Citation Nr: 21032635 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 17-60 112 DATE: May 27, 2021 ORDER The appeal as to the claim of entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected disabilities, is granted. The appeal as to the claim of entitlement to service connection for restless leg syndrome (RLS), to include as secondary to the service-connected OSA disability, is granted. The appeal as to the claim of entitlement to an effective date earlier than August 5, 2015, for the grant of service connection for pansinusitis, is dismissed. The appeal as to the claim of entitlement to an effective date earlier than August 5, 2015 for the grant of service connection for rhinitis, is dismissed. The appeal as to the claim of entitlement to service connection for chronic fatigue syndrome (CFS), to include as due to an undiagnosed illness, is denied. REMANDED The appeal as to the claim of entitlement to service connection for a cervical spine disorder is remanded. The appeal as to the claim of entitlement to service connection for a gastro- intestinal disorder, to include irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), and diverticulitis, is remanded. The appeal as to the claim of entitlement to an initial compensable evaluation for service-connected sinusitis is remanded. The appeal as to the claim of entitlement to an initial compensable evaluation for service-connected rhinitis is remanded. The appeal as to the claim of entitlement to an evaluation in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD) is remanded. The appeal as to the claim of entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran's current OSA disorder is etiologically related to his active service. 2. The Veteran's current RLS disorder is etiologically related to his service-connected OSA disorder. 3. In a January 2021 statement, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran, that a withdrawal of this appeal for the issues of entitlement to an effective date earlier than August 5, 2015, for the grant of service connection for pansinusitis, and entitlement to an effective date earlier than August 5, 2015 for the grant of service connection for rhinitis is requested. 4. The Veteran does not have a current CFS condition that manifested during, or as a result of, active service, and is not due to an undiagnosed illness or other multi-symptom illness. 5. For the entire rating period, the social and occupational impairment from the Veteran's PTSD more nearly approximates deficiencies in most areas than total. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for OSA have been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for establishing entitlement to service connection for RLS have been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2020). 3. The criteria for withdrawal of the appeal of entitlement to an effective date earlier than August 5, 2015, for the grant of service connection for pansinusitis, have been met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 19.55 (2020). 4. The criteria for withdrawal of the appeal of entitlement to an effective date earlier than August 5, 2015, for the grant of service connection for rhinitis, have been met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 19.55 (2020). 5. The criteria for establishing entitlement to service connection for CFS (claimed as an unexplained chronic multi-symptom illness), to include as due to an undiagnosed illness, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2020). 6. For the entire rating period, the criteria for entitlement to a disability rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Marine Corp from July 2000 to December 2000, and from June 2004 to May 2005. His service was under honorable conditions. Amongst other commendations, the Veteran is the recipient of the Combat Action Ribbon. The matters are on appeal from December 2016 and April 2017 rating decisions. In January 2021, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge (VLJ). A written transcript of this hearing has been prepared and associated with the evidence of record. The Veteran's claim has been developed and adjudicated as entitlement to service connection for IBS. In addition, the evidence of record demonstrates the Veteran has diagnoses of GERD, and diverticulitis. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In light of Clemons, the issue has been recharacterized (as stated on the cover page) to encompass all gastro- intestinal diagnoses. In Brokowski v. Shinseki, 23 Vet. App. 79 (2009), the Court extended the holding of Clemons to include disabilities outside of psychiatric disorders. In multiple statements throughout the appeal periods, the Veteran raised an informal claim of entitlement to a TDIU due to his service-connected disabilities. The issue of whether entitlement to a TDIU is warranted as a result of that disability is part and parcel of the increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, the issues are as noted on the title page. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Legal Criteria Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may 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). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (2020). This includes any increase in severity of a nonservice-connected disease that is proximately due to or the result of a service-connected disability as set forth in 38 C.F.R. § 3.310(b). See also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). A claimant is also entitled to service connection on a secondary basis when it is shown that a service-connected disability aggravates a nonservice-connected disability. 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 439. Where a veteran has served for 90 days or more during a period of war, or during peacetime service after January 1, 1947, and a chronic disorder, such as arthritis, becomes manifest to a degree of 10 percent or more within one year from the date of termination of service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309 (2020). Alternatively, service connection may be established under 38 C.F.R. § 3.303 (b) by a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307, and (ii) present manifestations of the same chronic disease or b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The use of continuity of symptomatology to establish service connection is limited to only those diseases listed at 38 C.F.R. § 3.309 (a). Under 38 U.S.C. § 1117 (a)(1) (2012), compensation is warranted for a Persian Gulf War Veteran who exhibits objective indications of a "qualifying chronic disability" that became manifest during service on active duty in the Armed Forces in the SWA Theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary. Effective October 16, 2012, VA extended the presumptive period in 38 C.F.R. § 3.317 (a)(1)(i) through December 31, 2016 (for qualifying chronic disabilities that become manifest to a degree of 10 percent or more after active duty in the SWA Theater of operations). See 77 Fed. Reg. 63225 (2012). Furthermore, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a), (b). Because the Veteran served in SWA during his active service, he is a Persian Gulf Veteran within the meaning of the applicable statute and regulation. The Board notes that Congress revised 38 U.S.C. § 1117, effective March 1, 2002. In the revised statute, the term "chronic disability" was changed to "qualifying chronic disability," and the definition of "qualifying chronic disability" was expanded to include (a) undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. Effective June 10, 2003, VA promulgated revised regulations to, in part, implement these statutory changes. See 38 C.F.R. § 3.317 (a)(2). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(4). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to: (1) fatigue, (2) unexplained rashes or other dermatological signs or symptoms, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs and symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the upper or lower respiratory system, (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, and (13) menstrual disorders. 38 C.F.R. § 3.317 (b). Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue."). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 1. Entitlement to service connection for OSA, to include as secondary to the service-connected acquired psychiatric disorder. The Veteran contends that his current sleep disorder is related to service, and in the alternative, to his service-connected acquired psychiatric disorder. Specifically, during the January 2021 hearing before the Board, the Veteran testified that his symptoms of snoring, difficulty sleeping, and fatigue began during active service. Service treatment records are negative for complaints of, treatment for, or a diagnosis of a sleep disorder, to include OSA. Following service, the Veteran's original claim for VA compensation for a sleep disorder was received in August 2015. Post-service treatment records include an August 2016 VA sleep study that indicates a diagnoses of OSA. An April 2017 VA Gulf War examination notes the Veteran's current diagnosis of OSA. In a December 2020 private opinion, D.B., Ph.D., reviewed the record and opined that the Veteran's current OSA is related to his active service. In providing the opinion, D.B. cited to relevant medical literature, and noted the Veteran's symptoms of snoring and fatigue began during service. In a January 2021 statement, R.D., who served with the Veteran in Fallujah in 2004-2005, noted that he bunked with the Veteran prior to, and post-service, in Iraq. R.D. reported that he witnessed the Veteran snoring, coughing, and awakening at night, when he was sleeping. R.D. reported that his noticed that the Veteran had trouble falling asleep and staying asleep. He further noted that the Veteran often looked fatigued from the moment he awoke in the morning. R.D. reported that the Veteran's symptoms continued once the platoon returned from Fallujah. The Board finds that the evidence of record supports a grant of service connection for OSA. The clinical evidence of record establishes that the Veteran has a current diagnosis of OSA in August 2016. Further, the Board finds the Veteran's statements concerning the nature of his symptoms during service, to be competent and credible. Similar, the Board also finds R.D.'s statement, that he witnessed the Veteran snoring, coughing, and awakening at night, to be competent and credible. Moreover, the December 2020 private opinion is presented as in support of the Veteran's claim. Accordingly, direct service connection for OSA is warranted. As such, the benefit of the doubt must be resolved in the favor of the Veteran. Accordingly, entitlement to service connection for OSA is warranted. 2. Entitlement to service connection for RLS, to include as secondary to the service-connected OSA disability. The Veteran contends that his current RLS disorder is due to his service-connected OSA disability. During the aforementioned hearing before the Board, he testified that his RLS symptoms began after his diagnosis of OSA. Service treatment records are negative for complaints of, treatment for, or a diagnosis of RLS. Following service, the Veteran's original claim for VA compensation for RLS as received in August 2015. Post-service treatment records include an August 2016 VA sleep study, during which RLS and OSA were diagnosed; the physician prescribed Gabapentin to treat the Veteran's RLS. Subsequent VA outpatient treatment records dated in 2016 through 2017, note symptoms of fatigue due to poor sleep. In a December 2020 private opinion, D.B., Ph.D., noted that he previously examined the Veteran in May 2018. D.B. reviewed the record and opined that the Veteran's current RLS symptoms could not be separated from his service-connected OSA disability. In this regard, D.B. noted the Veteran's use of a CPAP, and found that it did not resolve his RLS symptoms, nor would it resolve such symptoms. He further noted the Veteran and his spouse's report of continued RLS symptoms during the night. The Board finds that the evidence of record supports a grant of service connection for RLS due to the service-connected OSA disability. The clinical evidence of record establishes that the Veteran has a current diagnosis of RLS in August 2016. Further, the Board finds the Veteran's statements concerning the nature of his symptoms and onset after his diagnosis of OSA, to be competent and credible. Moreover, the private opinion is presented as in support of the Veteran's claim. Accordingly, secondary service connection for RLS is warranted. As such, the benefit of the doubt must be resolved in the favor of the Veteran. Therefore, the claim of entitlement to service connection for RLS is warranted. Withdrawal 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. 3. Entitlement to an effective date earlier than August 5, 2015, for the grant of service connection for pansinusitis. See argument Below at 4 4. Entitlement to an effective date earlier than August 5, 2015 for the grant of service connection for rhinitis. In the present case, the Veteran, during a January 2021 hearing before the Board, has withdrawn the appeal for the issues of entitlement to an effective date earlier than August 5, 2015, for the grant of service connection for pansinusitis, and entitlement to an effective date earlier than August 5, 2015 for the grant of service connection for rhinitis and, hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal and it is dismissed. 5. Entitlement to service connection for CFS to include as due to an undiagnosed illness. The Veteran contends that he is entitled to service connection for CFS, to include as due to an undiagnosed illness. Service treatment records are negative for complaints of fatigue, treatment for fatigue, or a diagnosis of CFS. Post-service records include a March 2017 VA Gulf War examination. Upon examination and review of the record, the examiner concluded that there was no diagnosis of CFS. The examiner noted the Veteran's complaint of fatigue, however, he concluded that, the claimed condition of CFS was not an undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, or a diagnosable chronic multi-symptom illness with a partially explained etiology. The examiner indicated that the Veteran's fatigue is a symptom with a clear and specific etiology and diagnosis. The examiner indicated that the Veteran's current fatigue was attributed to his OSA. In this regard, the examiner noted that the quality of the Veteran's sleep was reduced due to his OSA, which resulted in his daytime sleepiness that manifested as fatigue. The VA examiner found that the Veteran's complaints do not fit the diagnostic criteria for CFS, which is a disorder characterized by extreme fatigue that cannot be explained by any underlying medical condition. The examiner further noted the eight symptoms of CFS, which are fatigue, memory impairment, sore throat, enlarged lymph nodes in the neck or axilla, unexplained myalgias, migratory joint pains, headache of a new type, unrefreshing sleep, or extreme exhaustion lasting more than 24 hours after physical or mental exercise. The examiner determined that the Veteran did not have CFS because he did not report all of the symptoms of CFS included in the diagnostic criteria. Further, the examiner noted that the Veteran's service treatment records are negative for complaints of extreme fatigue, finding it less likely that the Veteran's fatigue symptoms manifested during service. The examiner also concluded that there is no nexus between fatigue and environmental exposures during service in SWA. The VA examiner noted that the Veteran had other diagnosed disorders that include symptoms of fatigue. Specifically, he noted that the Veteran's current OSA (herein service-connected), was a disorder for which the Veteran sought and received ongoing treatment. The Board finds that the signs or symptoms of CFS are not diagnosed as CFS, and the medical evidence does not support a diagnosis of CFS, nor does it support a diagnosis of undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, or a diagnosable chronic multi-symptom illness with a partially explained etiology. According to the March 2017 VA examiner, the Veteran's symptoms of fatigue are directly related to his service-connected OSA. The Veteran's service treatment records are devoid of any clear symptoms that are related to CFS or chronic symptomatology during the Veteran's active service. The Veteran's indication of fatigue in-service is not clearly indicated as being related to anything other than his already service-connected OSA. Due to this lack of symptoms in service, the lack of chronic symptomatology, and the VA examination dated in March 2017, the evidence suggests that the Veteran's symptoms of fatigue did not manifest during, or as a result of active military service, to include his service in Southwest Asia. The Board acknowledges the Veteran's lay statements of fatigue associated with interrupted sleep. However, the aforementioned VA examiner found that the claimed disability of CFS, was not a current diagnosable disability. Thus, the examiner concluded that the Veteran's symptom of fatigue is not related to his service in SWA. Therefore, in consideration of the VA examiner's findings, the medical evidence of record does not support a diagnosis of CFS. This lack of medical evidence precludes a finding of CFS as a chronic disability and precludes the finding of continuity of symptomatology. In addition, there is no medical evidence of record that any claimed fatigue experienced by the Veteran is due to an undiagnosed illness. Rather, the evidence of record has related the Veteran's symptomatology to a known and diagnosed conditions, including symptoms of the service-connected OSA. Also, the Veteran is not entitled to service connection for a medically unexplained chronic multisymptom illness (MUCMI). Under the proper interpretation of the law, an illness or disease is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. Conversely, a condition is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood. In the present case, the Veteran's fatigue symptomatology has an etiology that is at least "partially understood," and as such, the Veteran's condition cannot be classified as a MUCMI. See 38 C.F.R. § 3.317 (a)(2)(ii). While the Veteran believes that his current fatigue is related to service in the Persian Gulf War, as a lay person, the Veteran has not shown that he has specialized training sufficient to render such an opinion with regard to this condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis or etiology of his claimed disability is a matter that is not capable of lay observation, and requires medical expertise to determine. Accordingly, his opinion as to the diagnosis or etiology of his claimed disability is not competent medical evidence. Moreover, whether the injuries incurred in service are in any way related to his current disability is also a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's own opinion regarding the etiology of his current fatigue is not competent medical evidence. The Board finds the opinion of the VA examiner of record to be significantly more probative than the Veteran's lay assertions, as the examiner is thorough in his review of the medical records of the Veteran, thorough in his stated rationales, and thorough in his review of the service treatment records of the Veteran. When there is an approximate balance between positive and negative evidence the benefit of the doubt doctrine must apply in favor of the Veteran. But when the preponderance of the evidence weighs against the claims of the Veteran the claim will be denied on its merits. The evidence before the Board here indicates that the Veteran's claim must be denied as the preponderance of the evidence is against the claim, and the benefit of the doubt doctrine is inapplicable. Therefore, the Veteran's claim of entitlement to service connection for CFS, to include symptoms related to an undiagnosed illness/MUCMI, must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a cervical spine disorder. The Veteran contends that his current cervical spine disorder began during service in Iraq. Specifically, during a January 2021 hearing before the Board, he testified that he was assigned to scout in a Humvee for extended periods of time, and the required body armor pressed against his cervical spine. He asserted that he often slept in a Humvee, which meant he slept in body armor. The Veteran further testified that his cervical spine pain has progressively worsened since the initial onset. In addition, the Veteran's daughter submitted a written statement noting the Veteran's ongoing complaints of chronic cervical spine pain. Service treatment records are negative for complaints of, treatment for, or a diagnosis of a cervical spine disorder. Post-service treatment records include a July 2015 VA x-ray of the cervical spine; straightening of the cervical spine and multilevel degenerative changes of the cervical spine are noted. Private treatment records dated in 2016 demonstrate ongoing complaints of cervical spine pain. A May 2016 VA record notes complaints of chronic neck pain. A June 2016 record notes a diagnosis of degenerative disc disease of the cervical spine. An August 2016 record notes the Veteran's complaints of cervical spine pain; the examiner diagnosed cervical radiculopathy and prescribed baclofen. Private treatment records dated in 2018 note ongoing complaints of cervical pain and demonstrate the Veteran underwent physical therapy for several weeks. An August 2018 record indicates a diagnosis of cervical spine stenosis. Given the above, the Veteran must be scheduled for a VA examination and opinion to determine whether any previously or currently diagnosed cervical spine disorder, is related to his active service, to include an undiagnosed illness. 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for a gastro-intestinal disorder, to include IBS, GERD, and diverticulitis. The Veteran contends that his current intestinal disorder began during service in Iraq. Specifically, during the aforementioned hearing before the Board, he testified that his symptoms of severe reflux, cramps, diarrhea, constipation, and stomach pain have progressively worsened since active service. Service treatment records are negative for complaints of, treatment for, or a diagnosis of a gastro-intestinal disorder. Post-service records include VA outpatient treatment records dated in 2016 that note diagnoses of GERD. The report of a March 2017 VA examination that notes a diagnosis of GERD. Upon examination, the examiner found that the current GERD was not related to a specific exposure event experienced by the Veteran during service in Southwest Asia; the examiner did not opine as to whether the Veteran's GERD was directly related to his active service. A February 2018 private treatment record notes symptoms of abdominal pain, diarrhea, and nausea; the physician diagnosed diverticulitis. A May 2018 VA CT scan of the abdomen indicates diverticulitis. Subsequent VA outpatient treatment records note diagnoses of IBS. Given the above, the Veteran must be scheduled for a VA examination and opinion to clarify his current diagnosis and to determine whether any previously or currently diagnosed gastro-intestinal disorder(s), is related to his active service, to include an undiagnosed illness. 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). 3. Entitlement to an initial compensable evaluation for service-connected sinusitis. See argument Below at 4 4. Entitlement to an initial compensable evaluation for service-connected rhinitis. VA's duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994). In this regard, the Board notes that the Veteran was most recently afforded a VA examination to assess the severity of his service-connected pansinusitis and rhinitis disorders in November 2016, approximately four and a half years ago. During the course of subsequent treatment and the aforementioned hearing before the Board, the Veteran reported increased sinus symptoms on a daily basis, and daily incapacitating headaches. In light of the foregoing, more contemporaneous examinations are warranted in order to ensure that the record reflects the current severity of the Veteran's service-connected pansinusitis and rhinitis disabilities. Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (holding that where the record does not adequately reveal the current state of that disability, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination). 5. Entitlement to an evaluation in excess of 50 percent for service-connected PTSD. The Veteran contends that his service-connected PTSD is worse than the current 50 percent evaluation. In this regard, during the January 2021 hearing before the Board, the Veteran reported increased symptoms, to include suicidal ideation. With respect to impairment, the Veteran most recently underwent a VA examination to assess the severity of his PTSD in January 2017, more than four years ago. At the time of his last examination, the examiner noted symptoms of suspiciousness, panic attacks, and sleep impairment, and he denied suicidal ideation. As above, the Veteran is reportedly experiencing suicidal ideation. Thus, there is conflicting evidence regarding the Veteran's PTSD symptoms and severity during the appeal period. Accordingly, a more contemporaneous examination is warranted to assess the severity of the Veteran's service-connected PTSD. Id. In addition, in a May 2021 statement, the Veteran's representative reported that the Veteran was currently participating in an intensive PTSD program at Chicago Hospital. Thus, the private treatment records identified by the Veteran's representative from Chicago Hospital and updated VA outpatient treatment records, must be obtained and associated with the record. 38 C.F.R. § 3.159 (2020). 6. Entitlement to a TDIU due to service-connected disabilities. As noted above, the Veteran raised an informal claim of entitlement to a TDIU. With respect to symptoms due to his service-connected PTSD, the Veteran reported symptoms of suicidal ideation. Regarding symptoms due to his service-connected OSA, he reported that he was too fatigued during the day to complete basic daily activities. In addition, in a December 2020 private opinion, D.B., Ph.D. found that the service-connected PTSD, OSA, RLS, and claimed TBI disabilities were "totally disabling." Further, although the Veteran's current occupation(if any) is unclear to the Board, in a July 2018 private vocational assessment, the examiner found the Veteran totally disabled due his service-connected PTSD and nonservice-connected language disorder. The issue of whether entitlement to a TDIU is warranted as a result of that disability is part and parcel of the increased rating claim. See Rice, 22 Vet. App. 447 (2009). As the RO has not yet considered the issue of TDIU, the issue must be remanded to the RO for such consideration. Further, as the issues of entitlement to service connection for cervical spine and gastro-intestinal disorders, and increased evaluations for pansinusitis, rhinitis, and PTSD, are being remanded for additional development by the AOJ, and they are directly applicable to the question of employability, the issue of TDIU is also remanded as inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely ties together that a final Board decision cannot be rendered unless both are adjudicated). The matters are REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claims, to include VA outpatient treatment records from March 2018, to the present, and contemporaneous private treatment records from Chicago Hospital. If any requested records are unavailable, or the search for such records otherwise yields negative results, that fact should clearly be documented in the record and the Veteran so notified in accordance with 38 C.F.R. § 3.159(e). All steps taken to attempt to obtain the above records should clearly be documented in the record. 2. Provide the Veteran appropriate notice with respect to the claim of entitlement to TDIU benefits that includes an explanation as to the information or evidence needed to substantiate a claim for a TDIU on a schedular and extraschedular basis. 3. Provide the Veteran a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, for him to complete, with instructions to return the form to the AOJ, for the purpose of obtaining an updated work history. 4. Schedule the Veteran for a VA examination before an appropriate physician to determine the etiology of any cervical spine disability, to degenerative disc disease, spinal stenosis, and cervical radiculopathy. The examiner must review the record, to include service treatment records, VA treatment records, private treatment records, lay statements, and the Veteran's statements and testimony. The examiner must also consideration the Veteran's documented medical history, assertions, and reported symptoms. All necessary tests and studies should be completed, and all clinical findings reported in detail. The examiner must provide an opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that any cervical spine disorder(s), to include, degenerative disc disease, spinal stenosis, and cervical radiculopathy, manifested during, or as a result of, active military service. In providing the opinion, the examiner must discuss the contemporaneous VA and private diagnoses of degenerative disc disease, spinal stenosis, and cervical radiculopathy. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 5. Schedule the Veteran for a VA examination before an appropriate physician to determine the etiology of any gastro-intestinal disability, to IBS, GERD, and diverticulitis. The examiner must review the record, to include service treatment records, VA treatment records, private treatment records, lay statements, and the Veteran's statements and testimony. The examiner must also consideration the Veteran's documented medical history, assertions, and reported symptoms. All necessary tests and studies should be completed, and all clinical findings reported in detail. The examiner must provide an opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that any gastro-intestinal disorder(s), to include IBS, GERD, and diverticulitis, manifested during, or as a result of, active military service. In providing the opinion, the examiner must discuss the contemporaneous VA and private diagnoses of IBS, GERD, and diverticulitis. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 6. Schedule the Veteran for a VA examination by an appropriate physician to assess the nature and severity of his service-connected pansinusitis disability. The examiner must review the record, to include service treatment records, VA and private treatment records, and the Veteran's assertions. The examiner must also consideration the Veteran's documented medical history, assertions, and reported symptoms. All necessary tests and studies should be completed, and all clinical findings reported in detail. The examiner is requested to describe all manifestations and symptoms of the pansinusitis disability, as well as information required for rating purposes. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she should be directed to clearly explain why that is so. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 7. Schedule the Veteran for a VA examination by an appropriate physician to assess the nature and severity of his service-connected rhinitis disability. The examiner must review the record, to include service treatment records, VA and private treatment records, and the Veteran's assertions. The examiner must also consideration the Veteran's documented medical history, assertions, and reported symptoms. All necessary tests and studies should be completed, and all clinical findings reported in detail. The examiner is requested to describe all manifestations and symptoms of the rhinitis disability, as well as information required for rating purposes. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she should be directed to clearly explain why that is so. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 8. Schedule the Veteran for a VA examination by an appropriate physician to assess the nature and severity of his service-connected PTSD disability. The examiner must review the record, to include service treatment records, VA and private treatment records, and the Veteran's assertions. The examiner must also consideration the Veteran's documented medical history, assertions, and reported symptoms. All necessary tests and studies should be completed, and all clinical findings reported in detail. The examiner is requested to describe all manifestations and symptoms of the PTSD disability, as well as information required for rating purposes. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she should be directed to clearly explain why that is so. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. (Continued on the next page) 9. The AOJ should ensure that the Veteran is provided with adequate notice of the date and place of all scheduled examinations. A copy of all notifications, including the address where the notice was sent, must be associated with the record if the Veteran fails to report for any examination. The Veteran is to be advised that failure to report for a scheduled VA examination without good cause may have adverse effects on his claim. 10. Then, the AOJ should readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, he and his representative should be provided a supplemental statement of the case and an appropriate period of time for response before the case is returned to the Board for further appellate action B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sara Schinnerer, 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.