerance test results (GTT) of 200 mg/dl or higher, but that the Veteran’s February 2013 results had been 6.1 percent and 144 mg/dl, respectively. Notably, however, the examination report also reflects that the VA examiner explained to the Veteran and his son, who was also at the examination appointment, that the available records did not contain a current diagnosis of diabetes and invited them to submit additional records to support a diagnosis before he rendered his opinion. The examiner indicated that the Veteran could fax him his A1C and fasting glucose level results for him to review and that he could also order current lab work for A1C and random glucose level testing. However, the Veteran seemed confused as to the purpose of this testing because he told the examiner he did not want his labs to be “monitored” by VA. Moreover, the Veteran’s son told the examiner that he should already have all the evidence pertaining to diabetes from private doctors to review. The examination report reflects that the Veteran eventually submitted test results from 2004 but not any test results that were generated during the period on appeal. The examination report also indicates that the lab work orders were not completed, although the examiner did not explicitly provide a reason. The Board acknowledges that the duty to assist claimants in assembling evidence to substantiate their claims is not a one-way street, and that veterans cannot passively wait for help if they seek it. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). However, the Board also recognizes that the Veteran is proceeding pro se in this matter and appeared confused about the purpose of submitting his private treatment records to the VA examiner and undergoing additional tests. In the interest of assembling clear and reliable findings, the Board finds that remand would be helpful for the RO to attempt to obtain either additional private treatment records with respect to his A1C or GTT levels or for current lab work to be obtained to verify the Veteran’s diagnosis. In doing so, the RO should explain to the Veteran that diabetes mellitus is diagnosed when A1C levels are greater than or equal to 6.5 percent or GTT is greater than or equal to 200 mg/dl, and that the VA examiner cannot definitively diagnose diabetes absent medical evidence showing these results. If he does not submit private treatment records that reflect lab results consistent with a diagnosis of diabetes mellitus, or if he does not agree to undergo lab work pursuant to a VA examination, the examiner will have to evaluate his claim based on the evidence already in the record. 2. Bilateral eye condition Additionally, the Veteran has claimed that he is entitled to service connection for glaucoma and cataracts. His August 2015 VA treatment records also indicate that he reported being diagnosed with diabetic retinopathy, although it is unclear whether he has received a formal diagnosis of diabetic retinopathy, when this condition was diagnosed, or who diagnosed it. Nonetheless, to afford him every possible consideration, the Board has widened the scope of his claims for service connection for glaucoma and cataracts and recharacterized them as a claim for a bilateral eye condition, however diagnosed, to include as due to herbicide agent exposure or secondary to diabetes mellitus. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Because the Board is remanding the Veteran’s claim for diabetes mellitus, the claim for the bilateral eye condition must thus be remanded as well. See Harris, 1 Vet. App. at 183. 3. ED Last, the Board notes that the Veteran has claimed entitlement to service connection for ED, to include as due to herbicide agent exposure or secondary to PTSD, hypertension, peripheral neuropathy, and hypothyroidism. In its May 2019 remand, the Board instructed the RO to obtain a VA examination with respect to the Veteran’s ED claim that considered whether the Veteran’s ED was at least as likely not either caused or aggravated by these conditions, or instead caused by herbicide agent exposure. The Veteran underwent a VA examination in March 2020. The examiner ultimately opined that it was less likely as not that his ED had been caused or aggravated by his PTSD, hypertension, peripheral neuropathy, or hypothyroidism. The examiner’s opinion, however, is inadequate. For instance, the examiner’s opinion regarding aggravation was conclusory and assumed, without providing a detailed rationale, that the Veteran’s ED had simply worsened as he had aged. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). Additionally, the VA examiner wrongly stated that the Veteran first reported ED in 1996, when the record indicates that he had begun reporting sexual dysfunction or impotence decades prior. See, e.g., November 1977 West Paces Ferry Hospital Records (complaining of intermittent impotence). An opinion based on an inaccurate factual premise is inadequate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Moreover, the VA examiner failed to discuss various relevant pieces of evidence indicating that the Veteran’s ED could have been caused or aggravated by his psychiatric conditions, such as his lay statements to mental health treatment providers that he had been experiencing sexual difficulties due to his inability to concentrate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As such, remand is warranted to obtain an addendum opinion. Accordingly, the matters are REMANDED for the following action: 1. After obtaining appropriate authorization, obtain and associate with the claim file any outstanding VA treatment records and any outstanding, relevant private treatment records, including private treatment records reflecting a diagnosis of diabetes mellitus based on A1C levels at or above 6.5 percent or GTT levels at or above 200 mg/dl. The Veteran must assist in the matter by identifying his private health care providers and by submitting releases to VA to obtain any private records identified. If the private records identified are not received pursuant to the RO’s request, the Veteran should be so notified and advised that it is ultimately his responsibility to ensure that any available private treatment records are received. 2. After completing the development in the first instruction, the RO should arrange for a VA examination of the Veteran to determine the nature of his claimed diabetes mellitus. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with rationale that responds to the following: Has the Veteran had diabetes mellitus type II at any point during the appeal period (beginning December 2013)? Any indicated tests or studies should be performed. The Veteran is advised that tests or studies may be necessary to confirm his diagnosis of diabetes mellitus if private treatment records that confirm a diagnosis during the appeal period (beginning December 2013) are not submitted. He is also advised that failure to report for any indicated tests or studies with respect to his diabetes may result in the denial of his claim. 38 C.F.R. § 3.655. Additionally, if the examiner finds that the Veteran has a current diagnosis of diabetes mellitus, the examiner should provide an opinion with rationale that responds to the following: (a.) Has the Veteran had a bilateral eye condition (to include glaucoma, cataracts, or diabetic retinopathy) at any point during the appeal period? (b.) If the answer to (a.) is “yes,” is it at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral eye condition was (1) caused or (2) aggravated by the Veteran’s diabetes mellitus? Please explain why. The opinion must separately address whether the disability increased beyond its natural progression (i.e., aggravation). If aggravation was found, please identify to the extent possible the baseline level of disability prior to the aggravation. 3. After the first instruction is completed, the RO should obtain an addendum VA opinion to determine the nature and likely cause of the Veteran’s ED. The examiner should review the claim file (including this remand) and note such review was conducted. Based on a review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s ED was either (1) caused or (2) aggravated by the Veteran’s service-connected PTSD, hypertension, peripheral neuropathy, or hypothyroidism? Please explain why. The opinion must separately address whether the disability increased beyond its natural progression (i.e., aggravation). If aggravation was found, please identify to the extent possible the baseline level of disability prior to the aggravation. (b.) Is it at least as likely as not (50 percent or greater probability) that the disability was either incurred in or otherwise related to the Veteran’s active duty service, specifically exposure to herbicide agents in Vietnam? Please explain why. 4. If upon completion of the above the issues remain denied, the appeal should be returned to the Board after compliance with appellate procedures. E. I. Velez Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Rademacher, 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.