Citation Nr: 21028824 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 17-33 308 DATE: May 12, 2021 ORDER Entitlement to an earlier effective date prior to June 1, 2012 for the grant of service connection for an acquired psychiatric condition is dismissed. Entitlement to an initial disability rating of 50 percent for an acquired psychiatric disorder, prior to June 15, 2018, is granted. Entitlement to an initial disability rating in excess of 50 percent for an acquired psychiatric disorder is denied. REMANDED Entitlement to service connection for irritable bowel syndrome (IBS) is remanded. Entitlement to service connection for erectile dysfunction (ED) is remanded. Entitlement to special monthly compensation (SMC) based on loss of use of creative organ is remanded. Entitlement to an initial compensable disability rating for hypertension is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. On March 1, 2021, prior to the promulgation of a decision in the appeal, the Veteran requested that the Board withdraw his appeal of the entitlement to an earlier effective date prior to June 1, 2012 for the grant of service connection of an acquired psychiatric condition. 2. For the period on appeal, the Veteran's mental health disorder most closely approximates 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; difficulty in establishing and maintaining effective work and social relationships. CONCLUSIONS OF LAW 1. The criteria for withdrawal of entitlement to an earlier effective date prior to June 1, 2012 for the grant of service connection for an acquired psychiatric condition by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for entitlement to an initial disability rating of 50 percent for an acquired psychiatric disorder, prior to June 15, 2018, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9413. 3. The criteria for entitlement to an initial disability rating in excess of 50 percent for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, DC 9413. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Navy on active duty from May 1992 to May 2012. The issues come before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in March 2021. A transcript of the hearing has been included with the record. The Board notes that the Veteran submitted additional evidence to the Board with an attached waiver of RO consideration. 1. Entitlement to an earlier effective date prior to June 1, 2012 for the grant of service connection of an acquired psychiatric condition The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 19.55. During the March 2021 Board hearing, the Veteran explicitly, unambiguously, and with a full understanding of the consequences, withdrew the issue of entitlement to an earlier effective date prior to June 1, 2012 for the grant of service connection for an acquired psychiatric disorder. The undersigned clearly identified the withdrawn issue, and the Veteran affirmed that he was requesting a withdrawal as to that appeal. See Hearing Transcript at 2. The appellant's full understanding of the consequences is shown based on the fact that prior to the hearing, the consequences of withdrawal of these claims were fully discussed by the undersigned. See Acree v. O'Rourke, 891 F.3d 1009 (Fed. Cir. 2018), adopting the rule of DeLisio v. Shinseki, 25 Vet. App. 45, 57-58 (2011). Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the issue on appeal and it is dismissed. Increased Rating VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. The schedule recognizes that disability from distinct injuries or diseases may overlap. See 38 C.F.R. § 4.14. However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. Id. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). 2. Entitlement to an initial disability rating of 50 percent for an acquired psychiatric disorder, prior to June 15, 2018 3. Entitlement to an initial disability rating in excess of 50 percent for an acquired psychiatric disorder In the June 2017 rating decision, the RO granted the Veteran's service connection claim for the Veteran's other specified trauma and stressor related disorder, adjustment-like disorder (claimed as anxiety and posttraumatic stress disorder) and assigned a 30 percent rating. During the pendency of the Veteran's appeal, in a January 2020 rating decision, the RO granted an increased initial rating for the Veteran's acquired psychiatric disorder, to 50 percent disabling, effective June 15, 2018. As the full benefit was not granted, the claim remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran contends that he suffers from symptoms of an acquired psychiatric disorder that warrant a disability rating in excess of 30 percent prior to June 15, 2018. The Veteran testified at the March 2021 Board hearing that the symptoms of his mental health disorder have generally remained the same since his separation from service. The Veteran described symptoms of his psychiatric condition as persistent sleep disturbances and feelings of isolation from others. The Veteran noted his disturbance in motivation and impaired impulse control, to include overeating, due to his depression. The Veteran noted the June 2018 VA examination was a more accurate portrayal of his symptoms than his previous examination. The Veteran's unspecified trauma disorder is currently rated under DC 9413 using the General Rating Formula for Mental Disorders (General Rating Formula). 38 C.F.R. § 4.130, DC 9413. Under the General Rating Formula, a 30 percent rating is warranted for mental disorders manifested as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, 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/or inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name). Id. When determining the appropriate disability evaluation to assign for a mental disorder, the Board must make a finding as to how psychological symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The General Rating Formula criteria are associated with objectively observable symptomatology. The plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms. Thus, 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. Id. at 118. After a review of the evidence of record, the Board finds that the Veteran's symptoms of his psychiatric condition more closely approximate 50 percent disabling prior to June 15, 2018, under the General Rating Formula. 38 C.F.R. § 4.130, DC 9413. The record contains the Veteran's VA mental health treatment notes after separation, which demonstrate the Veteran sought treatment for symptoms of anxiety and depression, associated with reacclimating to civilian life after his military career. The Veteran's VA treatment records show the Veteran experienced sleep disturbances, decreased energy levels, and decreased motivation to interact with his family. The Veteran complained of feelings of impaired concentration and increased irritability. The Veteran's September 2012 VA therapy record noted the Veteran demonstrated variable moods with unknown triggers. The Veteran's VA treatment records noted the Veteran experienced isolation and anxiety with issues of coping with his family after active duty service. The evidence of record from November 2012 showed the Veteran reported difficulties with attention and memory. The Veteran's December 2012 VA therapy note reported that he actively avoided family members. The Veteran isolated to his room to avoid social interaction. In the Veteran's June 2013 VA therapy session, the Veteran noted worsening feelings of depression. He noted feeling that civilian culture after a military career was more challenging than he expected. He noted joining the American Legion to be able to connect with other veterans, but stated he tended to avoid other events. The Veteran reported he noticed a worsening mood. He stated that he tended to isolate at home and could not seem to motivate himself to do things that he enjoyed. The Veteran stated he gained weight but noted he did not have much interest in eating. The VA treatment record noted the Veteran experienced feelings of helplessness, low energy, poor concentration, and poor sleep. The Veteran reported a history of heavy alcohol use. He admitted to blackouts and complaints from his family about his level of drinking. The Veteran reported that he removed firearms from his house on his wife's request. The Veteran's VA therapist noted the Veteran demonstrated a slightly restricted affect and depressed mood. The Veteran denied any suicidal or homicidal thoughts. The VA therapist prescribed the Veteran antidepressants for his condition. The Veteran underwent a VA mental health condition examination in August 2013. The VA examiner provided the Veteran with a diagnosis of a non-specified anxiety disorder. The VA examiner noted the Veteran was experiencing difficulty adjusting to civilian life, including marital life. The VA examiner noted the Veteran's mental health condition was formally diagnosed, but symptoms were not severe enough to interfere with occupational and social functioning, or to require continuous medication. The VA examiner reported the Veteran's symptoms as depressed mood and anxiety. The RO provided an additional psychiatric VA examination in February 2015. The VA examiner diagnosed the Veteran with other specified trauma- and stressor-related disorder, adjustment-like disorder with prolonged duration of more than 6 months without prolonged duration of stressor. Additionally, the VA examiner provided the Veteran with a diagnosis of mild alcohol use disorder and noted it was possible to differentiate the symptoms attributable to each diagnosis. The VA examiner noted the Veteran's trauma disorder presented symptoms of hypervigilance, feeling on edge, and avoidance of crowds. The examiner noted the Veteran's alcohol abuse was evident by excessive use of alcohol despite negative consequences. The examiner also noted that the Veteran denied neurobehavioral effects related to his service-connected traumatic brain injury (TBI). The examiner noted the Veteran's trauma disorder manifested as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The VA examiner noted the Veteran's trauma disorder included symptoms of anxiety, suspiciousness, chronic sleep impairment, and disturbance of motivation and mood. The Veteran reported symptoms of zoning out, feeling very nervous in large crowds, trouble sleeping, waking in cold sweats, hypervigilance, difficulty focusing on tasks, and avoidance of crowds. The Veteran underwent a VA mental health examination again in June 2018. The VA examiner confirmed the Veteran's unspecified trauma and stressor related disorder and provided a diagnosis of moderate alcohol use disorder. The VA examiner noted that it was possible to differentiate the symptoms attributable to each diagnosis. The examiner stated the diagnoses are not independent of each other and result from the same etiology. However, the symptoms are distinct and identifiable. The VA examiner noted the Veteran was abusing alcohol. His alcohol use interfered with his marriage, increased the Veteran's depressed mood, and contributed to his obesity and weight gain. The VA examiner recorded the Veteran's symptoms attributable to the Veteran's trauma disorder as depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and impaired impulse control, such as unprovoked irritability with periods of violence. The VA examiner noted the Veteran's diagnosis of a TBI and reported the symptoms of insomnia and fatigue overlapped with the symptoms of the Veteran's mental health disorder. The VA examiner noted the Veteran's acquired psychiatric conditions manifested as occupational and social impairment with reduced reliability and productivity. The VA examiner noted the Veteran had not worked since his retirement from the Navy, which the Veteran attributed to his physical disabilities. During the clinical interview, the Veteran demonstrated appropriate dress and grooming. The Veteran's speech and eye contact demonstrated normal levels of activity. The VA examiner described the Veteran's mood as bored and down, but his affect was broad and appropriately reactive. The Veteran denied suicidal ideation but noted feeling reckless at times. The Veteran stated he drove 130 miles per hour on his motorcycle on the interstate, and later felt scared. The Veteran described an incident when he lost his temper with his neighbor. The Veteran noted breaking his phone and plates when he was angry but denied being aggressive with others. He noted that he was afraid if he fought someone, he would kill them. The Veteran denied hallucinations and delusions. The Veteran noted he eats throughout the day and gained 100 pounds in 6 years since discharge from active duty. Resolving all reasonable doubt in favor of the Veteran, the Board finds the Veteran's acquired psychiatric condition warrants an initial disability rating of 50 percent for the entire period on appeal. The Veteran testified that he suffered the same symptoms of his mental health condition since his separation from service. Here, the Board finds the evidence of record supports a finding that the Veteran's symptoms most closely approximate the level of social and occupational impairment compensated under the 50 percent rating of the General Rating Formula. 38 C.F.R. § 4.130. Specifically, the evidence of record demonstrates the Veteran's symptoms include flattened affect, impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Board acknowledges the evidence of record shows the Veteran's psychiatric disorder manifested as symptoms associated with lower disability ratings, to include chronic sleep impairment, mild memory loss, depressed mood, anxiety, and suspiciousness. However, taken as a whole, the severity of the Veteran's social and occupational impairment rises to the level of 50 percent disabling for the entire period on appeal. Moreover, the record demonstrated the Veteran suffered from impaired judgment, to include excessive eating and weight gain, and difficulty maintaining social relationships throughout the entire appeal period. Additionally, the Veteran's mental health condition manifested as symptoms of impaired impulse control with unprovoked irritability, raising the Veteran's social impairment above 30 percent disabling for the entire period on appeal. Thus, viewing the evidence in a light most favorable to the Veteran, the Board finds the Veteran's symptoms manifested throughout the entire period on appeal as social and occupational impairment with reduced reliability and productivity, and an initial rating of 50 percent disability is appropriate for the entire appeal period. See 38 C.F.R. §§ 4.3, 4.130, DC 9413. The Board finds that the evidence of record does not support a rating in excess of 50 percent at any time during the pendency of the Veteran's appeal. While the June 2018 VA examination demonstrates the Veteran displayed impaired impulse control (such as unprovoked irritability with periods of violence), the record does not show the Veteran's mental health condition presented occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to symptoms of 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. See 38 C.F.R. § 4.130. The Board notes that the Veteran demonstrated symptoms of avoidance and isolation, which characterized the Veteran's difficulty in establishing and maintaining social relationships. However, the evidence of record does not support a finding that the Veteran was unable to establish or maintain effective relationships. Therefore, a 70 percent disabling evaluation is not warranted. The Board further finds that a 100 percent rating is not warranted. The evidence of record does not show that the Veteran's symptoms produce total social impairment as to warrant a 100 percent rating. The Veteran has been able to maintain a relationship with his wife. The record does not establish that the Veteran is in persistent danger of hurting himself or others. There has been no evidence of delusions, gross impairment in thought processes or communication, grossly inappropriate behavior, intermittent inability to perform activities of daily living, or disorientation to time or place. The Veteran has denied auditory or visual hallucinations. Accordingly, the Board finds that the preponderance of evidence is against an initial disability rating in excess of 50 percent. The benefit of the doubt doctrine does not apply. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). REASONS FOR REMAND 1. Entitlement to service connection for irritable bowel syndrome (IBS) is remanded. The Veteran contends that he suffers from IBS related to his active duty service, to include his service in Southwest Asia. Remand is required to provide the Veteran with an adequate VA examination addressing the nature and etiology of the Veteran's intestinal condition, to include IBS. The Veteran underwent a Gulf War Medical Examination and Intestinal Conditions VA examination in October 2018. The VA examiner noted the Veteran's intestinal condition and reported the Veteran's disorder did not represent an undiagnosed illness or diagnosed medically unexplained chronic multisymptom illness. The VA examiner concluded that the Veteran did not meet the diagnostic criteria for IBS. The VA examiner noted the Veteran's service treatment records demonstrated that he was treated multiple times for symptoms of an intestinal condition, but the symptoms were accompanied by either sore throat, fever, or vomiting. The VA examiner opined that the Veteran's claimed condition was less likely than not incurred in or caused by the Veteran's claimed in-service injury event, or illness. The Board finds the October 2018 opinion is inadequate to properly adjudicate the Veteran's claim as the opinion is based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The VA medical examiner's opinion failed to address the Veteran's complete service treatment records, including records from September 1993, October 1993, November 1993, and January 1994, which showed the Veteran presented no symptoms of vomiting, fever, or sore throat along with his symptoms of an intestinal condition. The VA examiner's rationale is silent as to why these pieces of evidence in the record were not considered as the incurrences of the Veteran's claimed IBS. Thus, remand is required to provide the Veteran a VA examination addressing the evidence of the Veteran's intestinal condition in service. 2. Entitlement to service connection for erectile dysfunction (ED) is remanded 3. Entitlement to special monthly compensation (SMC) based on loss of use of creative organ is remanded. The Veteran contends that he suffers from ED related to his active duty service. Further, the Veteran contends that his ED is related to his service-connected disabilities, to include sleep apnea and medications taken for his service-connected disorders. VA's duty to assist includes providing an examination and obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159. Here, remand is needed to provide the Veteran a medical opinion with adequate rationale addressing whether the Veteran's service-connected disabilities, including treatments and medications taken for all his service-connected disabilities, proximately caused or aggravated the Veteran's ED condition. See El-Amin v. Shinseki, 26 Vet. App. 136, 138-40 (2012). When VA determines to provide an examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board must consider all theories of entitlement either expressly raised by the claimant or which are reasonably raised by the record. See Robinson v. Shinseki, 557 F.3d 1355, 1362 (Fed. Cir. 2009). The Veteran testified at the March 2021 Board hearing that he first noticed his symptoms of ED in 2009. Remand is required to address the Veteran's lay testimony regarding the in-service onset of his ED. Finally, the Veteran contended in the March 2021 Board hearing, that the Veteran's obesity was a substantial factor to his ED. The Veteran asserts that his acquired psychiatric condition has led to the Veteran's weight gain and obesity. Accordingly, VA must address the Veteran's obesity as an intermediate cause linking the Veteran's ED to his service-connected psychiatric disorder. See Walsh v. Wilkie, 32 Vet. App. 300, 305-07 (2020). The Veteran's claim for SMC based on loss of reproductive organ is inextricably intertwined with the remanded claim for entitlement to service connection for ED. As the outcome of the Veteran's ED claim could have a substantial effect on the award of SMC, the claim must also be remanded pending adjudication of the above claim. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). 4. Entitlement to an initial compensable disability rating for hypertension is remanded. At the hearing the Veteran testified that his symptoms of hypertension warrant a compensable disability rating. The Veteran testified that he was hospitalized in August 2017 due to hypertension and treated for his elevated blood pressure. Additionally, the Veteran reported testing his blood pressure at home daily. He noted his blood pressure readings routinely measured above 160 for systolic pressure and above 100 diastolic pressure. The Veteran noted worsening in his hypertension and elevated blood pressure readings despite his continuous medication to lower his blood pressure. A review of the Veteran's medical treatment records shows elevated blood pressure readings. However, for VA rating purposes, hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, DC 7101 Note (1). As the Veteran contends his hypertension condition worsened since the most recent VA examination of record, in August 2013, a new VA examination is needed to address the severity of the Veteran's condition. See Snuffer v. Gober, 10 Vet. App. 400 (1997). 5. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. The Veteran contends that he cannot work due to his service-connected disabilities as a whole. Notably, the Veteran contends that the combined effects of his service-connected disabilities, including his difficulty managing his hypertension, prevents the Veteran from securing and maintaining gainful employment due to the inevitable and excessive sick time caused by his disabilities. When a veteran files a claim for an increased rating, the veteran is presumed to be seeking the maximum benefit under any applicable theory, to include the entire period on appeal for a claim of TDIU. See generally Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). When evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for entitlement to TDIU will be considered to have been raised by the record as "part and parcel" of the underlying claim. Rice v. Shinseki, 22 Vet. App. 447 453-54 (2009). As the Veteran contends that he is unemployable due to his hypertension, the Board finds that the claim for a TDIU is part and parcel of the increased rating claim for hypertension and is inextricably intertwined with the remanded claims, as the outcome of the claims could have a substantial effect on the merits of the claim for a TDIU. Therefore, it must also be remanded pending adjudication of the above remanded claims. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate examiner to determine the etiology of the Veteran's claimed intestinal condition, to include irritable bowel syndrome (IBS). The record and a copy of this Remand must be made available to the examiner. The examination may be conducted via telehealth or similar service during the social distancing restrictions of the COVID-19 pandemic. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail, and correlated to a specific diagnosis. Following a review of the evidence of record, the examiner must opine as to whether it is at least as likely as not (50 percent probability or more) that the Veteran's claimed intestinal condition, to include IBS, had its onset during or is otherwise etiologically related to active duty service. The examiner must provide a comprehensive report including a clearly stated rationale for any opinions offered and conclusions reached, citing the objective medical findings leading to the conclusions, and must not be based solely on the lack of records. In this regard, the Board emphasizes that the Veteran is competent to report his symptoms and history, and such statements by the Veteran regarding symptomatology and medical history must be specifically acknowledged and considered in formulating any opinions concerning the onset and severity of his disability. If such reports are rejected by the examiner, a reason for doing so must be provided. 2. Schedule the Veteran for a VA examination with an appropriate examiner to determine the etiology of the Veteran's claimed erectile dysfunction (ED). The record and a copy of this Remand must be made available to the examiner. The examination may be conducted via telehealth or similar service during the social distancing restrictions of the COVID-19 pandemic. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail, and correlated to a specific diagnosis. Following a review of the evidence of record, the examiner must opine as to: a. Whether it is at least as likely as not (50 percent probability or more) the Veteran's ED, was proximately caused by, or the result of, the Veteran's service-connected disabilities (i.e., sleep apnea, hypertension, psychiatric condition, or lumbar spine disability), including as a result of medication taken for any service-connected disability. b. Whether it is at least as likely as not (50 percent probability or more) the Veteran's ED, was aggravated by, any of the Veteran's service-connected disabilities (i.e., sleep apnea, hypertension, psychiatric condition, or lumbar spine disability), including as a result of medication taken for any service-connected disability. Additionally, the reviewing clinician must address the Veteran's contention that his obesity is an intermediate cause of his ED. The examiner shall opine as to the following: c. Whether it is at least as likely as not (50 percent probability or more) that the Veteran's service-connected psychiatric disorder either alone or in combination with another service-connected disability or disabilities, caused the Veteran to gain weight or become obese. d. Whether it is at least as likely as not (50 percent probability or more) that the Veteran's weight gain or obesity was a substantial factor in causing the Veteran's ED. e. Whether it is at least as likely as not (50 percent or greater probability) that ED would not have occurred but for weight gain or obesity caused by the service-connected disability or disabilities. If secondary service connection is not established, the examiner must opine to whether it is at least as likely as not (50 percent probability or more) that the Veteran's ED had its onset during or is otherwise directly etiologically related to active duty service. The examiner must provide a comprehensive report including a clearly stated rationale for any opinions offered and conclusions reached, citing the objective medical findings leading to the conclusions, and must not be based solely on the lack of records. In this regard, the Board emphasizes that the Veteran is competent to report his symptoms and history, and such statements by the Veteran regarding symptomatology and medical history must be specifically acknowledged and considered in formulating any opinions concerning the onset and severity of his disability. If such reports are rejected by the examiner, a reason for doing so must be provided. 3. Schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and severity of the Veteran's service-connected hypertension. The record and a copy of this Remand must be made available to the examiner. The examination may be conducted via telehealth or similar service during the social distancing restrictions of the COVID-19 pandemic. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail, and correlated to a specific diagnosis. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. To the extent possible, the examiner should identify any symptoms and functional impairments due to hypertension alone and discuss the effect of the Veteran's hypertension on any occupational functioning and activities of daily living. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.V. Bona, 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.