Citation Nr: 21030770 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-39 943 DATE: May 19, 2021 ORDER Entitlement to a rating in excess of 70 percent prior to February 2, 2021 for posttraumatic stress disorder (PTSD) is denied. Entitlement to a rating in excess of 30 percent for chronic sinusitis is denied. Entitlement to service connection for hypertension as due to in-service herbicide exposure is granted. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected diabetes mellitus type II and/or PTSD, is denied. Entitlement to service connection for allergic rhinitis, to include as secondary to service-connected disabilities, is denied. REMANDED Entitlement to service connection for hemorrhoids, to include as secondary to service-connected diabetes mellitus type II and/or PTSD, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. Entitlement to additional special monthly compensation (SMC) prior to February 3, 2021 is remanded. Entitlement to basic eligibility for Dependents' and Educational Assistance (DEA) benefits prior to February 3, 2021 is remanded. FINDINGS OF FACT 1. Prior to February 3, 2021, the Veteran's PTSD was not shown to be manifested by total occupational and social impairment. 2. The Veteran's chronic sinusitis has not been shown to require surgery, nor has the Veteran had near-constant sinusitis at any point during the appeal period. 3. Resolving reasonable doubt in the Veteran's favor, his hypertension has been shown to be secondary to in-service exposure to herbicide agents. 4. The Veteran's GERD was not incurred in service and has not been shown to be caused or aggravated by his service-connected diabetes mellitus type II or PTSD. 5. The Veteran's rhinitis was not incurred in service and has not been shown to be caused or aggravated by his service-connected chronic sinusitis or diabetes mellitus type II. CONCLUSIONS OF LAW 1. Prior to February 2, 2021, the criteria for a rating in excess of 70 percent for PTSD was not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a rating in excess of 30 percent for chronic sinusitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.97, DC 6513. 3. The criteria for entitlement to service connection for hypertension, as secondary to herbicide exposure, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 4. The criteria for entitlement to service connection for GERD, to include as secondary to diabetes mellitus type II and/or PTSD, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. 5. The criteria for entitlement to service connection for allergic rhinitis, to include as secondary to chronic sinusitis and/or diabetes mellitus type II, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from April 1968 to April 1970, to include service in the Republic of Vietnam. He also had service of an unverified nature in the United States Army Reserves from April 1970 to March 1974. These matters arose to the Board of Veterans' Appeals (Board) from rating decisions in November 2015, February 2016, March 2017, April 2017, July 2018, and November 2018 by the Department of Veterans Affairs (VA) Regional Offices (RO). The Board remanded the claims in January 2020 for evidentiary development. In a February 2021 rating decision, the RO granted service connection for bilateral upper peripheral neuropathy, an issue that was previously remanded by the Board. The RO also granted an increased 100 percent rating for PTSD, effective February 3, 2021, and reinstated a 70 percent rating prior to that date. The RO also granted SMC and DEA benefits, effective February 3, 2021. Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.159 (2020). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. 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). Increased Ratings Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 1. Entitlement to a rating in excess of 70 percent for PTSD prior to February 2, 2021 The Veteran contends he is entitled to a rating in excess of 70 percent for his PTSD. The RO granted a 100 percent rating for this disorder, effective February 2, 2021. That constitutes a full grant of the benefit sought for that time period. The Veteran's symptoms are rated under 38 C.F.R. § 4.130, DC 9411. All psychiatric disabilities are evaluated under a general rating formula for mental disorders. Under the general rating formula, a 70 percent evaluation 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 situations (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A total schedular rating of 100 percent is warranted when the disorder results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Nevertheless, all ratings in the general rating formula are associated with objectively observable symptomatology, and in Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." The Federal Circuit further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Id. Thus, "[a]lthough the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in 'most areas.'" Id. at 118. As such, the Board will consider both the Veteran's specific symptomatology as well as the occupational and social impairment associated with the DC to determine whether an increased evaluation is warranted. As with all claims for VA disability compensation, the Board must assess the credibility and weigh all the evidence, including lay and medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert denied, 523 U.S. 1046 (1998). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126; see Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. Id. The "such symptoms as" language means "for example," and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples provides guidance as to the severity of symptoms contemplated for each rating. Id. However, this fact does not make the provided list of symptoms irrelevant. See Vasquez-Claudio v. Shinseki, 713 F.3d 112, 11617 (Fed. Cir. 2013). The Veteran must still demonstrate either the particular symptoms associated with the rating sought, or other symptoms of similar severity, frequency, and duration. Id. at 117. VA must engage in a holistic analysis that assesses the severity, frequency, and duration of the signs and symptoms of the psychiatric disability; quantifies the level of occupational and social impairment caused by those symptoms; and assigns an evaluation that most nearly approximates the level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). The Board notes that the Diagnostic and Statistical Manual, Fourth Edition, allowed for the assignment of Global Assessment of Functioning (GAF) scores, which are a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. However, VA regulations were amended to adopt the Diagnostic and Statistical Manual, Fifth Edition (DSM-5), which eliminated the use of GAF scores for evaluating mental illness. 80 Fed. Reg. 14,308 (Mar. 19, 2015). As GAF scores are no longer held to be an effective method of evaluating the severity of psychiatric disabilities, the Board will not rely on any GAF scores in adjudicating the present claim. Golden v. Shulkin, 29 Vet. App. 221, 22426 (2018). This appeal stems from the Veteran's December 2015 claim for increase. In February 2016, he was afforded a VA Compensation and Pension (C&P) examination. The examiner concluded the Veteran's PTSD caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; however, he was generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. He stated his current relationship had been ongoing for five or six years; he described the relationship as "very good." He also reported having a small group of friends. The Veteran was retired; he reported being able to complete chores around the house including some yard and housework, cooking, and laundry. He did not really care to be around other people. The examiner noted the Veteran was seen for therapy for his PTSD. His symptoms included depressed mood, suspiciousness, chronic sleep impairment, mild memory loss, and difficulty in establishing and maintaining effective relationships. The examiner noted the Veteran was alert and fully oriented with normal speech. His thought processes were logical and organized; he denied hallucinations, delusions, paranoia, and other psychotic manifestations. He also denied suicidal or homicidal ideation. In February 2017, the Veteran received another C&P examination. The examiner determined the Veteran suffered from the same level of overall level of impairment with the same symptoms identified in the February 2016 examination report. In November 2017, he was afforded another C&P examination. According to the report, the Veteran stated he had been suffering from an increase in flashbacks, approximately two to three per week, as well as panic attacks a few times a week. The examiner determined the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. To control his PTSD, he utilized B-12, Trazadone, Metoprolol, a multivitamin, and Vitamin C. The Veteran reported still experiencing nightmares and sleeping difficulties; he would sleep for a few hours and then toss and turn the rest of the evening, all the while experiencing night sweats. The examiner noted the Veteran experienced a depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, and an inability to establish and maintain effective relationships. Behaviorally, the Veteran presented with a flat affect, and his speech and eye contact were within normal limits; he was oriented to all four dimensions, and he denied hallucinations, suicidal or homicidal ideations, or acute distress. The Veteran reported that his symptoms had increased in severity since his last evaluation, particularly nightmares, flashbacks, and sleep difficulty. He reported increase drinking as an antidote to those increased symptoms. The Veteran received his most recent C&P examination in February 2021. (The Board notes this was the examiner that prompted the RO to award the Veteran a 100 percent rating.) According to the report, the examiner determined the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported that his wife had died in 2019, which was depressing and a "very, very stressful time for me." He said he enjoyed good relations with his children and grandchildren. He maintained contact with friends three or four times yearly; he enjoyed playing golf but had to change groups frequently, due to confrontations over the rules. The examiner stated the Veteran utilized prazosin and trazone, which "sometimes worked and sometimes didn't." Following his wife's death, the Veteran had increased his alcohol intake. In terms of current symptoms, the Veteran experienced anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a work like setting. Behaviorally, the Veteran's mood was anxious and his affect flattened. His thought and speech processes were intact and goal-directed. Lastly, the Veteran experienced flashbacks when he encountered sudden loud noises and military themed scenes on television, three or four times a week. He dreamt about his military service with night sweats and abrupt awakenings. He avoided conversation about military service, as well as eating in restaurants. He was mistrustful of others and more socially isolated He was emotionally numb; he is easily irritated and unable to relax. When angry, he yells and screams, and hypervigilant in public. He wakes up after two to four hours of sleep and then takes two to three hours to fall back to sleep. He had memory deficits for other people's names and bill due dates but denied suicidal ideation. Prior to his February 2021 C&P examination, the Board finds the Veteran's PTSD was not shown to result in total occupational and social impairmentthe main criterion of a 100 percent ratingas the Veteran was, by his own admission, able to maintain multiple relationships, including with his children and grandchildren and a few friends. As a result, he cannot be considered "totally" impaired socially. Furthermore, the C&P examinations did not demonstrate that the Veteran suffered from gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, or a persistent danger of hurting self or others. He has also not been shown to have intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. No other symptoms of similar severity, frequency, and duration to those listed under the 100 percent criteria have been demonstrated. In sum, prior to the grant of 100 percent, the evidence demonstrates that the overall impairment caused by the Veteran's PTSD more nearly approximates occupational and social impairment with deficiencies in most areas. Total social impairment has not been established. 2. Entitlement to a rating in excess of 30 percent for chronic sinusitis The Veteran contends he is entitled to a rating in excess of 30 percent for his chronic sinusitis. For the following reasons, the Board finds an increased rating is not warranted. The Veteran's sinusitis is rated under DC 6513. See 38 C.F.R. § 4.97. Under that DC, if sinusitis is detectable only by x-ray, then it is noncompensable. If sinusitis is productive of one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting, then a 10 percent rating is warranted. For a 30 percent rating, sinusitis must be productive of three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. The maximum 50 percent rating is warranted following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. Id. The Veteran received a C&P examination in February 2015. At the time of the examination, he reported suffering from chronic sinusitis. The examiner determined the Veteran suffered from maxillary sinusitis, and suffered from the following symptoms: chronic sinusitis detected only by imaging studies, headaches, pain of affected sinus, tenderness of affected sinus, purulent discharge, and other symptoms, such as pain and pressure of the sinuses, yellow nasal discharge, sinus headache, left eye pain and blurry vision. In the past 12 months, the Veteran suffered from seven or more non-incapacitating episodes of sinusitis, characterized by headaches, pain, and purulent discharge or crusting. He had not suffered from any incapacitating episodes of sinusitis requiring prolonged antibiotic treatment, nor had he undergone sinus surgery, or sinus-related surgical procedures. In August 2015, a C&P examiner noted the Veteran's symptoms had not gotten worse since the prior examination. The Veteran received another C&P examination in October 2015. He self-reported that he had not used any antibiotics or undergone any procedures on his sinuses since his last C&P examination in February 2015. He suffered from a runny nose, under eye puffiness, and sinus headaches about once every three or four weeks. The examiner determined the Veteran did not suffer from sinuses, nor did he have any findings, signs, or symptoms attributable to chronic sinusitis. In the past 12 months, the Veteran suffered from seven or more non-incapacitating episodes of sinusitis, characterized by headaches, pain, and purulent discharge or crusting. He had not suffered from any incapacitating episodes of sinusitis requiring prolonged antibiotic treatment, nor had he undergone sinus surgery, or sinus-related surgical procedures. The Veteran most recently received a C&P examination in February 2021. (In 2018 he received examinations for rhinitis, for which he has separately claimed service connection. The Board is denying that claim as discussed below.) The Veteran self-reported a runny nose, headaches, sneezing, and facial discomfort over the frontal and maxillary sinuses. The Veteran reported that his allergy symptoms had worsened over the years. The examiner determined the Veteran suffered from sinusitis and rhinitis in the maxillary and frontal sinuses. His symptoms included pain and tenderness of the affected sinus. The Veteran had not suffered from any non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting in the past 12 months. The Veteran had not also suffered from any incapacitating episodes of sinusitis requiring prolonged antibiotic treatment in the past 12 months, nor had he undergone sinus surgery. In addition to the examination reports and lay statements discussed above, the Board has reviewed the Veteran's VA outpatient notes. While these records show that the Veteran has reported regular sinus-related symptoms, there is no conclusive evidence that he has suffered surgeries or near-constant sinusitis symptoms. On review, the Board finds that the criteria for a rating in excess of 30 percent have not been met at any time during the appeal period. The Board acknowledges the Veteran's general lay reports of sinusitis symptomatology, including worsening symptoms at different times throughout the period on appeal. Moreover, the Board acknowledges the Veteran is competent to relate symptoms within the realm of his personal knowledge, just as he is competent to relate what he has been told by a medical professional. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the nature and significance of his sinusitis symptoms is a complex medical question, not capable of lay observation. See Jandreau, 492 F.3d at 1376; Barr v. Nicholson, 21 Vet. App. 303, 308-309 (2009). Regardless, in this case, the Veteran has never specifically asserted undergoing sinus surgery during the appeal period, nor that he has experienced near-constant symptoms related to his sinusitis. Furthermore, the competent and probative C&P examination reports reflect no evidence the criteria for a rating in excess of 30 percent have been met. In sum, the Board finds the most probative evidence of record, particularly including the conclusions of the VA medical professionals who, after reviewing the record, reviewing the medical literature, and analyzing the specific facts of the Veteran's case, determined that it was unlikely that the Veteran experienced manifestations of sinusitis that would warrant a rating in excess of 30 percent under the applicable diagnostic criteria. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (medical opinions are regarded as more probative when they include clear conclusions and supporting data with a reasoned analysis connecting the data and conclusions). The Board has no reason to call these conclusions into question. In light of the lay and medical evidence discussed above, the Board finds the most probative evidence of record demonstrates that the criteria for a rating in excess of 30 percent for sinusitis have not been met. Accordingly, the claim for an increased rating must be denied. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In determining entitlement to service connection, the claimant receives the benefit of the doubt so that the claimant prevails whenever the evidence in support of the claim is at least in equipoise. 38 C.F.R. § 3.102; 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-55 (1990). 3. Hypertension, as due to herbicide exposure The Veteran contends he is entitled to service connection for hypertension, secondary to herbicide exposure. For the following reasons, the Board finds service connection warranted. Here, the RO has concluded the Veteran was exposed to herbicides while serving in the Republic of Vietnam. Specifically concerning hypertension linked to herbicide exposure, the Board notes that although hypertension is not currently among the diseases which have been presumptively linked to herbicide exposure under 38 C.F.R. § 3.309(e), the National Academies of Sciences, Engineering, and Medicine (NAS) recently upgraded the likelihood of an association between hypertension and exposure to herbicides from "limited or suggestive" evidence of an association to "sufficient" evidence of an association. See Veterans and Agent Orange: Update 11 (2018) (available at http://nationalacademies.org/hmd/reports/2018/veterans-and-agent-orange-update-2018.aspx). By way of history, the Veteran was diagnosed with hypertension in 2014. In February 2021, the Veteran received a C&P examination in which the examiner determined it was more likely than not that the Veteran's hypertension was related to his Agent Orange exposure, due to a "causal relationship existing between hypertension and the Veteran's presumed herbicide exposure while he served in Vietnam." There is no probative evidence calling this conclusion into question. (A prior C&P opinion from March 2017 was negative but did not address the claimed link to herbicide exposure.) Accordingly, in this case, the Board finds the weight of the evidence supports an award of service connection for hypertension. In short, the record presents a case of a Veteran who is presumed to have been exposed to herbicides and suffers from hypertension which a credible medical practitioner has deemed related to or caused by exposure to herbicides. Thus, when resolving reasonable doubt in the Veteran's case, the elements of service connection have been met. Service connection for hypertension will be granted. 4. Entitlement to service connection for allergic rhinitis, secondary to diabetes mellitus type II As noted in the Board's January 2020 remand, the Veteran's representative contends the Veteran's diagnosed allergic rhinitis was caused or aggravated by his service-connected diabetes mellitus, type II. The Board noted that a prior opinion, from November 2018, was negative, but did not address the above contention. Instead, that opinion concluded it was not at least as likely as not that the Veteran's rhinitis was secondary to his service-connected chronic sinusitis; rhinitis was instead caused by allergens. (The Veteran has never contended, and the record does not indicate, that his rhinitis is directly related to his service.) In February 2021, the Veteran was afforded a C&P examination. The examiner determined the Veteran's allergic rhinitis was less likely than not caused by or aggravated by service-connected diabetes mellitus type II. As the examiner explained, allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure due to an IgE-mediated inflammation of membranes lining the nose. It is clinically defined as a symptomatic condition with four major symptoms as anterior or posterior rhinorrhea, sneezing, nasal itching, and congestion. Diabetes mellitus type II is a chronic disease characterized by high levels of sugar in the blood which occurs when your body's cells resist the normal effect of insulin which is to drive glucose into the inside of the cells, which then causes glucose to build up in the blood. Symptoms of diabetes included increased thirst, frequent urination, extreme hunger, unexplained weight loss, presence of ketones in the urine, fatigue, irritability, and blurred vision. The examiner explained the two disorders are entirely separate disorders with unique etiologies and symptomologies; the medical literature did not support a relationship between the two diseases or even hint at some sort of relationship between the two, as the two disease processes are completely different, with different baseline causes, risk factors, and symptomology. There are no medical opinions of record demonstrating a nexus between the Veteran's rhinitis and his diabetes mellitus type II, as caused by or on the basis of aggravation. After carefully reviewing the record, the Board finds the preponderance of the evidence is against the Veteran's claim for service connection for allergic rhinitis, to include as secondary to service-connected sinusitis or diabetes mellitus type II. The Board acknowledges the Veteran's claims that his diabetes mellitus type II caused or aggravated his allergic rhinitis, just as he previously claimed his rhinitis was related to his sinusitis. However, the probative findings of VA medical professionals, discussed above, weigh strongly against these contentions. The only positive evidence indicating the Veteran's rhinitis is causally related to his sinusitis and/or diabetes type II is the Veteran's general lay assertions to that effect, as well as his citation (noted in the Board's January 2020 remand) of "medical research from the International Forum of Allergy and Rhinology. As noted above, the Board acknowledges the Veteran is competent to relate symptoms within the realm of his personal knowledge, just as he is competent to relate what he has been told by a medical professional. Layno, 6 Vet. App. at 469-70; Jandreau, 492 F.3d at 1377. However, the question of the precise etiology of his rhinitis is a complex medical question, not capable of lay observation. See Jandreau, 492 F.3d at 1376 (noting that lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-309. In short, because the evidence does not indicate that the Veteran has the appropriate training, experience, or expertise to provide a medical opinion concerning the etiology of his rhinitis, he is not competent to comment on its etiology. Moreover, the record contains determinations by medical professionals that the Veteran's rhinitis is not related to either his sinusitis or his diabetes. These opinions included an acknowledgement of the Veteran's specific statements and contentions; the examiners found no common etiologies between rhinitis and sinusitis or diabetes and no overlapping symptomology such that one would cause or aggravate the other. In short, the opinions appear well-reasoned, fact-based, and responsive to the Veteran's specific contentions, and are therefore considered highly probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. at 304. The Veteran has not rebutted these medical opinions. Indeed, he has provided no objective evidence in support of his claim apart from a general citation to medical research, which has no specific application to the Veteran's circumstances and is outweighed by the VA examiners' findings (which, in turn, apply medical principles to the Veteran's medical history in the context of his contentions). Unfortunately, the Veteran has not put forth sufficient competent evidence to warrant a grant of service connection in this matter. He is not competent to substantiate his contentions, and there is no other probative evidence substantiating the claim. To reiterate, the Veteran has reported his rhinitis symptoms are related to his sinusitis and/or diabetes; however, VA medical professionals determined there was no relationship between these disorders. The Veteran has not presented or identified any competent evidence to support his contention that his rhinitis is related to his sinusitis or diabetes. For the reasons stated above, service connection for rhinitis must be denied. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is inapplicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to service connection for GERD, to include as secondary to diabetes mellitus type II and/or PTSD The Veteran contends his GERD was caused or aggravated by the medications prescribed for his service-connected diabetes mellitus type II and/or PTSD. (The Veteran has never contended, and the record does not indicate, that his GERD is directly related to his service.) Having reviewed the record, the Board finds the most probative evidence on this issue is a February 2021 C&P examination and accompanying opinion. According to this report, a VA examiner determined the Veteran's GERD was less likely than not caused or aggravated by either his diabetes mellitus type II, PTSD, or any of the medications taken to address either disorder. As the examiner explained, GERD and PTSD simply were not medically related; a review of the medical literature failed to demonstrate a causal relationship, and no nexus had been established. GERD was caused by obesity, bulging of the stomach into the diaphragm, pregnancy, connective tissue disorders, delayed stomach emptying, and was aggravated by smoking, eating large meals or eating late at night, eating certain fatty or fried foods, drinking certain beverages, and taking certain medications such as asprin. PTSD was a disorder that developed in some people who experienced a shocking, scary, or dangerous event. None of the symptoms of these two disorders was related, nor did anything in the medical literature indicate a relationship between the two. PTSD had no effect, either directly or indirectly, on the lower esophageal sphincter. Accordingly, the Veteran's PTSD neither caused nor aggravated his GERD. Furthermore, the examiner continued, the conditions of GERD and diabetes mellitus type II are not medically related. Diabetes is a chronic disease characterized by high levels of sugar in the blood due to the body's natural resistance to insulin, causing a buildup on glucose in the blood. It causes symptoms such as increased third, frequent urination, extreme hunger, and unexplained weight loss. None of the diabetes symptoms interact in any way to cause or aggravate GERD or cause or aggravate any mechanics of the lower esophageal sphincter. Again, the medical literature reveals no links, either direct or indirect, indicating a relationship between PTSD and GERD. Finally, considering the medications taken for both PTSD and diabetes mellitus type two and any potential ramifications on GERD, the examiner could find no relationship. He explained that if the medications did cause any GERD or GERD-like symptoms, the medical provider in question would discontinue use of the medication and all symptoms would cease. Furthermore, none of the medications the Veteran utilized to combat his diabetes could cause or aggravate GERDin other words, the Veteran's diabetes medications did not cause an abnormal relaxation of the lower esophageal sphincter would could allow acid from the stomach to flow back into the esophagus. And none of the medications the Veteran utilized to combat his PTSD caused an abnormal relaxation of the lower esophageal sphincter, allowing acid from the stomach to flow back into the esophagus. There are no medical opinions of record demonstrating a nexus between the Veteran's GERD and his PTSD or diabetes mellitus type II. The Veteran has not put forth any evidence rebutting the conclusions of the February 2021 C&P report discussed above. The Board finds the preponderance of the evidence is against the Veteran's claim for service connection for GERD related to diabetes mellitus or PTSD. The Board acknowledges the Veteran's claims that his medication for PTSD and diabetes mellitus aggravates his GERD symptomatology. However, there is no probative evidence of record that those medications actually increase his GERD symptoms. The only positive evidence indicating that the Veteran's GERD is related to PTSD or diabetes is the Veteran's general lay assertions. As noted above, the Board acknowledges the Veteran is competent to relate symptoms within the realm of his personal knowledge, just as he is competent to relate what he has been told by a medical professional. Layno, 6 Vet. App. at 469-70; Jandreau, 492 F.3d at 1377. However, the question of whether his current disability was incurred in service or is otherwise related to service is a complex medical question, not capable of lay observation. See Jandreau, 492 F.3d at 1376 (noting that lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-309. In short, because the evidence does not indicate that the Veteran has the appropriate training, experience, or expertise to provide a medical opinion concerning the etiology of GERD, he is not competent to comment on its etiology. Moreover, the record contains a determination by a medical professional that the Veteran's GERD is not related to his diabetes or PTSD, to include medications for those disorders. This opinion included an acknowledgement of the Veteran's specific statements; the examiner found that the Veteran's two disorders, PTSD and diabetes mellitus type two, had no common etiologies and no overlapping symptomology such that one would cause or aggravate the other; the examiner went through a list of all of the Veteran's medications for treating the two diseases and determined that none of the medications listed increased risk for esophagal sphincter problems or more general GERD like symptoms. In short, the opinion appears well-reasoned, fact-based, and responsive to the Veteran's specific contentions, and is therefore considered highly probative. See Nieves-Rodriguez, 22 Vet. App. at 304. The Veteran has not rebutted this medical opinion. Indeed, he has provided no objective evidence in support of his claim. Unfortunately, the Veteran has not put forth sufficient competent evidence to warrant a grant of service connection in this matter. He is not competent to substantiate his contentions, and there is no other credible evidence substantiating the claim. To reiterate, the Veteran has credibly reported GERD symptoms related to his diabetes and PTSD; however, a VA medical professional determined there was no relationship between PTSD and diabetes and GERD. The Veteran has not presented or identified any competent evidence to support his contention that his GERD is directly related to his PTSD or diabetes. For the reasons stated above, service connection for GERD must be denied. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is inapplicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 6. Entitlement to service connection for hemorrhoids, to include as secondary to service-connected diabetes mellitus type II and/or PTSD, is remanded. The Board directed the RO in its January 2020 remand to obtain a medical opinion "concerning whether the Veteran's hemorrhoids are at least as likely as not caused or aggravated by a service-connected disability, to include gastrointestinal symptoms associated with the medications prescribed for symptom management of PTSD and diabetes mellitus, type II." Although a C&P examination was afforded the Veteran in February 2021, and opinions provided regarding whether symptoms of PTSD and diabetes mellitus type II had a causal impact on the Veteran's hemorrhoids, no opinion was provided regarding whether the medications prescribed for these service-connected disabilities caused or aggravated the Veteran's hemorrhoids. As such, a remand is required for an updated examination. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 7. Entitlement to a TDIU is remanded. 8. Entitlement to additional SMC prior to February 3, 2021 is remanded. 9. Entitlement to basic eligibility for DEA benefits prior to February 3, 2021 is remanded. The Veteran contends he has been unemployable throughout the appeal period due to his service-connected disabilities. Additionally, VA's duty to maximize a claimant's benefits includes consideration of whether his disabilities establish entitlement to SMC under 38 U.S.C. § 1114, and whether eligibility for DEA benefits are met. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). Here, the Veteran is in receipt of a 100 percent rating and SMC and DEA benefits from February 3, 2021. Because the RO has yet to assign an initial rating for hypertension (granted above), and because the Veteran's claim for service connection for hemorrhoids could result in additional compensation, the Board finds the issues of earlier effective dates for these benefits are inextricably intertwined and must be remanded as well. The matters are REMANDED for the following action: 1. Obtain all outstanding VA medical records pertaining to the Veteran and associate them with the claims file. 2. Schedule the Veteran for a VA examination by an examiner to determine the nature and etiology of the Veteran's hemorrhoids. The examiner is asked to review the claims file and provide the following opinions, with consideration of the Veteran's lay statements: (a) State whether the criteria for a diagnosis are met. (b) Opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hemorrhoids were incurred in service or are otherwise related to his service. (c) Opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hemorrhoids are caused or aggravated by the medications prescribed for any of the Veteran's service-connected disabilities, specifically to include his diabetes mellitus type II and PTSD. (d) If it is determined that there is another likely etiology for the Veteran's disability, that should be stated. The examiner should set forth all examination findings, with a clear rationale for the conclusions reached. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issues of entitlement to a TDIU and entitlement to earlier effective dates for SMC and/or DEA benefits eligibility. If the benefits sought are not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ryan, 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.