Citation Nr: 21024161 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 20-13 368 DATE: April 22, 2021 ORDER Entitlement to an effective date earlier than July 11, 2012 for the grant of service connection for posttraumatic stress disorder (PTSD) is dismissed. Entitlement to a rating in excess of 70 percent for PTSD is denied. Entitlement to service connection for tinnitus is denied. REMANDED Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected PTSD, is remanded. Entitlement to a total rating based on individual unemployability due to service connected disability (TDIU) is remanded. FINDINGS OF FACT 1. In a July 2013 rating decision, the Veteran was granted service connection for PTSD, and assigned a 70 percent rating, effective July 11, 2012. 2. The Veteran did not perfect an appeal of the July 2013 rating decision nor has he asserted clear and unmistakable error (CUE) in that decision. 3. Throughout the period on appeal, the Veteran’s PTSD manifested in occupational and social impairment with deficiencies in most areas without total occupational and social impairment. 4. Tinnitus did not manifest in service or to a compensable degree within the applicable presumptive period, a continuity of symptomatology is not established and tinnitus is not otherwise etiologically related to in-service disease or injury, including noise exposure. CONCLUSIONS OF LAW 1. The Veteran’s freestanding claim seeking an effective date prior to July 11, 2012 for the grant of service connection for PTSD lacks legal merit. 38 U.S.C. §§ 5109A, 7105; 38 C.F.R. § 20.101; Rudd v. Nicholson, 20 Vet. App. 296 (2006). 2. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.125, 4.126, 4.130, Diagnostic Code 9411. 3. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from June 1978 to June 1982. These matters come to the Board of Veterans’ Appeals (Board) on appeal from August 2018 and February 2019 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction of this appeal is currently with the RO in Baltimore, Maryland. 1. Earlier Effective Date for the Grant of Service Connection for PTSD The Veteran has generally asserted that he is entitled to an effective date prior to July 11, 2012 for the grant of service connection for PTSD. Specific argument in support of this appeal has not been provided. Generally, except as otherwise provided, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim, or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400. An exception to that rule provides that the effective date of an award of an increase shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date. 38 U.S.C. § 5110(b)(2), 38 C.F.R. § 3.400(o)(2); see also Harper v. Brown, 10 Vet. App. 125 (1997). A “claim” is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement to a benefit. 38 C.F.R. § 3.1(p). Any communication indicating an intent to apply for a benefit under the laws administered by the VA may be considered an informal claim provided it identifies, but not necessarily with specificity, the benefit sought. See 38 C.F.R. § 3.155(a). An informal claim must identify the benefits sought; and 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. If received within one year from the date it was sent to the claimant, it will be considered filed as of the date of the receipt of the informal claim. Id. The mere presence of medical evidence does not establish intent on the part of the Veteran to seek service connection for a disability. Brannon v. West, 12 Vet. App. 32, 35 (1998). The effective date of service connection is not based on the date of the earliest medical evidence demonstrating a causal connection, but rather, on the date the application was filed with VA. Lalonde v. West, 12 Vet. App. 377, 382 (1999). A rating decision becomes final and binding if the Veteran does not timely perfect an appeal of the decision. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104(a), 3.160(d), 20.200, 20.302, 20.1103. Previous determinations that are final and binding, including decisions of service connection, will be accepted as correct in the absence of collateral attack by showing the decision involved CUE. 38 C.F.R. § 3.105(a). The Court of Appeals for Veterans Claims (Court) held in Sears v. Principi, 16 Vet. App. 244, 248 (2002) that, “[t]he statutory framework simply does not allow for the Board to reach back to the date of the original claim as a possible effective date for an award of service-connected benefits that is predicated upon a reopened claim.” In order for the Veteran to be awarded an effective date based on an earlier claim, he has to show CUE in the prior denial of the claim. Flash v. Brown, 8 Vet. App. 332, 340 (1995). Moreover, there is no basis for a free-standing earlier effective date claim from matters addressed in a final and binding rating decision. See Rudd v. Nicholson, 20 Vet. App. 296 (2006). By way of history, the Veteran filed his initial claim of service connection for PTSD in July 2012. See VA Form 21-526 Veteran’s Application for Compensation or Pension. Entitlement to service connection for PTSD was granted in a July 2013 rating decision and assigned a 70 percent rating effective July 11, 2012. The Veteran did not appeal this decision and it became final, and it is not subject to revision in the absence of CUE. 3 8 U.S.C. §§ 5109A, 7105; see Rudd, 20 Vet. App. 296 (2006). Then, in March 2018, the Veteran filed a claim the instant claim for entitlement to an increased rating for his PTSD. See VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. In a February 2019 rating decision, the RO denied an increased rating for PTSD. In his July 2019 Notice of Disagreement, the Veteran indicated he disagreed with the evaluation of disability and effective date of award for his PTSD. He stated that he was seeking the “highest possible rating at the earliest possible effective date.” No specific argument in support of his claims was provided. Those facts are not in dispute. As the Veteran has not submitted a motion for CUE in the July 2013 rating decision that granted entitlement to service connection for PTSD, the Board finds that the present assertions for entitlement to an effective date earlier than July 11, 2011 for the grant of service connection for PTSD is an attempt to establish a freestanding claim for an earlier effective date, which is not permitted under Rudd. Accordingly, this claim is dismissed. 2. Increased Rating for PTSD The Veteran generally contends that his PTSD symptoms are more severe than contemplated by the rating assigned. Specific argument in support of this appeal has not been provided. However, the Board notes that the Veteran seems to assert that his PTSD symptoms are more severe because they result in unemployability. See e.g. VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, March 14, 2018. Disability ratings are determined by application of the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 509–10 (2007). The Veteran’s entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the veteran’s case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The Veteran’s PTSD is rated under the General Rating Formula for Psychiatric Disabilities (General Formula). 38 C.F.R. § 4.130. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings are based on a spectrum of symptoms. “A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 442–43 (2002). VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran’s service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula for Mental Disorders per 38 C.F.R. § 4.130, a 70 percent rating is warranted if the disability is productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A schedular maximum 100 percent rating is warranted if the disability ir productive of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. The Board notes that with regard to the use of the phrase “such as” in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association has released the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5), and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. This appeal was certified to the Board in April 2020. As such, the DSM-5 applies, and the GAF scores will not be considered. When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A review of the record reveals that the Veteran sought mental health treatment from VA and private treatment providers, as well as treatment for his other health needs. To the extent that the Veteran’s treatment records contain information relevant to the severity of his mental health, to include mental health screenings, the Board will summarize this evidence. Turning to the evidence, of record is a July 2017 lay statement submitted by Ms. P.P., the Veteran’s caretaker. At this time, she stated that the Veteran suffered from PTSD and relived the trauma and stress he experienced in the Navy on a daily basis. She reported he never slept restfully, screamed in his sleep, that had become unbearable. She wrote that the Veteran was aggressive, that he spoke in a harsh, mean, and extremely disrespectful tone due to his anxiety, that he had a fragile emotional state, with or without his medications and he needed constant 24 hour care. Ms. P.P. indicated the Veteran had health issues that resulted in needing assistance with daily hygiene and activities of daily living. The Veteran was afforded a VA examination in August 2017. At that time, the Veteran reported that he continued to have trauma related nightmares, intrusive thoughts, psychological distress, physiological reactivity to re-experiencing and avoided of situations that cute his trauma, for example, he did not go outside alone or after dark, avoided crowds, and avoided elevators. The Veteran had persistent negative beliefs that others cannot be trusted, was persistently anxious, had diminished interest and participation in significant activities, was irritable, hypervigilant and had an exaggerated startle response. He had sleep problems and experienced nightmares about three times per month. The August 2017 examiner diagnosed PTSD, alcohol use disorder, stimulant use disorder, and cannabis use disorder. The examiner noted that the Veteran had more than one mental disorder diagnosed, and that it was possible to differentiate what symptoms were attributable to each diagnosis. With regard to his PTSD, the examiner noted that the PTSD symptoms were as described above. The examiner opined the Veteran’s PTSD manifested in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner noted that the portion of the occupational and social impairment could not be differentiated to each mental disorder diagnosed. At the August 2017 VA examination, the Veteran reported that he maintained contact with his older sister, that he lived with his mother, that his brother would stay with him when home from his job as a truck driver, that he maintained contact with his younger sister and that he maintained contact and had good relationships with his children, except for two daughters that he enjoyed his grandchildren. He also reported that was separated from his wife, that he had a girlfriend that took care of him and his mother, that he was active on social media, that he looked up friends and people he served with in the Navy and did not go out much due to anxiety of crowds. He reported that if he left his home, he returned before dark and only left for necessities. The Veteran reported he did not work, that he watched television, that he attended appointments and he used his exercise bike two or three times a week. He reported that he went to physical therapy sessions but stopped about three weeks prior. The Veteran reported regular therapy for his psychiatric symptoms and diagnoses, medications, and continued mental health symptoms that included nightmares, anxiety, depressed mood, anger, rage, and verbal aggression. He noted that his depressed mood was sometimes due to physical pain that he experienced. Symptoms attributable to his PTSD at the August 2017 VA examination included a depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including work or a work like setting. Behavioral observations showed the Veteran presented on time and with his girlfriend, that he was appropriately assertive in stating his needs during the interview, that he was neatly groomed and casually and appropriately dressed. The Veteran was noted to be alert, oriented to person, place, and time and open and cooperative. Eye contact was found to be good, affect was found to be moderately constricted and mood was found to be mildly depressed and mildly anxious. Speech was found to be of normal rate and rhythm and thought processes were found to be logical and goal-directed. There was no evidence of a thought disorder, delusions, flight of ideas, or obsessional thinking. Memory was found to be grossly intact. The Veteran denied suicidal or homicidal ideation and denied auditory or visual hallucinations. The August 2017 examiner remarked that the Veteran’s most difficulty comes from physical or medical issues at this time, while the areas impacted by the combination of physical and mental health issues indicated mild to moderate difficulty in understanding and communication and getting along with people, and moderate to severe in participation in society. The examiner found the Veteran was not considered a current imminent or increased risk. Of record is a December 2017 private evaluation submitted by Ms. E.B., MSW, LCSW. At this time, Ms. E.B. noted that the Veteran experienced PTSD symptoms that included flashbacks, vivid and disturbing dreams, night terrors and an inability to sleep through the night without disruption related to the trauma. She noted that the Veteran avoided even small gatherings of people, was hypervigilant, that he had an inability to trust, that he had an exaggerated startle response and that he had relationship dysfunction and cognitive problems. She noted that his symptoms were unpredictable as to when and where they would occur, and opined that it was more likely than not that his PTSD and depressive symptoms would make it impossible for the Veteran to be gainfully employed in the foreseeable future. Ms. E.B. stated that she “hoped that his disability rating” would be adjusted to 100 percent. The Veteran was afforded a VA examination in June 2018. At that time, the examiner opined the Veteran’s PTSD manifested in occupational and social impairment with deficiencies in most areas. The Veteran reported that he continued to live by himself, and had recently broken up with his girlfriend several months prior due to difficulties surrounding his sexuality, irritability, self-isolation, and reluctance to socialize outside of the home. He denied having any close friends, continued to be irritable and guarded, avoided and self-isolated, and could not remember when he last participated in any social activities outside of his home. He did not eat meals in restaurants or go to public places, such as, movie theaters or sporting events. The examiner noted he had moderate to severe psychosocial maladjustment. At the June 2018 VA examination, the Veteran was not working, and noted that his current level of anxiety, depression, insomnia, irritability, difficulty with attention and concentration, hypervigilance, and avoidance would be expected to cause moderate to severe occupational impairment. The examiner opined that the Veteran may be able to handle a situation where he would not be exposed to many cognitive or temporal demands, and in a job that did not involve much interaction with others. Otherwise, the June 2018 examiner opined that the Veteran would have significant problems with work. The Veteran reported he continued in treatment, and had recently requested mild anti-anxiety medication. He denied panic attacks, suicidal or homicidal ideation, and there was no evidence of psychosis. He had recently begun participation in sexual trauma group therapy, that had led to an increase in symptomatology due to having to deal with buried memories. The Veteran reported he was clean and sober for about three years. Symptoms attributable to his PTSD at the June 2018 VA examination included a depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, direction or recent events and impaired judgment. Other symptoms included 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 worklike setting and an inability to establish and maintain effective relationships. Behavioral observations showed the Veteran was alert, cooperative, somber, guarded, anxious in mood, and somewhat irritable. A November 2018 VA treatment record indicates the Veteran identified his son as his “rock,” and that they had the closest relationship. The Veteran reported that he kept in touch with two of his adult children and his sister and that his family would offer support by phone but could not offer in-person care. He explained that his family members had others to care for. He also identified his church as a source of support, and was regularly involved in his church group and substance abuse support relapse group. Further review of the record shows that the Veteran receives treatment from private treatment providers for various disabilities, to include his PTSD. However, there is no indication from the treatment notes of record that the Veteran has reported mental health symptoms that are worse than those noted above. VA treatment records generally indicate that the Veteran had social support from a significant other, family, and church members. See e.g. VA treatment record, July 23, 2019. Based on the foregoing, the Board finds that a rating in excess of 70 percent for PTSD is not warranted at any time during the period on appeal. In this regard, the Board finds that such disability was manifested by occupational and social impairment with deficiencies in most areas without total occupational and social impairment. For the entire period on appeal, the record reflects that the Veteran’s symptoms have not been consistent with total occupational and social impairment such that a 100 percent rating is warranted at any point during the period on appeal. In that regard, the Veteran has not displayed gross impairment in thought processes or communication, nor has the record shown that he is a persistent danger of hurting himself or others or grossly inappropriate behavior. The Veteran has reported some rage and aggression, as well as irritability and suspiciousness, but has consistently denied any suicidal or homicidal ideations. Homicidal or suicidal attempts were not reported by the Veteran or demonstrated in the record. Moreover, there is no evidence that the Veteran has experienced hallucinations or delusions, or obsessive rituals. Further, the Veteran has not displayed disorientation to time or place, or memory loss for names of close relatives, his prior occupations, or his own name. Additionally, there is no evidence or allegation that he was unable to maintain minimal personal hygiene. Mental status examinations during the appeal period consistently found the Veteran’s grooming and hygiene to be appropriate or adequate. There is no evidence or allegation that the Veteran’s psychiatric symptoms manifested in interference or difficulties resulted in the inability to perform activities of daily life, to include maintenance of minimal hygiene. Notably, the Veteran has consistently reported having a good relationship with his son, most of his children, his sister, and his mother; and regularly attended church and therapy related activities. Such does not demonstrate total social impairment. Additionally, the August 2017 and June 2018 VA examiners noted the Veteran had significant impairment of occupational functioning, but such impairment was not total. Therefore, this is not a disability picture indicating total occupational and social impairment at any time during the appeal period. In assessing the severity of his PTSD, the Board has considered the competent lay assertions regarding symptoms experienced and observed. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board notes the contentions of the Veteran and his representative that his PTSD is more severe than currently shown on examination; and the Board observes that the Veteran, while he was competent to report his observable symptoms, is not competent to report that the his mental health symptoms were of sufficient severity to warrant a higher rating under VA’s tables for rating such disabilities because such an opinion requires medical expertise which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002). Despite the foregoing, the Board acknowledges the Veteran’s representative’s assertions that the Veteran’s various symptoms and functional impairments warrant a total 100 percent rating. However, even after considering such contentions as to the effects of the disability on his daily life, the Board finds that the criteria for a higher rating are not met. The Rating Schedule contemplates such impairment under the ordinary conditions of daily life. 38 C.F.R. § 4.10; see also Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). This argument is therefore without merit. The Board has considered whether staged ratings under Hart, supra is appropriate; however, the Board finds that his symptomatology was been stable throughout the period on appeal. Therefore, assigning staged ratings is not warranted. The Veteran nor his representative have not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 70 percent for PTSD, and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 3. Service Connection for Tinnitus The Veteran generally asserts that he has tinnitus as a result of his active service. Specific argument in support of this appeal has not been provided. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities such as arthritis and organic diseases of the nervous system are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In an October 4, 1995, opinion, VA’s Under Secretary for Health determined that it was appropriate to consider high frequency sensorineural hearing loss an organic disease of the nervous system and therefore a presumptive disability. Additionally, in Fountain v. McDonald, 27 Vet. App. 258 (2015), the Court determined that tinnitus is an “organic disease of the nervous system” subject to presumptive service connection where there is evidence of acoustic trauma and nerve damage. Tinnitus is defined as “a noise in the ears, such as ringing, buzzing, roaring, or clicking. It is usually subjective in type.” Dorland’s Illustrated Medical Dictionary, 1956 (31st ed. 2007). Because tinnitus is “subjective,” its existence is generally determined by whether the veteran claims to experience it. For VA purposes, tinnitus has been specifically found to be a disorder with symptoms that can be identified through lay observation alone. See Charles v. Principi, 16 Vet. App. 370 (2002). Accordingly, as the Veteran has reported having tinnitus, the Board finds he has a current disability. Service treatment records and post service treatment records are silent for complaints of, treatment for, or diagnosis of tinnitus. No post-service clinical records have been submitted related to any such diagnosis for tinnitus. However, as noted above, the Board concedes the Veteran has a current disability of tinnitus. The Board notes that the Veteran has not been afforded a VA examination addressing his claimed tinnitus. However, the Board finds that such an examination is not required. In this regard, in determining whether the duty to assist requires that a VA medical examination be provided, or medical opinion obtained with respect to a Veteran’s claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran’s service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court has stated that this element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and the veteran’s service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The service treatment records are otherwise negative for complaints, treatments or diagnoses related to tinnitus. Further, the evidence does not indicate that the Veteran has sought treatment for tinnitus at any time. See McLendon v. Nicholson, supra. Rather, the Veteran merely submitted a claim for tinnitus, without any elaboration. In this regard, while the Veteran himself has advanced such a theory, a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Court has held that VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Therefore, the Board finds that a VA examination and/or opinion is not necessary to decide this claim. Moreover, the Veteran does not report that he had tinnitus in or since service, including within one year of service. The Board notes that the Veteran was afforded a VA audiology examination in August 2018, however the audiogram results were invalid for testing purposes and the Veteran did not discuss nor report tinnitus. As tinnitus was not otherwise noted during service and characteristic manifestations of the disease process were not identified during service, presumptive service connection, to include on the basis of continuity of symptomatology, is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. To the extent the Veteran believes that his current tinnitus is related to service, as a lay person, the Veteran has not shown that he has specialized training sufficient to render such an opinion. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In this regard, tinnitus can have many causes and medical expertise is needed to determine the etiology of the disorder. Accordingly, the Veteran’s opinion as to the etiology of his tinnitus, which was first shown by competent and credible evidence many years after service, is not competent medical evidence. Upon review of the evidence, the Board finds the preponderance of the evidence is against the claim. Consequently, service connection for such disorder is not warranted. As the preponderance of the evidence is against the Veteran’s claim, the benefit of the doubt doctrine is not applicable to this claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND 1. Service Connection for Obstructive Sleep Apnea The Veteran seeks service connection for obstructive sleep apnea. Specifically, the Veteran’s representative seems to assert that the Veteran’s obstructive sleep apnea is secondary to his service-connected PTSD. See Third Party Correspondence, October 8, 2020. Post-service VA and private treatment records show the Veteran has a diagnosis of obstructive sleep apnea. See generally, VA treatment record, February 14, 2020. The Board finds the record incomplete to decide the claim. In the instant case, the Board finds evidence has been received showing that a nexus may potentially exist between the claimed obstructive sleep apnea and active service and/or service connected PTSD. Specifically, the Veteran’s representative asserts that his obstructive sleep apnea is secondary to his service-connected PTSD. In this regard, the Veteran’s attorney states that a March 2018 neurology consult indicates that obstructive sleep apnea comorbidities include PTSD, as well as a variety of other disorders, that could worsen any sleep disordered breathing. See Third Party Correspondence, October 8, 2020. In light of the foregoing, the Board concludes that the Veteran should be afforded VA examinations to determine the nature and etiology of the claimed obstructive sleep apnea. See McLendon v. Nicholson, supra. 2. Entitlement to a TDIU Regarding the TDIU issue, the Board notes that the issue of entitlement to a TDIU is inextricably intertwined with the claim remanded herein. Harris v. Derwinski, 2 Vet. App. 180, 183 (1991). Hence, a determination on the claim for TDIU should be deferred pending final dispositions of the claim of entitlement to service connection for obstructive sleep apnea. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Then, schedule the Veteran for a VA examination with an appropriate clinician to determine the etiology of the Veteran’s claimed obstructive sleep apnea. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Thereafter, the examiner is asked to furnish an opinion with respect to the following questions: (A) Is at least as likely as not (50 percent or greater probability) that the Veteran’s obstructive sleep apnea had its onset during any period of service, or is otherwise related to such period of service? The examiner should discuss the significance, if any, of the lay statements and contentions indicating the Veteran’s obstructive sleep apnea symptoms began during active service, and continued since. (B) Is at least as likely as not (50 percent or greater probability) that the Veteran’s obstructive sleep apnea was caused or permanently aggravated by his service-connected PTSD? In offering such opinions, the examiner should consider the lay statements of record. Any medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; any medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as against it. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mariah N. Sim, 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.