Citation Nr: 21025723 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 14-41 066 DATE: April 28, 2021 ORDER An initial disability rating in excess of 50 percent prior to February 25, 2016, for post-traumatic stress disorder (PTSD) is denied. Subject to the laws and regulations governing the award of VA monetary benefits, a 70 percent rating, but no more, from February 25, 2016, for PTSD is granted. REMANDED Entitlement to service connection for obstructive sleep apnea (OSA) as secondary to service-connected PTSD is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Prior to February 25, 2016, the Veteran’s PTSD consistently manifested in depressed mood, anxiety, panic attacks that occurred weekly or less often, occasional nightmares, chronic sleep impairment, anhedonia, irritability, decreased concentration, avoidance, impaired impulse control, and disturbances of motivation and mood, demonstrating occupational and social impairment with reduced reliability and productivity. 2. From February 25, 2016, the Veteran’s PTSD worsened, manifesting in additional symptoms of marital trouble, poor hygiene, severe irritability and avoidance, and impaired impulse control, demonstrating occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 50 percent prior to February 25, 2016, for PTSD have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a 70 percent rating, but no more, from February 25, 2016, for PTSD have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1968 to January 1970. These matters were most recently before the Board in September 2020 at which time they were remanded for further evidentiary development. As pertains to the increased rating claim for PTSD, substantial compliance with the remand requests has been accomplished and the Board may proceed to consider the claim. Regarding the other claims on appeal, the Board finds that additional remand is needed to ensure substantial compliance with the prior remand requests. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran was granted service connection for PTSD at 50 percent disabling, effective January 11, 2012, under 38 C.F.R. § 4.130, DC 9411, the General Rating Formula for Mental Disorders. He appealed the assigned rating and in a September 2019 rating decision, the Agency of Original Jurisdiction (AOJ) increased the rating to 100 percent, effective June 25, 2019. The Board will consider entitlement to a rating in excess of 50 percent from January 11, 2012, to June 25, 2019. In a December 2019 statement, the Veteran contended that his disability warranted a 100 percent rating as of November 19, 2013. Under 38 C.F.R. § 4.130, a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent evaluation is assignable where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. The symptoms associated with the psychiatric rating criteria are not intended to constitute exhaustive lists, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Thus, the Board will consider whether “the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code,” and, if so, the “equivalent rating will be assigned.” Id. In Vazquez-Claudio v. Shinseki, the Federal Circuit held that a Veteran may only qualify for a given disability rating “by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” 713 F.3d 112, 117 (Fed. Cir. 2013) (“Reading [38 C.F.R. §§ 4.126 and 4.130] together, it is evident that the ‘frequency, severity, and duration’ of a Veteran’s symptoms must play an important role in determining his disability level.”). Turning to the evidence of record, the Veteran sought VA mental health treatment in February 2012. He described difficulty sleeping/insomnia, nightmares, an inability to accomplish things, aggravation/irritability, social withdrawal, appetite decrease, energy decrease, restlessness, crying spells, intrusive recollection, hypervigilance, exaggerated startle response, poor concentration, and changes in memory. He noted that when he stopped drinking 2 years previously, his symptoms began. He believed that his drinking masked all of his symptoms before. Upon evaluation, appearance was appropriate; attitude was calm and cooperative; affect and mood were appropriate; motor skills were not remarkable; speech form was normal; thought process was coherent, logical, and goal-directed; thought content was reality-based; intellectual function was normal; insight was fair; and he was oriented on all spheres. The Veteran denied current suicidal ideation and a history of suicidal ideation. Clinicians determined that his presentation was mild, with some distress and easily identified stressors, and the Veteran was referred for outside counseling. VA treatment records reflected an ongoing prescription for Zolpidem to aid sleep. A February 2012 private mental health intake assessment reflected the Veteran’s reported symptoms of difficulty sleeping, nightmares, easy aggravation, weight loss/gain, change in libido, agitation, concentration difficulty, panic attacks, decreased energy, anhedonia, crying spells, feeling of detachment, hypervigilance, exaggerated startle response, flashbacks twice a week, and intrusive memories of trauma 2 to 3 times a week. He denied suicidal ideation and past attempts. He described an extensive past use of drugs and alcohol to suppress memories of combat. The Veteran stated that he was married four times and was currently married without relationship issues. He noted that he had lost several jobs in the past. He was currently living independently with others and had a friend from service who was his social support system. A mental status examination revealed a casually dressed and groomed appearance; behavior calm, quiet, and within normal limits; thought processes and content within normal limits; memory described as losing days and forgetting what he has done during flashbacks; perception and intellectual functioning within normal limits; flat affect; irritable and angry mood; impulse control that was not impaired; judgment that was not impaired; and insight that was mildly impaired. Clinicians diagnosed PTSD; major depression, recurrent, moderate; panic attacks without agoraphobia; and polysubstance dependence in partial remission, and prescribed outpatient therapy. He thereafter had several sessions of outpatient therapy with the private provider. In March 2012 private therapy records, the Veteran was diagnosed with PTSD and it was noted that he had or would predictably have repeated episodes of decompensation. A risk assessment resulted in a determination that the Veteran was a low risk for suicide/self-harm, violence/homicide, and inability to protect self. The Veteran reported to private clinicians that his wife was afraid to sleep with him due to his nightmares. He noted that he had never attacked her but with one of his previous wives, he kicked her out of bed. He discussed combat stressors and guilt over losses in service. Clinicians suggested that the Veteran seek psychiatric medication from VA providers. The Veteran’s brother submitted a statement in April 2012 describing his attitude, behavior, and social interactions as very temperamental, confrontational, and argumentative. The Veteran was reportedly distant and did not attend family functions. He had difficulty sleeping, an inability to accomplish things, and constant worry. The Veteran’s wife reported that she had been unable to sleep next to him for the past two years due to his nightmares as she felt that he might unknowingly cause her injury. The Veteran underwent a VA PTSD examination in April 2012. He described his marital history and noted that his current wife was a registered nurse and very understanding and supportive of him. He stated that he had problems with irritability but that his marriage was fairly stable. He had a son from his third marriage with whom he had occasional contact. The Veteran described becoming irritable and anxious around others and that over time he had become socially withdrawn. He avoided being in crowds, as well. In the past, he had used alcohol to control his social anxiety but since ceasing the use of alcohol, his social avoidance had worsened. Regarding employment, he had worked as a firefighter and in construction for many years but had not held steady employment for the past 20 years. He described temper problems when employed. The Veteran denied prior mental health treatment or psychiatric medications. The examiner indicated that the current symptoms of the Veteran’s PTSD included depressed mood, anxiety, panic attacks that occurred weekly or less often, chronic sleep impairment, and disturbances of motivation and mood. Based on the evaluation, the examiner determined that the Veteran’s symptoms were moderate in severity and occurred frequently. This resulted in occupational and social impairment with reduced reliability and productivity. In July 2014, the Veteran submitted a statement discussing his attempts to treat his PTSD symptoms. He described problems with previous clinicians and disliking the effects of psychiatric medication. The Veteran noted that he had difficulties when previously trying to work due to irritability with coworkers. He also discussed his personal relationships, reflecting that his wife was particularly understanding due to her employment as a nurse and that his relationship with his son was less stable than reflected in the recent VA examination. Another VA PTSD examination was conducted in June 2014. The Veteran noted that he and his current wife continued to get along well but that they slept apart due to her fear that he would hit her in his sleep. He described his relationship with his son as “good” and that he saw him monthly. He noted that he had no friends outside of his family, but that he enjoyed his solitude and often walked in the woods or went fishing. Regarding employment, his work history had not changed since the previous examination. He added that he quit his most recent job (20 years previously) because he did not get along with people, had breathing problems, and had chronic pain. He had verbal confrontations with prior coworkers, but they did not get physical. He did not like being told what to do and did not like receiving feedback. The Veteran had had no mental health treatment since the last examination but did take a sleep aid. He noted that his mood over the past month had been “pretty good.” When he got upset it was from having thoughts about the past and he would go for a long walk. He denied having panic attacks. His appetite was good, and weight was stable. His level of interest in things was “fine” most days. His energy level was low most days, which he attributed in part to his health problems. He occasionally had nightmares which tended to come in spurts. He could go 6 months without a nightmare. The Veteran reported problems with irritability and agitation. He stated he had no major problems with hygiene or self-care, had normal memory functioning, and mild problems with attention and concentration. He denied suicidal and homicidal ideation, plan, or intent and hallucinations. The examiner indicated that the symptoms associated with the Veteran’s PTSD included depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. Upon observation, the Veteran was dressed casually and appropriately with no notable deficits with grooming or hygiene; he was attentive and cooperative; his thought patterns and expressions were linear, relevant, and logical; his mood was euthymic; and his affect was congruent with appropriate range. The examiner determined that the Veteran’s ability to perform day to day activities, especially in a work setting, was within normal limits. His ability to interact appropriately with others was moderately impacted by irritability and sensitivity to criticism, but he evidenced adequate impulse control. His mental flexibility, concentration, and memory were deemed to be within reasonable limits. The examiner concluded that the Veteran’s PTSD resulted 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 Veteran sought mental health treatment at a new VA facility in July 2014 for mood swings, depression, and anxiety. He also endorsed insomnia, agitation, fatigue/low energy, feelings of worthlessness/guilt, difficulty with concentration, nightmares once or twice a week or month, difficulty controlling temper, avoiding crowds, panic attacks, and excessive worry. Panic attacks were described as including palpitations, sweating, trembling, or shaking, shortness of breath, feeling of nausea, lightheadedness, fear of losing control/going crazy, and numbness/tingling. He stated that he did not like to be with other people but enjoyed fishing. He denied auditory/visual hallucinations, delusions, and suicidal ideation. Upon observation, the Veteran’s appearance was casual; affect was appropriate to content; mood was “ok;” speech rate and tone, quality of thought, and intellectual capacity were within normal limits; orientation was full; insight was fair to good; and judgment was good. In August 2014, the Veteran reported to VA clinicians that he was feeling tense all the time. He reported a history of violence and destroying objects but had since gained better self-control overall. The Veteran also endorsed nightmares a couple of times per week, daily intrusive memories, feeling tired and unmotivated during the day, feeling down and discouraged about not being able to find and keep a job over the years, and not enjoying hobbies he used to such as fishing. A mental status evaluation demonstrated that he was alert, attentive, and oriented times three; he was cooperative and reasonable and grooming was appropriate; speech had normal rate and rhythm; language was intact; affect was blunted, restricted, and constricted; mood was depressed; perceptual disturbances were denied; thought process and association were normal and coherent; regarding thought content, it was noted that he did not trust others; insight and judgment were good; and suicidal or violent ideation were denied. A VA psychiatrist prescribed a trial of Sertraline for his symptoms. A subsequent treatment note reflected that the Veteran did not continue the Sertraline as it made him felt sedated. He preferred to focus more on therapy than on medication management of his symptoms. He was later started on Trazodone. In November 2014, the Veteran endorsed to VA mental health providers having a short temper with his wife and having recently gotten into a physical fight with a younger brother. Upon observation, he was dressed appropriately with good hygiene; he appeared guarded with minimal eye contact; speech was normal; mood was anxious and agitated; affect was congruent with content; thought process was clear and logical; thought content was coherent; judgment was good; insight was poor; and rapport was good. The Veteran chose to stop Trazodone in December 2014 and was prescribed Hydroxyzine for sleep. He attended ten group therapy sessions beginning in December 2014. He subsequently was seen by VA mental health providers every six-months for individual therapy and medication management. The Veteran’s son submitted a statement in May 2015. He reported that he and his father did not have a good relationship and that throughout time his father suffered from depression and anger issues. He noted that the Veteran rarely had any interactions with anyone, including him. The Veteran was short-tempered and distanced from everyone. In May 2015, the Veteran reported that Hydroxyzine had improved his sleep though he continued to have middle insomnia for brief periods. He endorsed occasional nightmares 2 to 3 times a month; being irritable at times but managing it; and having periods of feeling depressed for 1 to 2 days at most. He reported engaging in regular exercise and enjoying some activities such as fishing. A mental status evaluation demonstrated that he was casually dressed and adequately groomed, pleasant, and cooperative; his mood was euthymic; his affect was calm and reactive; his speech had normal rate, rhythm, and volume and was linear and coherent; his insight and judgment were good; he was alert and oriented; there was no evident psychosis; and he denied suicidal ideation. In December 2015, a mental status examination revealed that the Veteran was casually dressed and adequately groomed, pleasant, and cooperative; his mood was euthymic; his affect was calm and reactive; his speech had normal rate, rhythm, and volume and was linear and coherent; his insight and judgment were good; he was alert and oriented; there was no evident psychosis; and he denied suicidal ideation. Hydroxyzine was discontinued and Trazadone was instead prescribed for sleep. In a February 2016 VA treatment record, the Veteran reported that he was currently separated from his wife. She told him that she was tired of having to “do everything” around the house and pay the bills. The Veteran reported that he had the skills to perform such activities but had lost interest in doing so. The clinician suspected a clinical depression. Upon observation, his appearance was unkempt with poor hygiene; eye contact, gait, and posture were within normal limits; speech had normal rate and rhythm; attitude and behavior were guarded; mood was euthymic with congruent affect; thought processes were coherent, goal-directed, and concrete; thought content was appropriate but with diminished interest; perceptions were within normal limits; memory was intact; insight and judgment were normal; he was oriented on all spheres; and he denied suicidal and homicidal ideation. The Veteran did not want to consider PTSD medication or further counseling. The Veteran submitted a statement in October 2016. He described a negligible impact during his initial treatment for PTSD. He stated that he attempted to cope with his issues for years, but most of the time he got angry and had a hard time dealing with people, affecting his ability to hold a job and maintain a healthy relationship with his wife. The Veteran’s sister-in-law submitted a statement in October 2017. She described the Veteran as distanced from everyone, irritated at little things, unwilling to socialize or go out, and uneasy in crowded places. The Veteran’s mother-in-law also described him as always on alert to everything around him and uncomfortable around others. The Veteran sought treatment for PTSD symptoms and medication management in May 2018. He described recurrent service-related nightmares, irritability, anger outbursts, and isolating behavior. He also was thinking depressing thoughts more frequently. He noted that his marriage was somewhat shaky but had been like that for years. Upon observation, he was alert, attentive, and oriented; he was cooperative and reasonable; his grooming was appropriate; speech had normal rate and rhythm; language was intact; mood was anxious and affect was wide range; thought process and association was normal and coherent; thought content was normal; insight and judgment were good; memory was intact; there were no perceptual disturbances; and he denied suicidal or violent ideation. He was prescribed Escitalopram for mood and anxiety and Prazosin for nightmares. An August 2018 treatment record reflected that the Veteran had chosen to stop both Escitalopram and Prazosin. He described dealing with his PTSD his own way, such as going to the woods or somewhere else to be alone. A mental status evaluation demonstrated that the Veteran was alert, fully oriented, and appropriately dressed and groomed. Eye contact was good, speech was clear and coherent, mood was sometimes irritable, affect was broad, thought process was organized, memory was intact, insight and judgment were good, and the Veteran denied perceptual disturbance and suicidal or homicidal thoughts. The Veteran reported being anxious, edgy, and short with people in September 2018. A mental status evaluation was normal other than the reported mood. He was started again on Escitalopram and Prazosin. The Veteran described improvement with the medication in November 2018 but still feeling anxious and irritable occasionally. He had nightmares once in a while. A mental status evaluation was normal other than irritable mood and broad affect. In January 2019, the Veteran reported continued benefit with Escitalopram, Prazosin, and Trazodone, but that he still felt anxious and easily angered sometimes. The Veteran underwent another VA examination in June 2019. Diagnoses of PTSD; alcohol use disorder, cocaine use disorder, and hallucinogen use disorder in remission; and cannabis use disorder in sustained remission. The Veteran reported that he got along “sometimes good” with his wife. He did not have a good relationship with his son and did not have friends with which he socialized. Regarding his work history, he stated that he had lost many jobs due to difficulty getting along with others and having verbal altercations. The Veteran described his mental health treatment as going for counseling when he needed it and taking Trazadone, Prazosin, and Escitalopram. The examiner determined that symptoms associated with the Veteran’s PTSD included depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, near-continuous panic or depression, chronic sleep impairment, mild memory loss, impairment of short and long-term memory, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, impaired impulse control, nightmares twice weekly, flashbacks with triggers, difficulty falling and staying asleep, isolating behavior, irritability, and verbal aggression. Upon observation, the Veteran’s demeanor and responsiveness to questions was cooperative. His manner of relating, social skills, and overall presentation were adequate. He was appropriately dressed with adequate personal hygiene and grooming. Eye contact was appropriate and motor behavior was normal. His speech was fluent and clear. His thought processes were coherent and goal-directed with no evidence of delusions, hallucinations, or disordered thinking. His mood was dysthymic, and affect was flat. Sensorium was clear and he was fully oriented. Attention and concentration appeared age appropriate. The examiner determined that the Veteran was likely to have moderate to marked difficulty in an occupational environment due to symptoms of PTSD which would cause difficulty coping at work, being forgetful, and difficulty concentrating resulting in difficulty completing tasks at work. The examiner concluded that the Veteran’s PTSD resulted in occupational and social impairment with deficiencies in most areas. 1. An initial disability rating in excess of 50 percent prior to February 25, 2016, for PTSD is denied. Based on the foregoing, the Board finds that a rating in excess of 50 percent prior to February 25, 2016, for the Veteran’s PTSD is not warranted. Prior to that date, he consistently endorsed, and clinicians noted depressed mood, anxiety, panic attacks that occurred weekly or less often, occasional nightmares, chronic sleep impairment, anhedonia, irritability, decreased concentration, avoidance, impaired impulse control, and disturbances of motivation and mood. Clinicians described his symptomology as moderate. The Board finds that this symptom presentation, as well as the severity, frequency, and duration of the Veteran’s symptomology best approximates impairment with reduced reliability and productivity, warranting a 50 percent disability rating. The Veteran’s symptom presentation does not suggest deficiencies in most areas. Prior to February 25, 2016, his PTSD did not result in symptoms of suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene, or symptoms of a similar severity. Although he had some of the symptoms noted in the 70 percent criteria (i.e., impaired impulse control), his overall disability picture did not approximate deficiencies in most areas. Although he isolated from others, the Veteran had a generally stable marriage and interest in hobbies that he enjoyed. There was no evidence of deficiencies in judgment or thinking nor any evidence of cognitive impairment. As such, the Board finds that prior to February 25, 2016, the Veteran’s PTSD did not result in deficiencies in most areas and the criteria for a 70 percent rating were not met. 2. A 70 percent rating, but no more, from February 25, 2016, to June 25, 2019, for PTSD is granted. The VA treatment record dated February 25, 2016, reflected a worsening in the Veteran’s PTSD manifestations. The Veteran’s marriage had deteriorated, resulting in a separation. His hygiene was poor and his appearance unkempt. When offered mental health treatment or medication management, he refused. The Board finds that this worsening in symptomology most closely approximates the 70 percent rating criteria. Although symptom severity varied subsequently on clinical evaluation, the Veteran’s extended family members described severe irritability and avoidance. As such, the Board finds that a 70 percent rating is warranted as of the first date that worsening was first factually ascertainable, February 25, 2016. A rating in excess of 70 percent is not warranted from February 25, 2016. The evidence did not demonstrate 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name, or symptoms of similar severity such that the Veteran was totally occupationally and socially impaired. As such, the criteria for a 100 percent rating were not met. Accordingly, a 70 percent rating, but no more, from February 25, 2016, to June 25, 2019, for PTSD is warranted. The Board finds that the Veteran’s disability is fully capable of evaluation under the rating schedule. REASONS FOR REMAND 1. Entitlement to service connection for OSA as secondary to service-connected PTSD is remanded. The Veteran has contended that his OSA was proximately caused or aggravated by his service-connected PTSD or the medications taken to treat PTSD, or that the medications taken to treat PTSD caused weight gain, which in turn caused OSA. See VAOPGCPREC 1-2017 (January 6, 2017) (obesity may be an “intermediate step” between a service-connected disability and a current disability that may be service connected on a secondary basis). Several attempts have been made to obtain medical opinions which address all contentions, and which are supported by adequate rationales. However, none of the opinions of record adequately address aggravation. An October 2016 opinion determined that the Veteran’s OSA was less likely than not aggravated beyond natural progression by PTSD and medications to treat it. In support, the examiner stated that the Veteran’s OSA had been addressed by surgery and required no other treatment. However, the current disability requirement for service connection is satisfied if a “claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim.” McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Although the Veteran underwent surgery to (….) in January 2016 and has been asymptomatic since that time, his claim for service connection was submitted in March 2015. As such, the opinion does not adequately address the contentions. Another opinion was obtained in June 2019. The examiner stated that the Veteran’s OSA was less likely than not aggravated by PTSD, but the supporting rationale addressed causation only. An opinion was again sought in April 2020 but no opinion regarding aggravation was given. Following the September 2020 remand, another opinion was obtained in November 2020. Despite stating that OSA was less likely than not aggravated beyond natural progression by PTSD, the rationale given only addressed direct service connection and causation. An addendum was sought by the AOJ in November 2020 to address the weight gain contention, however, the offered opinion again did not address aggravation. Although the Board regrets the additional delay, a new opinion is needed which adequately addresses an aggravation theory of entitlement. 2. Entitlement to a TDIU is remanded. As the Veteran’s claim for service connection for OSA could affect entitlement to TDIU, the claim for TDIU is inextricably intertwined with the claim to service connection for OSA and a decision may not be rendered regarding the TDIU claim until the service connection claim is determined. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (holding that where a decision on one issue would have a “significant impact” upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined). The matters are REMANDED for the following action: 1. Obtain an addendum VA medical opinion from an appropriate medical professional regarding the etiology of the Veteran’s OSA. Following a review of the claims file, the clinician is addressed to address the following: 2. Determine whether the Veteran’s OSA is at least as likely as not (50 percent probability or greater) proximately aggravated (i.e., worsened beyond natural progression) by his service-connected PTSD. Special attention is directed to the fact that the Veteran submitted his claim for service connection in March 2015 and underwent surgery in January 2016, after which treatment records reflected that he was asymptomatic. Any opinion must address the timeframe from March 2015 to January 2016 when the Veteran’s OSA was symptomatic and not merely state that he no longer requires treatment. 3. Determine whether the Veteran’s OSA is at least as likely as not (50 percent probability or greater) proximately aggravated (i.e., worsened beyond natural progression) by treatment for his service-connected PTSD. The clinician should specifically address the effects of medications prescribed to the Veteran for manifestations of his service-connected PTSD, including but not limited to Zolpidem, Sertraline, Hydroxyzine, and Trazodone. 4. Determine whether the Veteran’s OSA is at least as likely as not (50 percent probability or greater) proximately aggravated (i.e., worsened beyond natural progression) by weight gain caused by treatment, including his medication, for his service-connected PTSD. The clinician should specifically address the Veteran’s documented weight throughout the appeal period. Special attention is directed to the 2007 to 2020 body weight history in the November 2020 addendum. 5. Discuss a baseline level of severity of the claimed condition established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity. 6. The clinician is reminded that all opinions must specifically address aggravation (whether OSA worsened beyond natural progression), not causation. 7. All opinions should be accompanied by supporting rationale. 8. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of entitlement of TDIU. If the benefits sought are not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. R.R. WATKINS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Rachel E. Jensen, 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.