Citation Nr: 21028083 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 11-02 232 DATE: May 10, 2021 ORDER Service connection for pituitary adenoma as due to herbicide exposure is granted. Service connection for diabetes insipidus as secondary to service-connected pituitary adenoma is granted. Service connection for headaches as secondary to service-connected pituitary adenoma is granted. Service connection for a vision/eye disorder, diagnosed as bilateral dry eye syndrome, is granted. Service connection for a vision/eye disorder, diagnosed as heteronymous bilateral field defect temporal as due to herbicide exposure, is granted. Service connection for hypothyroidism as due to herbicide exposure is granted. Service connection for a joints disorder of the left hand is granted. Service connection for a joints disorder of the left shoulder is granted. An effective date prior to June 6, 2018, for the grant of service connection for tinnitus, is denied. An initial rating in excess of 10 percent for tinnitus is denied. A rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for a sleep disorder, to include as secondary to service-connected PTSD, is remanded. Entitlement to service connection for a joints disorder (other than left hand and left shoulder), including left elbow, right knee, and feet/heel, is remanded. Entitlement to service connection for amyloidosis, to include as due to herbicide exposure and/or secondary to service-connected pituitary adenoma, is remanded. Entitlement to service connection for a vision/eye disorder (other than bilateral dry eye syndrome and heteronymous bilateral field defect temporal), to include as due to herbicide exposure and/or secondary to service-connected pituitary adenoma, is remanded. FINDINGS OF FACT 1. In the August 2010 VA rating decision, the agency of original jurisdiction (AOJ) noted the Veteran's service in Vietnam during his period of active service and conceded his in-service herbicide exposure. 2. The Veteran's current pituitary adenoma is more likely than not attributable to his in-service herbicide exposure. 3. The Veteran's current diabetes insipidus is caused by his service-connected pituitary adenoma. 4. The Veteran's current headaches are as likely as not caused by his service-connected pituitary adenoma. 5. The Veteran's vision/eye disorder, diagnosed as bilateral dry eye syndrome, is more likely than not attributable to an in-service eye injury in December 1971. 6. The Veteran's vision/eye disorder, diagnosed as heteronymous bilateral field defect temporal, is more likely than not attributable to his in-service herbicide exposure. 7. Hypothyroidism is listed among the diseases presumptively associated with exposure to certain herbicide agents under applicable regulations. 8. The Veteran's current hypothyroidism manifested to a compensable degree of at least 10 percent after separation from service. 9. The Veteran's current left hand disorder manifested from an injury in February 2007 during a period of ACDUTRA or INACDUTRA. 10. The Veteran's current left shoulder disorder manifested from an injury in February 2007 during a period of ACDUTRA or INACDUTRA. 11. The Veteran's first claim for service connection for tinnitus was received by VA on June 6, 2018. 12. The Veteran's service-connected tinnitus is assigned at 10 percent, the maximum rating authorized under Diagnostic Code 6260. 13. For the entire rating period, the Veteran's service-connected PTSD has not been manifested by both total occupational and total social impairment due to psychiatric symptomatology. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for pituitary adenoma as due to herbicide exposure have been satisfied. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. With resolution of reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for diabetes insipidus as secondary to service-connected pituitary adenoma, have not been satisfied. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). 3. With resolution of reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for headaches as secondary to service-connected pituitary adenoma have been satisfied. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310. 4. With resolution of reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for a vision/eye disorder, diagnosed as bilateral dry eye syndrome, have been satisfied. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303. 5. With resolution of reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for a vision/eye disorder, diagnosed as heteronymous bilateral field defect temporal as due to herbicide exposure, have been satisfied. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303. 6. With resolution of reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for hypothyroidism as due to herbicide exposure have been satisfied. 38 U.S.C. §§ 1110, 1116(a)(2)(K), 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307 (2020). 7. With resolution of reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for a joint disorder of the left hand have been satisfied. 38 U.S.C. §§ 101, 1111, 5107; 38 C.F.R. §§ 3.1(d), 3.6, 3.304. 8. With resolution of reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for a joint disorder of the left shoulder have been satisfied. 38 U.S.C. §§ 101, 1111, 5107; 38 C.F.R. §§ 3.1(d), 3.6, 3.304. 9. The criteria for an effective date prior to June 6, 2018, for the grant of service connection for tinnitus, have not been met. 38 U.S.C. §§ 5107(b), 5110 (2012); 38 C.F.R. §§ 3.102, 3.400 (2020). 10. There is no legal basis for the assignment of a schedular evaluation for tinnitus in excess of 10 percent. 38 C.F.R. § 4.87, Diagnostic Code 6260 (2020). 11. The criteria for entitlement to a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1969 to February 1972 and in the Army reserves until 2009. In July 2013, the Board remanded the issue of entitlement to service connection for pituitary adenoma for additional evidentiary development. There was substantial compliance with the July 2013 remand directives for this issue on appeal discussed below. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, identified private treatment records and outstanding service treatment records and service personnel records were obtained and associated with the record. The issue was also readjudicated in an October 2020 supplemental statement of the case (SSOC). This issue has been returned to the Board for appellate review. In July 2013, the Board also remanded issues of entitlement to service connection for diabetes insipidus, amyloidosis, loss of visual acuity or peripheral vision of the left eye, hypothyroidism, and headaches for issuance of a statement of the case (SOC). These issues were adjudicated in an October 2020 SOC, the Veteran submitted a timely substantive appeal in October 2020, and these issues were properly certified to the Board in November 2020. With regard to the claim of entitlement to service connection for a joint disorder, including arthralgia, additional relevant service treatment records were obtained and associated with the record in June 2018, which were not associated with the claims file when VA last decided the issue in the September 1997 and September 1999 VA rating decisions. Accordingly, the claim will be adjudicated on a de novo basis rather than on the basis of whether new and material evidence has been received. See 38 C.F.R. § 3.156(c) (2020). Neither the Veteran nor his attorney has raised any issues with the duty to notify or duty to assist with regards to the issue of entitlement to a rating in excess of 70 percent for PTSD discussed below on the merits. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. § 1110. Service connection may be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In the August 2010 VA rating decision, the AOJ noted the Veteran's service in Vietnam during his period of active service during the Vietnam Era and conceded the Veteran's in-service herbicide exposure. There is no affirmative evidence that the Veteran did not have herbicide exposure therein. If a veteran was exposed to an herbicide agent during active military, naval, or air service, a specified list of diseases shall be service connected if manifests to a compensable degree at any time after service. See 38 U.S.C. § 1116(a)(2); 38 C.F.R. §§ 3.307(a)(6)(ii); 3.309(e); McCartt v. West, 12 Vet. App. 164, 166 (1999). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, a veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Lastly, in general, every "veteran" shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304. A "veteran" is defined as a person "who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable." 38 U.S.C. § 101(2); 38 C.F.R. § 3.1(d). The term "active military, naval, or air service" includes: (1) active duty; (2) any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(a). INACDUTRA includes duty (other than full-time duty) performed by a member of the National Guard of any State, under 32 U.S.C. §§ 316, 502, 503, 504, or 505, or the prior corresponding provisions of law. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d)(4). Only service department records can establish if and when a person served on active duty, ACDUTRA, or INACDUTRA. Cahall v. Brown, 7 Vet. App. 232, 237 (1994). 1. Pituitary adenoma, to include as due to herbicide exposure During the course of the appeal, the Veteran contends that service connection is warranted for his pituitary adenoma as a result of his exposure to herbicide agents during active service. The Board acknowledges that while exposure to herbicides is conceded in this case, pituitary adenoma is not listed or contemplated among the diseases associated with certain herbicide agents under 38 C.F.R. § 3.309 (e), thus consideration of service connection for this disability on appeal on a presumptive basis due to herbicide exposure is not warranted in this case. However, direct service connection remains available. Combee v. Brown, 34 F.3d 1039 (Fed Cir. 1994). Since separation from active service, review of the evidentiary record shows the Veteran underwent a pituitary tumor biopsy in June 2007 and the reoccurrence of the tumor in June 2009, as noted in private treatment records and records from the Social Security Administration (SSA). As a result, the Board finds the element of a current disability has been met in this case. As previously noted, the Veteran's in-service herbicide exposure has been conceded by VA. As a result, the element of an in-service occurrence has been met in this case. In a January 2021 private medical opinion, Dr. C. R. explained why the Veteran's pituitary macroadenoma was more likely as not a result of his conceded in-service herbicide exposure. She also cited to studies about veterans exposed to herbicides and endocrine disorders. The Board finds this opinion was based on an accurate factual history, after noted review of the Veteran's claims file, and there is no probative contrary medical opinion of record. As a result, the Board finds the element of a nexus between the Veteran's pituitary adenoma and his in-service herbicide exposure has been met in this case. For the reasons and bases discussed above and after resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection is warranted for pituitary adenoma on a direct basis. See 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. Diabetes insipidus, to include as secondary to service-connected pituitary adenoma 3. Headaches, to include as secondary to service-connected pituitary adenoma During the appeal period, the Veteran raised the theory of service connection for diabetes insipidus as secondary to his pituitary gland disorder in a November 2018 correspondence. Since separation from active service, review of the evidentiary record shows diagnoses of diabetes insipidus and headaches, as noted in private treatment records. As a result, the Board finds the element of a current disability has been met in this case. Service connection for the Veteran's pituitary adenoma has been granted. In her January 2021 medical opinion, Dr. C. R. concluded the Veteran's diabetes insipidus and headaches are secondary disorders of his pituitary macroadenoma. The Board finds this opinion was based on an accurate factual history, after noted review of the Veteran's claims file, and there is no probative contrary medical opinion of record. For the reasons and bases discussed above and after resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection is warranted for diabetes insipidus and headaches as secondary to his service-connected pituitary adenoma. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310. 4. Vision/eye disorder, diagnosed as bilateral dry eye syndrome Since separation from active service, review of the evidentiary record shows the Veteran's diagnosis of bilateral dry eye syndrome, as provided in the April 2020 VA examination for eye conditions. As a result, the Board finds the element of a current disability has been met in this case. Review of the Veteran's service treatment records shows treatment for an injury to the eyes and face in December 1971. As a result, the element of an in-service occurrence has been met in this case. Lastly, review of the April 2020 VA medical opinion shows the VA examiner explained why the Veteran's diagnosis of bilateral dry eye syndrome is at least as likely as not related to his document treatment for an eye injury in December 1971. The Board finds this opinion was based on an accurate factual history, after noted review of the Veteran's claims file, and there is no probative contrary medical opinion of record. As a result, the Board finds the element of a nexus between the Veteran's vision/eye disorder, diagnosed as bilateral dry eye syndrome, and his in-service injury in December 1971 has been met in this case. For the reasons and bases discussed above and after resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection is warranted for a vision/eye disorder, diagnosed as bilateral dry eye syndrome, on a direct basis. See 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 5. Vision/eye disorder, diagnosed as heteronymous bilateral field defect temporal, to include as due to herbicide exposure During the course of the appeal, the AOJ has developed the Veteran's issue on appeal for a vision/eye disorder as due to herbicide exposure during active service. The Board acknowledges that while exposure to herbicides is conceded in this case, heteronymous bilateral field defect temporal is not listed or contemplated among the diseases associated with certain herbicide agents under 38 C.F.R. § 3.309 (e), thus consideration of service connection for this disability on appeal on a presumptive basis due to herbicide exposure is not warranted in this case. However, direct service connection remains available. Combee, 34 F.3d at 1039. Since separation from active service, review of the evidentiary record shows the Veteran's diagnosis of heteronymous bilateral field defect temporal, as provided in the April 2020 VA examination for eye conditions. As a result, the Board finds the element of a current disability has been met in this case. As previously noted, the Veteran's in-service herbicide exposure has been conceded by VA. As a result, the element of an in-service occurrence has been met in this case. Lastly, review of the April 2020 VA medical opinion shows the VA examiner explained why the Veteran's diagnosis of heteronymous bilateral field defect temporal is at least as likely as not related to his conceded in-service herbicide exposure. The Board finds this opinion was based on an accurate factual history, after noted review of the Veteran's claims file, and there is no probative contrary medical opinion of record. As a result, the Board finds the element of a nexus between the Veteran's vision/eye disorder, diagnosed as heteronymous bilateral field defect temporal, and his in-service herbicide exposure has been met in this case. For the reasons and bases discussed above and after resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection is warranted for a vision/eye disorder, diagnosed as heteronymous bilateral field defect temporal, on a direct basis. See 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 6. Hypothyroidism, to include as due to herbicide exposure and/or secondary to service-connected pituitary adenoma Hypothyroidism is listed among the diseases presumptively associated with exposure to certain herbicide agents under applicable regulations. 38 U.S.C. § 1116(a)(2)(K). Review of the evidentiary record demonstrates the Veteran has a post-service diagnosis of hypothyroidism manifested to a compensable degree of at least 10 percent after separation from service. Such finding is shown in multiple private and VA treatment records dated during the appeal period. After resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran has presumed in-service herbicide exposure and a current disability of hypothyroidism manifested to a compensable degree of at least 10 percent. As a result, service connection is warranted for hypothyroidism on a presumptive basis and there is no probative contrary medical opinion of record. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.307(a)(6). 7. Joint disorder of the left hand 8. Joint disorder of the left shoulder Due to the similar dispositions for the claims on appeal, the Board will address them in a common discussion below. Review of service personnel records document the Veteran served on ACDUTRA or INADUCTRA in the Army Reserves after his period of active service ended in 1972 until 2009. At the November 2019 VA examinations for hand and finger conditions and for shoulder and arm conditions, the Veteran reported that in 2007 at Fort Knox he slipped on ice and injured his left shoulder, elbow and hand, was told he had sprains, treated with a sling and pain medication, and it took approximately two to three weeks to improve. Review of service treatment records document the Veteran's reported symptoms and treatment for the left side in February 2007 at Fort Knox after a slip and fall on ice. Review of post-service medical evidence reveals current VA x-ray findings of mild osteoarthritis of the left hand and wrist and degenerative changes in the left shoulder in November 2019. Following the VA examinations for hand and finger conditions and for shoulder and arm conditions, the VA examiner rendered diagnoses of degenerative and traumatic arthritis of the left hand and traumatic arthritis of the left shoulder. Following the clinical evaluations and review of the claims file, the VA examiner concluded the following: [The Veteran] had [l]eft hand trauma on [active duty]. He has current [l]eft hand conditions consistent with results of that trauma. [The Veteran] had [l]eft shoulder trauma on [active duty]. He has current [l]eft shoulder conditions consistent with results of that trauma. After a review of the pertinent and probative evidence of record, the Board resolves all reasonable doubt in the Veteran's favor and finds that his current joint disorders of the left hand and left shoulder manifested from an injury during a period of ACDUTRA or INADUCTRA while in the Army Reserves in 2007. There is no probative contrary medical opinion of record. As such, service connection is warranted for these disorders. See 38 U.S.C. §§ 101, 1111, 5107; 38 C.F.R. §§ 3.1(d), 3.6, 3.304. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, such as for the service-connected PTSD in this case, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. 9. Tinnitus A. Entitlement to an effective date prior to June 6, 2018 for the grant of service connection for tinnitus At the outset, the Board notes that the Veteran filed a timely notice of disagreement (NOD) with the July 2018 VA rating decision that granted service connection for tinnitus and established the effective date for the assignment of a 10 percent disability rating, and he perfected this appeal. Thus, the Board has proper jurisdiction over this claim on appeal for an earlier effective date. See Rudd v. Nicholson, 20 Vet. App. 296, 299 (2006) (there is no such thing as a freestanding claim for an earlier effective date). Except as otherwise provided, the effective date for a grant of compensation will be the day following separation from active service or the date entitlement arose, if a claim is received within one year of separation. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. The evidence shows that the Veteran did not file a claim for service connection for tinnitus within one year of his separation from service in February 1972, nor does he so contend. Otherwise, the effective date of the award of an evaluation based on an original claim, a claim reopened after a final disallowance, or a claim for an increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. Id. The effective date for an award of service connection is not based on the earliest medical evidence demonstrating a causal connection, but on the date of the claim for service connection. See Lalonde v. West, 12 Vet. App. 377 (1999); see also McGrath v. Gober, 14 Vet. App. 28 (2000). The Veteran filed his first claim for service connection for tinnitus on June 6, 2018. He does not assert, nor does the record show, that he filed a claim for tinnitus prior to that date. The evidence that established entitlement was the positive etiology opinion rendered by the July 2018 VA examiner. Thus, entitlement arose in July 2018. The AOJ assigned the date of claim as the effective date, which is more favorable to the Veteran. An effective date prior to June 6, 2018, for the grant of service connection for tinnitus, is denied. B. Entitlement to an initial rating in excess of 10 percent for tinnitus In the July 2018 VA rating decision on appeal, service connection for tinnitus was granted. The Veteran was assigned a 10 percent disability rating for the entire appeal period effective from June 6, 2018. See 38 C.F.R. § 4.87, Diagnostic Code 6260. In the March 2019 NOD, the Veteran also expressed disagreement with the assigned evaluation. The Board considers whether an initial rating in excess of 10 percent for tinnitus is warranted at any time since the date of claim on June 6, 2018. Tinnitus is evaluated under Diagnostic Code 6260, which provides for a 10 percent rating, the maximum available, for recurrent tinnitus. 38 C.F.R. § 4.87. A single evaluation is assigned for recurrent tinnitus whether the sound is perceived in one or both ears. See Smith v. Nicholson, 451 F.3d 1344 (2006). Since the Veteran's service-connected tinnitus has been assigned the maximum schedular rating available for tinnitus, the Board finds there is no legal basis upon which to award a higher schedular evaluation for tinnitus. As such, entitlement to an initial rating in excess of 10 percent for tinnitus is not warranted on a schedular basis. See Sabonis v. Brown, 6 Vet. App. 426 (1994). 10. PTSD A. Contention regarding an earlier effective date In the March 2019 NOD to the July 2018 VA rating decision which denied an increased rating for PTSD, the Veteran checked the "effective date of award" box on the VA Form 21-0958 (Notice of Disagreement). In an additional March 2019 NOD to the December 2018 VA rating decision which proposed to decrease the disability rating for PTSD from 70 percent to 50 percent, the Veteran checked the "effective date of award" box on the VA Form 21-0958 (Notice of Disagreement). Under 38 C.F.R. § 20.201, "...a valid NOD must contain 'terms that can reasonably be construed as disagreement with that determination and a desire for appellate review.'" (emphasis added). Gallegos v. Principi, 283 F.3d 1309, 1314 (Fed. Cir. 2002). Since a rating decision denying an increased rating claim does not make a determination regarding an effective date, the NOD is not valid with respect to an effective date. Were the Board to consider the issue, it would constitute a freestanding earlier effective date claim and would be dismissed as a matter of law pursuant to Rudd v. Nicholson, 20 Vet. App. 296 (2006). Therefore, the Board does not need to address the matter further. B. Entitlement to a rating in excess of 70 percent for PTSD On June 6, 2018, the Veteran's request for a higher rating for PTSD was obtained and associated with the record. In the September 2018 VA rating decision, the AOJ assigned the service-connected PTSD a 70 percent disability rating effective from August 17, 2018. Id. In the September 2019 VA rating decision, the AOJ assigned the service-connected PTSD a 50 percent disability rating effective from January 1, 2020. Id. Most recently in the January 2020 VA rating decision, the AOJ assigned the service-connected PTSD a 70 percent disability rating effective from June 6, 2018. Id. The Board considers whether a rating in excess of 70 percent for PTSD is warranted at any time since or within one year prior to the date of claim on June 6, 2018. Pursuant to the General Rating Formula for Mental Disorders, a 70 percent is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); or an inability to establish and maintain effective relationships. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The next-higher and maximum rating available of 100 percent is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; danger of hurting self or others; intermittent inability to perform activities of living (including maintenance of minimal hygiene); disorientation to time or place; or, memory loss for names of close relatives, occupation, or own name. Id. The Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The nomenclature employed in the portion of VA's rating schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). See 38 C.F.R. § 4.130. The Board notes VA implemented usage of the DSM-5, effective August 4, 2014. As this issue was initially certified to the Board in June 2020, the DSM-5 is for application in this case. According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126(b). Review of the evidentiary record since June 6, 2017 (one year prior to the date of claim) documents the following psychiatric symptomatology of the service-connected disability. Review of VA treatment records shows negative PTSD screening test results in November 2017. On June 8, 2018, the Veteran underwent an initial mental health evaluation. He reported spending his time working on his property and cars, attending church, completing sudoku puzzles, and having supportive spouse and children. The Veteran also reported the following symptoms: memory loss, occasional panic, nervousness, excessive worry, nightmares, and avoidance of people and crowds. Upon observation of the Veteran, the evaluating physician noted the following: appropriate grooming and hygiene, alert, cooperative, good eye contact, normal speech, logical content, euthymic mood, blunted affect, and intact attention and long-term memory. Approximately five days later in June 2018, the Veteran underwent a neurobehavioral interview and neuropsychological screening. The evaluating physician noted the same observations pertaining to the Veteran's mental status as on June 8th. At the July 2018 VA examination for PTSD, the Veteran reported having a good relationship with family, enjoys watching television and movies, belongs to a veterans organization but rarely attends events, occasionally attends church, connects best with other active duty military and veterans because feels he has more in common with them, and keeps in touch with one friend from Vietnam. He also reported that he hates to go out in crowds, avoids restaurants, and does not like when someone touches him unexpectedly. He described an incident approximately six months prior when he got into a verbal altercation with someone in a store parking lot but attributed his level of aggression with others more likely to his familial history than to his PTSD. The Veteran also reported that he retired in 2007, has not worked since then, and does tasks around the home. With regards to PTSD symptomatology, the Veteran reported he is irritable at times and when thinking about current stressors, anxiety is worse in anticipation of stressful events, occasional nightmares, more common military themed stressful dreams, generally has a "just tired" mood, normal level of fatigue, and that "stupid people" make him angry. He also denied a history of psychiatric hospitalizations, private or VA mental health care, use of psychotropic medication, history of suicide attempts, and any current suicidal or homicidal ideation. The VA examiner noted anxiety as the symptom that actively applies to the Veteran's diagnosis of PTSD. The VA examiner noted the following observations of the Veteran: alert and oriented, casually dressed, appropriate hygiene, clear and coherent speech, no indication of significant intellectual or cognitive impairment, appropriate eye contact, psychomotor activity within normal limits, linear and logical though processes, normal affect, good mood, intact memory, adequate insight, sound judgment, pleasant, and talkative. The VA examiner concluded the Veteran's level of occupational and social impairment due to his PTSD was best summarized as 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 conservation. At the September 2018 VA examination for PTSD, the Veteran denied use of psychotropic medication and receiving treatment for PTSD. The VA examiner noted the following present symptoms: depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, inability to establish and maintain effective relationships, suicidal ideation, and obsessional rituals which interfere with routine activities. The VA examiner noted the following observations of the Veteran: appeared anxious, casually dressed, well-groomed, cooperative, attentive, alert and oriented, normative eye contact, psychomotor activity within normal limits, and no indication of clinically-significant long-term memory dysfunction. The VA examiner concluded the Veteran's level of occupational and social impairment due to his PTSD was best summarized as with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The VA examiner further noted there no change in the service-connected diagnosis of PTSD and no additional diagnoses were rendered. At the November 2018 VA examination for PTSD, the Veteran reported no significant changes in his psychosocial history. The VA examiner noted the following present symptoms: anxiety, panic attacks more than one a week, chronic sleep impairment, mild memory loss, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The VA examiner noted the following observations of the Veteran: blunted affect, appropriate mood, lessened awareness or lack of orientation (characterized as the Veteran reported he was there for a vision examination), partial insight, fair judgment, and no indication of possible psychotic indicators. While the Veteran's denial of any current wish to be dead or to hurt another was noted, the VA examiner also noted the Veteran's report that he might consider suicide if his vision gets to the point he can no longer care for himself and that he has ready access to guns in his home. The VA examiner also concluded the Veteran's level of occupational and social impairment due to his PTSD was best summarized as with reduced reliability and productivity. Review of additional VA treatment records dated during the appeal period shows ongoing reports of the Veteran's PTSD as stable and his decline for the need or want to follow with mental health. In a November 2020 statement, the Veteran's wife reported her observations of the Veteran's mental health over the last 10 years. Such symptomatology she observed includes the following: sleep impairment, declined energy and motivation, no desire to be productive or to make new friends, desire to remain indoors, avoidance of crowds, nervousness when in crowds or at the store, maintains communication with children over the phone, irritability, maintains a daily routine, easily overwhelmed, road rage, worsening memory (difficulty remembering appointments and taking medications), and waking up sweating and freaking out. She further noted the Veteran has not worked since 2009. As discussed below, the Board finds that total occupational impairment has been demonstrated, in part, due to the service-connected PTSD. Nevertheless, the Veteran's service-connected PTSD has not been manifested by total social impairment due to psychiatric symptomatology at any time during the appeal period to warrant assignment of the next-higher rating of 100 percent. "Total" is defined as "whole, not divided; full; complete," and "utter, absolute." Black's Law Dictionary, 1498 (7th ed. 1999). The Veteran's psychiatric symptoms have not resulted in a level of social impairment that is accurately described as total, given that he maintains relationships with his spouse, children, and a few other veterans. Additionally, the record shows that he is consistently able to interact appropriately with his health care providers, VA examiners, and to leave his home for appointments and occasionally for shopping with his wife. Although his PTSD symptoms negatively impact his relationships, his level of social impairment is not more accurately described as "total." The Board acknowledges the November 2018 VA examiner's observations of the Veteran included lessened awareness or lack of orientation, specified as the Veteran unsure for which VA examination he was attending. Although disorientation to time or place is contemplated by the 100 percent criteria, the severity of the Veteran's reported disorientation does not rise to the level of frequency, severity, or duration sufficient to cause total social impairment in this case. Additionally, the Board acknowledges that the September 2018 VA examiner noted the Veteran's present symptoms included suicidal ideation, and the Veteran's report at the November 2018 VA examination of maybe considering suicide if his vision gets to the point he can no longer care for himself. These indications of record are similar to danger of hurting self or others, which is contemplated by the 100 percent criteria. Bankhead, 29 Vet. App. at 19. However, the severity, frequency, and duration of the Veteran's reported suicidal ideation occurrence has not risen to the level contemplated by the 100 percent disability rating. Subsequent review of the evidentiary record does not show findings of active suicidal ideation, plans, and attempts nor does the Veteran or his attorney assert as such. Moreover, the Veteran appeared no more acutely dangerous to others, and demonstrated full orientation to time and place, normal speech and thought processing, and intact judgment during the rating period since June 2017. For these reasons, a rating in excess of 70 percent is not warranted. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board is aware that the symptoms listed under the maximum rating of 100 percent are essentially examples of the type and degree of symptoms for that rating, and that the Veteran need not demonstrate those exact symptoms to warrant a higher rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002); Vazquez-Claudio, 713 F.3d at 117-18. In this case, the Board has considered the maximum rating for the appeal period since June 6, 2017 but finds that it is rated appropriately. The signs and symptoms manifested are contemplated by the currently assigned rating of 70 percent as they do not manifest with the severity, frequency, or duration required for the 100 percent rating which requires both total occupational and total social impairment. The Board has considered the Veteran's reported history of symptomatology related to the service-connected PTSD. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through one's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). His credible descriptions of his observable symptoms are not more closely described by 100 percent criteria at any time during the entire appeal period. The Board has also considered the possibility of staged ratings and finds that the scheduler rating for the service-connected disability on appeal has been in effect for appropriate period on appeal. Accordingly, staged ratings are inapplicable. Hart v. Mansfield, 21 Vet. App. 505 (2007). REASONS FOR REMAND 1. Entitlement to a TDIU During the appeal period for the issue of entitlement to a higher rating for PTSD, the Veteran submitted a VA Form 21-8940 in November 2020 requesting entitlement to a TDIU due to all of his service-connected disabilities, including PTSD. The Board finds this issue has been raised in connection with the claim on appeal for a higher initial rating for PTSD and the date of claim is on June 6, 2018. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Additionally, in light of the decisions above, the Veteran's service-connected disabilities now include pituitary adenoma, diabetes insipidus, headaches, vision/eye disorders, including bilateral dry eye syndrome and heteronymous bilateral field defect temporal, and hypothyroidism, for which the AOJ has not yet assigned the disability rating. 2. Entitlement to service connection for a back disorder In June 2018, the Veteran requested service connection for a back condition. Review of the Veteran's service personnel records, including the DD Form 214, documents his receipt of the parachute badge. Additionally, review of the evidentiary record documents the Veteran's reported chronic back pain, as noted by the AOJ in the April 2020 SOC and in VA treatment records. As such, the Board finds that additional development is needed to determine the etiology of a current back disorder on a direct basis. 38 U.S.C. § 5103A(a); 38 C.F.R. §§ 3.159, 3.303; McLendon v. Nicholson, 20 Vet. App. 79 (2006). 3. Entitlement to service connection for a sleep disorder, to include as secondary to service-connected PTSD In June 2018, the Veteran requested service connection for sleep conditions. Review of the evidentiary record documents the Veteran's reported symptoms of sleep impairment likely secondary to PTSD symptoms as well as a diagnosis of insomnia in June 2018. Most recently, in an October 2018 VA Form 21-526EZ, the Veteran raised the theory of entitlement to service connection for sleep condition as secondary to PTSD. As such, the Board finds that additional development is needed to determine the existence and etiology of a sleep disorder. See 38 C.F.R. § 3.310; McLendon, 20 Vet. App. at 79. 4. Entitlement to service connection for a joints disorder (other than left hand and left shoulder), including left elbow, right knee, and feet/heel In addition to the Veteran's claim on appeal for a joints disorder of the left hand and left shoulder, he also asserts symptomatology of his left elbow, right knee, and feet/heel. In November 1996, the Veteran reported having feet, heel and knee pain as well as joint pain in relation to the years of running. The Veteran also reported in an October 1998 to have pain in his feet, heel, knee, and joints. Additionally, as previously noted, review of his service personnel records, including the DD Form 214, documents his receipt of the parachute badge. The Board acknowledges a VA examination and medical opinion has been provided for the left elbow; however, the Board finds that additional development is needed to determine the etiology of a current joints disorder (other than left hand and left shoulder), including right knee and feet/heel, on a direct basis. 38 U.S.C. § 5103A(a); 38 C.F.R. §§ 3.159, 3.303; McLendon, 20 Vet. App. at 79. 5. Entitlement to service connection for amyloidosis, to include as due to herbicide exposure and/or secondary to service-connected pituitary adenoma In June 2010, the Veteran submitted an internet article pertaining to amyloidosis and pituitary macroadenomas. In the June 2020 VA Form 9, the Veteran asserted service connection for amyloidosis as a result of his exposure to herbicides. While the January 2021 private medical opinion from Dr. C. R. provides a positive nexus between amyloidosis and the service-connected pituitary adenoma, review of the record is currently silent for any current disability. In light of the Veteran's contentions and absence of a VA examination identifying the current residuals of the service-connected pituitary adenoma, the Board finds that additional development is needed to determine the existence and etiology of amyloidosis in this case. See 38 C.F.R. § 3.310; McLendon, 20 Vet. App. at 79. 6. Entitlement to service connection for a vision/eye disorder (other than bilateral dry eye syndrome and heteronymous bilateral field defect temporal), to include as due to herbicide exposure and/or secondary to service-connected pituitary adenoma Review of the record shows additional eye diagnoses of bilateral early non exudative macular degeneration, bilateral choroidal nevus, or bilateral pseudophakia, as provided in the April 2020 VA examination for eye conditions. In the April 2020 VA medical opinion, the VA examiner concluded these diagnose are congenital, age-related, and less likely than not related to the conceded in-service herbicide exposure. After review of the pertinent evidence record noted above, the Board finds that the record is unclear as to whether the Veteran's diagnoses of bilateral early non exudative macular degeneration, bilateral choroidal nevus, or bilateral pseudophakia are congenital diseases or defects. See 38 C.F.R. § 3.303(c); Quirin v. Shinseki, 22 Vet. App. 390, 394 (2009) (holding that congenital diseases, but not defects, may be service connected, although service connection may be granted for additional disability due to disease or injury superimposed upon a congenital defect during service). As such, additional development is needed to properly adjudicate the appeal, to include obtaining an additional VA medical opinion. See 38 U.S.C. § 5103A(a); 38 C.F.R. § 3.159; Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Congenital or developmental defects are not diseases or injuries within the meaning of the applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9. VA's General Counsel has further explained that service connection may be granted for diseases (but not defects) of congenital, developmental or familial origin, as long as the evidence as a whole establishes that the familial conditions in question were incurred or aggravated during service within the meaning of VA laws and regulations. VAOPGCPREC 82-90 (July 18, 1990). VA's General Counsel has also expressly stated that the terms "disease" and "defects" must be interpreted as being mutually exclusive. The term "disease" is broadly defined as any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. On the other hand, the term "defects" would be definable as structural or inherent abnormalities or conditions that are more or less stationary in nature. See VAOPGCPREC 82-90 (July 18, 1990). However, VA General Counsel has further noted that if, during service, superimposed disease or injury occurs, service connection may be warranted for the resultant disability. See Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993) (citing Hunt v. Derwinski, 1 Vet. App. 292 (1991)); VAOPGCPREC 67-90 (July 18, 1990). The matters are REMANDED for the following actions: 1. Provide the Veteran and his representative with notice concerning how to substantiate the claim for TDIU. 2. Then, schedule the Veteran for an examination (physical or telehealth) with an appropriate clinician for his back disorder. The entire claims file and a copy of this remand must be made available to the examiner for review. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's current back disorder (a) began during active service, (b) is related to an incident of service, to include in-service parachute jumps, or (c) if any symptoms of arthritis began within one year after discharge from active service. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Schedule the Veteran for an examination (physical or telehealth) with an appropriate clinician for his sleep disorder. The entire claims file and a copy of this remand must be made available to the examiner for review. The examiner must opine as to the following: (a.) Identify whether the Veteran's diagnosis of a sleep disorder (including insomnia even if since resolved) is separate and distinct from his diagnosed PTSD. (b.) If so, whether it is at least as likely as not (50 percent or greater probability) that the Veteran's sleep disorder (including insomnia) began during active service or is related to an incident of service. (c.) Whether it is at least as likely as not that the Veteran's sleep disorder (including insomnia) was proximately due to or the result of his service-connected PTSD. (d.) Whether it is at least as likely as not that the Veteran's sleep disorder (including insomnia) was aggravated beyond its natural progression by his service-connected PTSD. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. Schedule the Veteran for an examination(s) (physical or telehealth) with an appropriate clinician for joints disorder (other than left hand and left shoulder), including right knee and feet/heel. The entire claims file and a copy of this remand must be made available to the examiner for review. The examiner must opine as to the following: (a.) Identify whether the Veteran has a current diagnosis of a right knee disorder at any time since 2010 (even if since resolved). (b.) Identify whether the Veteran has a current diagnosis of a foot/heel disorder at any time since 2010 (even if since resolved). (c.) If so, whether it is at least as likely as not (50 percent or greater probability) that each disability began during active service, is related to an incident of service, to include consideration of the Veteran's reported years of running and in-service parachute jumps, or if symptoms of arthritis have been continues since discharge from active service. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 5. Schedule the Veteran for an examination (physical or telehealth) with an appropriate clinician for amyloidosis. The entire claims file and a copy of this remand must be made available to the examiner for review. The examiner must opine as to the following: (a.) Identify whether the Veteran has had a diagnosis of amyloidosis at any time since 2010 (even if since resolved). (b.) If so, whether it is at least as likely as not (50 percent or greater probability) that the disability began during active service or is related to an incident of service, to include the presumed in-service herbicide exposure. The examiner is advised that it is not sufficient to provide negative opinion solely because amyloidosis is not a disease that is presumptively associated with exposure to herbicides. (c.) Whether it is at least as likely as not that the disability was proximately due to or the result of his service-connected pituitary adenoma. (d.) Whether it is at least as likely as not that the disability was aggravated beyond its natural progression by his service-connected pituitary adenoma. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 6. Return the Veteran's claims file to the examiner who conducted the April 2020 VA examination for eye conditions and provided the medical opinion so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran's claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination is only required if deemed necessary by the examiner. The examiner must provide opinions as to the following: (a.) Whether the Veteran's diagnosis of bilateral early non exudative macular degeneration is a congenital defect, congenital disease, or neither. (b.) Whether the Veteran's diagnosis of bilateral choroidal nevus benign is a congenital defect, congenital disease, or neither. (c.) Whether the Veteran's diagnosis of bilateral pseudophakia is a congenital defect, congenital disease, or neither. Note - A defect is defined as a structural or inherent abnormality or condition which is more or less stationary in nature. A disease is any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. (d.) For any identified congenital defect, whether the diagnosis(es) was subject to a superimposed disease or injury during his period of active service that resulted in additional disability (other than bilateral dry eye syndrome and heteronymous bilateral field defect temporal). (e.) For any identified congenital disease, whether the diagnosis(es) clearly and unmistakably existed prior to his entry into active military service. If found to have clearly and unmistakably existed prior to service, whether it is also clear and unmistakable that it was not aggravated to a permanent degree in service beyond that which would be due to the natural progression of the disease. If not found to have preexisted his period of active service, determine whether it is at least as likely as not (50 percent or greater probability) that it was aggravated beyond its natural progression by his service-connected pituitary adenoma. Note - The examiner is advised that the evidentiary standard for whether a condition existed prior to service is "clear and unmistakable," which is a formidable evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be "undebatable." The examiner must provide all findings, along with a complete rationale for his or her opinions in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 7. Then, review all examination reports and medical opinions provided to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the AOJ must implement corrective procedures. 8. Assign the additional disability ratings and effective dates for the service-connected adenoma, diabetes insipidus, headaches, vision/eye disorders, including bilateral dry eye syndrome and heteronymous bilateral field defect temporal, hypothyroidism, and joint disorders of the left hand and left shoulder. (Continued on the next page) 9. Then, readjudicate the remaining claims on appeal including TDIU. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Carter, 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.