Citation Nr: 21042390 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 17-16 787A DATE: July 12, 2021 ORDER New and material evidence having been received, a claim for entitlement to service connection for hypertension is reopened. Entitlement to service connection for hypertension, to include as secondary to service-connected unspecified trauma-related disorder with adjustment disorder with mixed anxious and depressed mood, is granted. Entitlement to service connection for coronary artery disease (CAD), to include as secondary to unspecified trauma-related disorder with adjustment disorder with mixed anxious and depressed mood, is granted. Entitlement to service connection for a headache disorder, to include as secondary to unspecified trauma-related disorder with adjustment disorder with mixed anxious and depressed mood, is granted. Entitlement to a compensable initial disability evaluation for a scar on the head is denied. Entitlement to an initial disability evaluation in excess of 10 percent for tinnitus is denied. Effective April 19, 2017, entitlement to a disability rating in excess of 50 percent for unspecified trauma-related disorder with adjustment disorder with anxious and depressed mood is granted. REMANDED Entitlement to service connection for a dental disorder, to include as secondary to service-connected CAD, is remanded. Entitlement to service connection for acid reflux is remanded. Entitlement to service connection for myotonia congenita is remanded. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance and/or housebound status is remanded. Entitlement to total disability based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. An October 2014 rating decision denied the Veteran's claim for service connection for hypertension. No new and material evidence pertinent to the claim was received within one year of the issuance of that decision. The Veteran was notified of the decision and his appellate rights but did not appeal the decision to deny service connection for hypertension. Evidence received since that time is new and raises a reasonable possibility of substantiating his claim. 2. Resolving all reasonable doubt in the Veteran's favor, his service-connected mental health condition caused his hypertension to develop. 3. Resolving all reasonable doubt in the Veteran's favor, his service-connected mental health condition caused his CAD to develop. 4. Resolving all reasonable doubt in the Veteran's favor, his service-connected mental health condition caused his headache disorder to develop. 5. The Veteran has one scar on his head, but there is no associated visible or palpable tissue loss with either gross distortion or asymmetry of any features or paired sets of features, and none of the eight characteristics of disfigurement are present. The scar is not painful or unstable and does not cause a limitation of function not otherwise considered. 6. Throughout the period on appeal, the Veteran's bilateral tinnitus has been assigned a 10 percent disability rating, the maximum schedular rating authorized under diagnostic code 6260. 7. Throughout the period on appeal, the Veteran's mental health condition has resulted in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSIONS OF LAW 1. The October 2014 rating decision became finale, but new and material evidence has been received sufficient to reopen the previously denied claim for hypertension. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. The criteria for entitlement to service connection for hypertension, to include as secondary to unspecified trauma-related disorder with adjustment disorder with mixed anxious and depressed mood, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for entitlement to service connection for CAD, to include as secondary to unspecified trauma-related disorder with adjustment disorder with mixed anxious and depressed mood, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for entitlement to service connection for a headache disorder, to include as secondary to unspecified trauma-related disorder with adjustment disorder with mixed anxious and depressed mood, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for entitlement to a compensable initial disability evaluation for a scar on the head have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.31, 4.118, Diagnostic Code 7800. 6. The criteria for entitlement to an initial disability evaluation in excess of 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.87, Diagnostic Code 6260. 7. Effective April 19, 2017, the criteria for entitlement to a disability rating of 70 percent, but no higher, for unspecified trauma-related disorder with adjustment disorder with anxious and depressed mood have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9400-9413. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from June 1984 to April 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2014 and June 2017 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In an April 2019 decision, the Board remanded the Veteran's claims for service connection for myotonia congenita and adjustment disorder with depression and anxiety for additional evidentiary development. In a September 2020 supplemental statement of the case, the RO denied the claim for myotonia congenita, which now returns to the Board. In a separate September 2020 rating decision, the RO granted service connection for adjustment disorder with depression and anxiety. However, service connection was granted as part of the evaluation for his service-connected unspecified trauma-related disorder. When the September 2020 rating decision granting service connection for adjustment disorder with depression and anxiety was issued, a claim for an increased disability rating for unspecified trauma-related disorder was already pending on appeal. The Board also notes that the Veteran has not filed a notice of disagreement with respect to the September 2020 rating decision. As such, the Board's analysis in this decision will focus on whether a disability rating in excess of 50 percent is warranted for his service-connected mental health condition, which has been recharacterized as unspecified trauma-related disorder with adjustment disorder with anxious and depressed mood, from April 19, 2017 (i.e., the date when his increased rating claim was received). New and Material Evidence By way of procedural history, the Veteran originally filed a claim for service connection for hypertension in May 2013 that was denied in an October 2014 rating decision. In that rating decision, the RO stated that his hypertension had neither occurred during nor was caused by service. The Veteran did not appeal this rating decision to the extent that his claim for hypertension was denied. Although additional VA treatment records were generated during the one-year period following notice of the October 2014 rating decision, the RO reviewed those VA-generated records before finding that new and material evidence had not been received to reopen the claim in a June 2017 rating decision. As such, the October 2014 rating decision became final. Generally, a claim that has been denied by an unappealed decision may not thereafter be reopened. 38 U.S.C. § 7105(c). An exception to this rule exists for cases in which new and material evidence is presented or secured with respect to a claim that has been disallowed, in which case the claim must be reopened and the former disposition reviewed. 38 U.S.C. § 5108. "New" evidence means evidence not previously submitted to agency decisionmakers, and "material" evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). This is a "low threshold" in which the phrase "raises a reasonable possibility" should be interpreted as "enabling rather than precluding reopening." Shade v. Shinseki, 24 Vet. App. 110, 121 (2010). The credibility of the newly-submitted evidence is presumed, though not blindly accepted as true if patently incredible. Justus v. Principi, 3 Vet. App. 510 (1992). To that end, additional evidence submitted since the October 2014 rating decision includes an August 2018 positive nexus opinion from M.B. with respect to the etiology of his hypertension. This evidence is new, as it was not of record at the time of the prior October 2014 rating decision. The evidence is also material, as it relates to the previously unestablished elements of his claim (i.e., whether hypertension occurred in or was caused by service). As such, new and material evidence has been received with respect to the claim for hypertension and reopening of the claim is warranted. Last, the Board notes that new evidence, such as VA treatment records, was added to the claims file after the matter was certified to the Board. In March 2021 correspondence, however, the Veteran waived the RO's consideration of this evidence in the first instance. The Board is thus permitted to evaluate his claims on the merits. Service Connection The Veteran alleges that he is entitled to service connection for hypertension, heart disease, and a headache disorder. More specifically, he argues that these conditions are secondary to his service-connected mental health condition. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three criteria: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In addition, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Here, the Veteran has submitted evidence establishing that he has current diagnoses of hypertension, CAD, and tension headaches. As such, the chief question for the Board is whether these conditions are caused or aggravated by his service-connected mental health condition. With respect to hypertension and CAD, the Veteran submitted an August 2018 private medical opinion on the etiology of his disabilities. In the medical opinion, Dr. M.B. opined that his service-connected mental health condition more likely than not caused his hypertension and CAD to develop, as well as that his mental health condition more likely than not aggravated his hypertension and CAD. To that end, he opined that anxiety and depression caused overactive nerve activity and dysfunctional immune responses, as well as activated the hormone system that controls the blood pressure. Because the Veteran experienced this sort of stress on every day in connection with his service-connected mental health condition, it had damaged his heart. As a result, he concluded that the problems with his heart and hypertension had likely been developing since his service. Additionally, he noted that research had shown that anxiety and depression were predictive of later incidences of hypertension. Last, he noted that there were several risk factors for CAD, such as depression and hypertension, and that medical literature indicated that depression was a risk factor in both the development and worsening of CAD. Dr. M.B.'s opinion is thorough, based on a review of the Veteran's claims folder, and supported by medical literature. For instance, Dr. M.B. attached various articles to his report, including an abstract of a study entitled, "Hypertension; Are Symptoms of Anxiety and Depression Risk Factors for Hypertension? Longitudinal Evidence from the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study," as well as a study entitled "Depression and Coronary Artery Disease: The Association, Mechanisms, and Therapeutic Implications." As such, the Board affords his positive nexus opinion with respect to hypertension and CAD significant probative value. Additionally, the Veteran submitted an August 2018 medical opinion from Dr. M.B. with respect to his headache disorder. In that medical opinion, Dr. M.B. diagnosed tension headaches and opined that his headache disorder was more likely than not secondary to his unspecified trauma-related disorder. More specifically, the Veteran reported to Dr. M.B. that he had several headaches each month that were brought on by the stress caused by his unspecified trauma-related disorder. When he feels stressed and depressed, this will bring on a headache or make an existing headache worse, which requires him to lie down in a dark, quiet room for relief. In his rationale, Dr. M.B. observed that research showed that patients with mental health disorders were more likely to develop headaches, because pain and mood were regulated by the same part of the brain. Citing a recent study, he noted that mental health disorders can cause or aggravate headaches. Based on his interview with the Veteran, a review of the claims file, and medical literature, he concluded that his unspecified trauma-related disorder more likely than not caused and aggravated his headaches. As with his other medical opinion, the Board finds that Dr. M.B.'s positive nexus opinion on headaches is entitled to significant probative weight. Like his other opinion, it is well-researched, based on a review of the claims file and interview with the Veteran, and supported by medical literature. He also attached a medical study entitled, "Depression in Headaches: Chronification," which suggested that depressed patients might develop headaches because of increased pain sensitivity. Ultimately, the preponderance of the evidence weighs in favor of finding that the Veteran's mental health condition causes his hypertension, CAD, and headaches. As such, service connection is warranted on a secondary basis for these disabilities. Increased Rating The Veteran also claims entitlement to increased disability ratings for a service-connected facial scar, tinnitus, and unspecified trauma-related disorder with adjustment disorder with anxious and depressed mood. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity due to such diseases and injuries and the residual conditions in civilian occupations. 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 various disabilities and the criteria for specific ratings. In every instance where the rating schedule does not provide for a noncompensable evaluation under a diagnostic code, a noncompensable evaluation will be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Where, as here, entitlement to service connection has already been established and 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). In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each piece of evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). 1. Scar The Veteran is currently receiving a noncompensable disability rating for his facial scar from April 19, 2017, under diagnostic code 7800. At an October 2019 VA examination, the VA examiner noted a scar on the left portion of the Veteran's calp. She noted that it was 4 centimeters long and 0.2 centimeters wide. The scar was not painful or unstable and did not have a total area equal to or greater than 39 square centimeters. Effective August 13, 2018, VA amended its regulations governing skin disabilities. VA's intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. For applications filed on or after the effective date, only the new criteria will be applied. 83 Fed. Reg. 32592 (July 13, 2018). As the appeal period began before the August 13, 2018, effective date, the Board will consider whether either the old or new rating criteria is more favorable to the Veteran. Diagnostic code 7800, pertaining to burn scar(s) of the head, face, or neck, scar(s) of the head, face, or neck due to other causes, or other disfigurements of the head, face, or neck, was unchanged by the recent amendments. Under the new and old rating criteria, there are eight characteristics of disfigurement: (1) a scar 5 or more inches (13 or more centimeters) in length; (2) a scar at least one-quarter inch (0.6 centimeters) at the widest part; (3) surface contour of a scar is elevated or depressed upon palpation; (4) a scar adherent to underlying tissue; (5) skin that is hypo- or hyperpigmented in an area exceeding 6 square inches (39 square centimeters); (6) skin with abnormal texture (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 square inches (39 square centimeters); (7) underlying soft tissue missing in an area exceeding 6 square inches (39 square centimeters); and (8) skin indurated and inflexible in an area exceeding 6 square inches (39 square inches). 38 C.F.R. § 4.118, Diagnostic Code 7800 n.1. A 10 percent disability is warranted with one characteristic of disfigurement, while a 30 percent disability is available with two or three characteristics of disfigurement, or with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears, cheeks, lips). A 50 percent rating is assigned for four or five characteristics of disfigurement, or with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features. Last, an 80 percent rating is warranted with six or more characteristics of disfigurement, or with visible or palpable tissue loss and either gross distortion of asymmetry of three or more features of paired sets of features. 38 C.F.R. § 4.118, Diagnostic Code 7800. Here, the evidence indicates that the Veteran's scar is on the head, face, or neck. However, the evidence does not suggest, and the Veteran has not argued, that his scar has any of the eight characteristics of disfigurement. Moreover, the evidence does not indicate that there is any associated tissue loss or gross distortion or asymmetry of any feature or paired sets of features. As such, the requirements for a compensable evaluation under diagnostic code 7800 are not satisfied, and a compensable rating is not warranted under this diagnostic code. See 38 C.F.R. § 4.31. The Board has also considered whether higher or separate ratings are available for the Veteran's scar under diagnostic codes 7801, 7802, 7804 and 7805. The pre-amended version of diagnostic code 7801 provided disability ratings for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear. 38 C.F.R. § 4.118, Diagnostic Code 7801. In contrast, the amended version of diagnostic code 7801 contemplates burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801 (Aug. 13, 2018). Moreover, the old version of diagnostic code 7802 provided rating criteria for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear. 38 C.F.R. § 4.118, Diagnostic Code 7802. The amended version is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802 (Aug. 13, 2018). However, as set forth above, the Veteran's scar is on his head, face, or neck. As such, neither version of diagnostic code 7801 nor 7802 is applicable. Under both the old and new rating criteria, diagnostic code 7804 provides disability ratings for scars that are unstable or painful. A 10 percent rating is warranted for one or two scars that are unstable or painful, while a 20 percent rating is warranted for three or four scars and a 30 percent rating is warranted for five or more scars. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, an additional 10 percent should be added to the evaluation based on the total number of unstable or painful scars. Note (3) states that scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118, Diagnostic Code 7804. Here, the objective examination findings from the October 2019 VA examination do not reflect, and the Veteran has not argued, that his scar is painful or unstable. As such, a compensable rating is not available under diagnostic code 7804. Last, under the old rating criteria, diagnostic code 7805 provided that other scars (including linear scars) and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, and 7804 require the evaluation of any disabling effects not considered in a rating provided under diagnostic codes 7800-7804 under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. The Board notes that this diagnostic code is largely unchanged under the new amendments, apart from the replacement of the phrase "(including linear scars)" with "and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, or 7804." 38 C.F.R. § 4.118, Diagnostic Code 7805 (Aug. 13, 2018). Here, the Veteran has not reported that his scars result in any symptomatology that are not expressly considered under an applicable diagnostic code. As such, a compensable rating is not available under either version of diagnostic code 7805. Based on the foregoing, the Board finds that the Veteran is not entitled to a compensable initial disability rating for the scar on his head. 2. Tinnitus The Veteran's service-connected bilateral tinnitus is currently rated as 10 percent disabling under diagnostic code 6260. 38 U.S.C. § 4.71a. The Veteran has appealed the initial disability rating assigned for tinnitus but has not made any specific arguments that explain why a higher rating is warranted for this disability. Under diagnostic code 6260, a single 10 percent evaluation is assigned for bilateral tinnitus, regardless of whether the sound is perceived as being in one ear, both ears, or the head. 38 C.F.R. § 4.87, DC 6260, n.2. Diagnostic code 6260 precludes separate 10 percent schedular ratings for bilateral tinnitus. Because the Veteran's service-connected tinnitus has been assigned the maximum schedular rating available under diagnostic code 6260, there is no basis upon which to award a higher schedular evaluation. Moreover, he has not reported any signs or symptoms not accounted for by the rating criteria which would merit extraschedular consideration. See 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008). Accordingly, the claim for a disability rating in excess of 10 percent for tinnitus must be denied. 3. Mental health condition The Veteran's mental health condition is rated at 50 percent from April 19, 2017, under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under the General Rating Formula, a 50 percent evaluation is warranted where the disorder is manifested by 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. Id. A 70 percent evaluation is warranted where the disorder is manifested by 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 that is 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 an inability to establish and maintain effective relationships. Id. Last, a 100 percent rating is warranted for total occupational and social impairment, due to symptoms such as gross impairment of 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 minimum personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. The Board has carefully considered the evidence of record from up to one year prior to the beginning of the period on appeal (i.e., April 19, 2017). In April 2016 VA treatment records, the Veteran complained of panic attacks that were controlled using Klonopin and increasing anxiety. The Veteran reported to his treatment provider that he would like to stop taking his Klonopin because he knew that it was addictive, but also that he was worried about having more panic attacks if he discontinued using the medication. He denied suicidal ideation, homicidal ideation, and obsessive compulsive and psychotic symptoms. On mental status examination, he was anxious, while his thought content and perceptions were reality-based without delusions or hallucinations. In June 2016 VA treatment records, the Veteran reported that he experienced adverse side effects while using Lexapro. He voiced the same concerns regarding mounting anxiety despite taking his Klonopin. On mental status examination, his mood was the same, while thought processes were goal-directed and organized. At a May 2017 VA examination, the VA examiner noted his reports of problems regarding panic attacks. He reported to the May 2017 VA examiner that he stopped working in 2012 due to a muscle disease and that he had not received mental health treatment in years because his physical problems had worsened. The VA examiner noted symptoms including a depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, and mild memory loss such as forgetting names, directions, or recent events. The Veteran was neatly groomed, but his mood was "somewhat down." On mental status examination, he was alert and oriented to all spheres. His immediate memory was good, while delayed recall was fair. His communication skills, abstract thinking, and judgment were good. His thought content was clear, logical, and unremarkable, with no signs of delusions or hallucinations. However, he reported that he worried all the time and that he had become much more anxious over the past few years. He had stopped going to church because he was too anxious around people. He also reported that his sleep was "terrible" and that he had "zero" energy. He denied suicidal or homicidal ideation and did not appear to be a threat to himself or others. His score on the PCL-5 test indicated severe symptoms, while his score on the Beck Depression Inventory indicated borderline clinical depression. In a July 2018 lay statement submitted by J.L., the Veteran's wife, she reported that he had multiple debilitating panic attacks every week. The panic attacks happen at random. She also reported that he struggled to remember things, that she must remind him to take his medications every morning, and that he is easily sidetracked. Additionally, she reported that he lacked motivation to do anything and says things that do not make sense. According to J.L., he will occasionally lose focus and forget what he is saying mid-sentence. She also described his mood swings and short temper. Although the Veteran had a few friends, he never attended family events due to anxiety and cannot be in crowds or public places. She indicated that he avoids stressful situations as much as possible and is easily overwhelmed. In addition, she reported that he often becomes disproportionately angry and occasionally sees and hears things that aren't there. She also indicated that he had a difficult time sleeping and has recurring nightmares. Furthermore, she stated that she did not think that her husband could function independently. Similarly, in a July 2018 lay statement submitted by G.K., the Veteran's daughter, G.K. reported that the Veteran becomes frustrated over small issues and has difficulty accomplishing even minor tasks like cooking for himself. She also reported that he lacked motivation, stayed home most of the time, and hated large crowds. He frequently worries about bad things happening and does not go in public places because of anxiety. She also reported that he frequently has panic attacks multiple times per week and that he struggles with remembering things like recent conversations and events. Like his wife, G.K. described how he easily lost focus on tasks and that he struggles to get sufficient sleep due to stress. Last, she stated that she did not think that her father could live independently, because her mother does so many tasks for him. In August 2018, the Veteran submitted a disability benefits questionnaire completed by a private psychologist, Dr. H.H.-.G. In her report, Dr. H.H.-G. indicated that the Veteran had unspecific trauma and stressor-related disorder and adjustment disorder and that it was not possible to differentiate between the symptoms of each diagnosis. She reported that his symptoms resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. After reviewing his claims file and performing a mental status examination, she noted that he was socially isolated and withdrawn. His symptoms included a depressed mood, anxiety, suspiciousness, near-continuous panic or depression that affect his ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work relationships, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, and intermittent inability to perform activities of daily living. His concentration was variable, and he reported struggling with remembering basic information. The Veteran's responses to her questions were vague, suspicious, and paranoid. However, his thought content was appropriate, organized, and goal-directed, with no report of overt hallucinations. Last, the Veteran attended a VA examination in October 2019 with respect to the symptomatology of his mental health condition. The October 2019 VA examiner noted diagnoses of unspecified trauma and stressor-related disorder, with adjustment disorder with mixed anxious and depressed moods. The symptoms of these disorders overlapped and shared a multidirectional relationship. The October 2019 VA examiner opined that the Veteran's symptomatology was characteristic of 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. To that end, the examiner noted that he was limiting his driving and physical activities due to a muscle disorder, and that he tried to help his wife with household tasks. He reported that he became physically unable to work due to myotonia congenita in 2012. Since his last VA examination, he described symptoms such as anxiety, fear, worrying about his wife, daughter, money, the weather, and his muscle disorder, and feeling "down" about his loss of functioning. Symptoms noted on examination included a depressed mood, anxiety, panic attacks occurring weekly or less often, chronic sleep impairment, and disturbances in mood or motivation. The Veteran was appropriately dressed and groomed but had an anxious affect. His thought content was tangential, and he needed to be redirected several times, although insight was good and there were no perceptual disturbances. He reported that he did not regularly socialize or engage in hobbies, but also that he had good relationships with his wife, daughter, mother-in-law, and a neighbor. Ultimately, having considered the relevant evidence of record from the pertinent period on appeal, the Board finds that the Veteran's symptomatology warrants a 70 percent rating throughout the period on appeal. To that end, the Veteran has endorsed symptoms such as near-continuous panic or depression, neglect of his personal appearance and hygiene, difficulty adapting to stressful circumstances, and an inability to establish and maintain effective relationships. As such, his symptoms more closely approximate a 70 percent rating throughout the entire period on appeal. Nonetheless, the Board finds that the record indicates that the Veteran's mental health condition has resulted in total occupational and social impairment during this period. To that end, the record does not indicate that he suffers from persistent delusions or hallucinations. Although he has become socially isolated, the record also demonstrates that he has maintained good relationships with his wife and various family members. Despite his wife's reports that he sometimes says things that do not make sense, he has generally displayed organized, clear thought content and processes. The record does not reflect a history of grossly inappropriate behavior or that he is a persistent danger of hurting himself or others due to his mental health condition. While the record reflects some short- and long-term memory impairments and forgetfulness, the record does not indicate that he has memory loss for information such as the names of close relatives or his own name. Moreover, the various evidence of record indicates that he is generally oriented to time and place. The Board acknowledges that portions of the evidence in the record suggests that the Veteran suffers from an intermittent inability to perform activities of daily living, such as maintaining minimal personal hygiene, due to his mental health condition. For instance, Dr. H.H.-G. reported that the Veteran suffered from intermittent inability to perform activities of daily living and that his wife must assist him with tasks such as food shopping, meal preparation, and reminding him to shower, shave, and get haircuts. However, various evidence in the record (such as the October 2019 VA examination) indicates that the Veteran struggles to complete activities of daily living not because of his mental health conditions, but instead due to myotonia congenita. The Board takes judicial notice that myotonia congenita is a genetic disorder that prevents the skeletal muscles from quickly relaxing after voluntary movements. Symptoms include muscle stiffness, muscle weakness, and attacks of weakness brought on by movement after rest. In her report, Dr. H.H.-G. failed to account for the impact of his myotonia congenita on his ability to complete activities of daily living, such as preparing meals and doing household chores. As such, the probative value of the portion of her report that attributes his intermittent inability to perform activities of daily living to his mental health condition is diminished. For similar reasons, the portions of J.L. and G.K.'s lay statements indicating that the Veteran could not live independently are less probative in this respect. Ultimately, while the evidence of record indicates that the Veteran's mental health condition might perhaps cause him to neglect his personal appearance and hygiene such that he must be reminded to shower, shave, and get haircuts, the preponderance of the evidence does not demonstrate that he suffers from intermittent inability to perform activities of daily living due to his mental health condition. In sum, the Board finds that a 70 percent rating, but no higher, is warranted for his mental health condition throughout the period on appeal. REASONS FOR REMAND 1. Dental disorder and acid reflux The Veteran also asserts that he is entitled to service connection for acid reflux and for a dental disorder, to include as secondary to his CAD. For instance, he has reported to various health care providers that he has lost teeth as a result of taking blood thinners for his now service-connected heart condition. At this juncture, however, the Board cannot adjudicate these claims on their merits, as additional development is necessary. To that end, the Board notes that the Veteran sees non-VA treatment providers for gastrointestinal issues and dental care. For instance, an August 2017 VA treatment record reflects that he sees a non-VA gastroenterologist to treat gastroesophageal reflux disease, while other VA treatment records indicate that he had several teeth removed by a non-VA dentist in June 2016. However, these records are not in the record. As such, remand is necessary for the RO to attempt to obtain these private treatment records. 2. Myotonia congenita The Veteran also claims that he is entitled to service connection for myotonia congenita. As set forth above, myotonia congenita is a genetic muscle disorder. In its April 2019 remand instructions, the Board directed the RO to obtain a VA examination with respect to myotonia congenita. More specifically, the Board directed the VA examiner to discuss whether the condition was congenital, developmental, or familial in origin, and to indicate whether the condition was a congenital disease or disability. If the condition could be classified as a congenital disease, the Board asked for the examiner to opine as to whether the disease was permanently worsened during his service. If, on the other hand, the condition was classified as a congenital defect, the Board asked for the examiner to opine as to whether his service resulted in additional disability. Thereafter, the RO arranged for the Veteran to undergo a VA examination in October 2019. Pursuant to the VA examination, the Veteran reported that he did not exhibit symptoms of myotonia congenita (also called Becker's disease) until 1984, when he was in bootcamp. At that time, he saw a doctor and reported difficulty walking, which was diagnosed as muscle stiffness with an unknown etiology. He reported that his lower legs would "lock up" and others would run into him on the steps of his barracks. He also indicated that he was taken off the physical readiness test due to his inability to meet timed runs due to muscle stiffness and his lower legs locking up. Additionally, he reported that he fell while onboard a ship due to his lower legs locking up, which caused him to fall and hit his head. After he was discharged in 1988, he worked as a maintenance supervisor at a metal finishing factory and his muscle stiffness worsened. He was ultimately diagnosed with myotonia congenita in 2008. Three years prior, he was bedridden. However, after he began taking Loratab, he has been able to walk again. As a result of his muscle disorder, he finds it hard to relax or release his hand grip and he has pain with prolonged walking after 10 minutes. In a July 2020 medical opinion, a different VA examiner opined that the Veteran's condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service event, injury, or illness. More specifically, the VA examiner stated that his May 1984 enlistment examination was silent for myotonia congenita. She noted his complaints of stiffness in his legs in July 1984 but also stated that his separation examination from March 1988 did not include any remarks about myotonia congenita. She also noted that he was diagnosed in 2008 and listed various records regarding his current treatments for the condition. Citing an Internet article from the National Institutes of Health, the examiner also stated that myotonia congenita was a genetic disease characterized by the inability of the skeletal muscles to quickly relax after voluntary movements. Symptoms typically began during childhood and varied from person to person, but may include muscle stiffness, muscle weakness, and weakness brought on by movement after rest. There are two forms of myotonia congenita, which were both caused by a mutation of the CLCN1 gene: Becker's disease, which is the most common form, and Thomsen disease, which is a rare and milder form. The examiner ultimately concluded that his enlistment and separation examinations were silent for myotonia congenita and that, although he was diagnosed with knee stiffness of an unknown etiology in July 1984, his myotonia congenita was not diagnosed during service. Although he displayed symptoms of myotonia congenita during service, such as his stiff and sore legs, he was not diagnosed until 23 years after leaving service, and no chronic manifestations of myotonia congenita were noted during service. Having carefully reviewed the July 2020 VA medical opinion, the Board finds that it is inadequate in various respects. First, the July 2020 VA examiner did not address all relevant evidence of record, such as the report of medical history accompanying the March 1988 separation examination. For instance, in that report of medical history, the Veteran endorsed cramps in his legs, as well as minor stiffness in his legs in the morning. Moreover, the July 2020 VA examiner failed to address the Veteran's lay statements regarding his symptoms of muscle stiffness during service. A medical opinion that does not discuss all relevant evidence, including lay statements, is inadequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Second, the examiner appeared to base their negative opinion solely on a lack of contemporaneous medical treatment records. This, however, is impermissible. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Last, although the VA examiner indicated that myotonia congenita is a genetic disease, the VA examiner failed to sufficiently discuss whether the Veteran's reported in-service symptoms of muscle stiffness and leg cramps were aggravated beyond their natural progression by his service or whether his reported symptoms were due to the natural progression of the disease. In the interest of assembling clear and reliable findings, remand is warranted to obtain an addendum medical opinion. Furthermore, the record reflects that the Veteran is receiving disability benefits from the Social Security Administration (SSA) due to his myotonia congenita. These SSA records are relevant to the instant claim. To date, however, the RO has not attempted to obtain them. On remand, the RO must make efforts to acquire these records and associate them with the claims file. See Murincsak v. Derwinski, 2 Vet. App. 363, 372 (1992) (holding that the duty to assist requires obtaining SSA records of which the Board has notice). 3. SMC The Veteran also asserts that he is entitled to SMC based on the need for aid and attendance and/or due to housebound status. To that end, the record reflects that, due to his myotonia congenita, he requires regular assistance with mobility, coordination, bathing, and tending to hygiene needs. The record also reflects that he is largely confined to his home due to his physical disabilities. See, e.g., September 2015 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance. As set forth above, however, the Board is remanding his claim for entitlement to service connection for myotonia congenita for additional development. As such, the resolution of the claim for SMC must be deferred until the claim for myotonia congenita is also resolved. See Harris v. Derwinski, 1 Vet. App. 180 (1991). 4. TDIU In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims held that a TDIU claim is a claim for a higher rating when such claims are raised by the record or asserted by the Veteran. During the course of the Veteran's increased rating appeal, the Veteran has submitted evidence of unemployability due to service-connected disabilities, such as his mental health condition. For instance, in Dr. H.H.-G.'s report, she opined that the Veteran could not sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his mental health condition. As such, the record reasonably raises the issue of TDIU. However, as discussed earlier, the record indicates that the Veteran is currently unemployed and receiving SSA disability benefits. Remand is necessary to obtain these outstanding SSA records, which could potentially impact the outcome of the issue of entitlement to TDIU. For this reason, this development must be undertaken prior to adjudicating the issue of entitlement to TDIU. Accordingly, the matters are REMANDED for the following action: 1. Obtain the Veteran's federal records from the SSA and associate them with the claims file. All reasonable attempts should be made to obtain such records. If they cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile and allowed the opportunity to provide such records. 2. After obtaining proper authorization, obtain any VA treatment records not currently in the Veteran's claims file, as well as any relevant private treatment records not currently in the Veteran's claims file. The Veteran must assist in the matter by identifying his private health care providers and by submitting releases to VA to obtain any private records identified. If the private records identified are not received pursuant to the RO's request, the Veteran should be so notified and advised that it is ultimately his responsibility to ensure that any available private treatment records are received. 3. Thereafter, obtain an addendum medical opinion from an appropriate examiner with respect to the claim for myotonia congenita. After reviewing the claims file in its entirety, including a copy of this remand, the examiner is asked to do the following: (a.) State whether myotonia congenita is a congenital disease or congenital defect. For VA purposes, a disease is any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. A defect is defined as structural or inherent abnormalities or conditions which are more or less stationary in nature. (b.) If the condition is a congenital disease, provide an opinion as to whether it was aggravated by any in-service event or injury (i.e., increased in severity beyond the natural progression of the disease). (c.) If the condition is a congenital defect, provide an opinion as to whether it was aggravated by a superimposed disease or injury due to the Veteran's service. In doing so, the examiner must provide a complete rationale for all opinions expressed. The examiner is reminded to consider all relevant evidence, including the Veteran's lay statements, his service treatment records, and other pertinent medical and lay evidence of record. 4. After the aforementioned development has been completed, as well as any other development deemed necessary, adjudicate the Veteran's claims for entitlement to TDIU and SMC based on the need for aid and attendance and/or housebound status. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Rademacher, 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.