Citation Nr: 22017998 Decision Date: 03/27/22 Archive Date: 03/27/22 DOCKET NO. 17-01 304 DATE: March 27, 2022 ORDER For the entire rating period on appeal a maximum 100 percent rating for pulmonary sarcoidosis with decreased pulmonary function, granuloma, chronic fatigue, headaches, and joint pain, is granted. For the entire rating period on appeal a 70 percent rating, but not higher, for depressive disorder and posttraumatic stress disorder (PTSD) is granted. For the entire rating period on appeal, a total disability evaluation based on individual unemployability (TDIU) due to his service-connected disabilities is granted. REMANDED Entitlement to service connection for chronic bronchitis is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the appellant's favor, for the entire rating period on appeal prior to the Veteran's death, his pulmonary sarcoidosis with decreased pulmonary function, granuloma, chronic fatigue, headaches, and joint pain was predominantly manifested by pulmonary function testing showing forced expiratory volume in one second of less than 40 percent. 2. Resolving reasonable doubt in the appellant's favor, for the entire rating period on appeal prior to the Veteran's death, his depressive disorder and PTSD symptoms more nearly approximated occupational and social impairment with deficiencies in most areas. 3. Resolving reasonable doubt in the appellant's favor, for the entire rating period on appeal prior to the Veteran's death, he was unable to secure and follow a substantially gainful occupation due to his service-connected depressive disorder, PTSD, and lumbar spine strain disabilities. CONCLUSIONS OF LAW 1. The criteria for a maximum 100 percent rating for pulmonary sarcoidosis with decreased pulmonary function, granuloma, chronic fatigue, headaches, and joint pain have been approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ .102, 34.1, 4.3, 4.7, 4.97, Diagnostic Codes 6600, 6846 (2021). 2. The criteria for a 70 percent rating for depressive disorder and PTSD have been approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102 4.7, 4.130, Diagnostic Codes 9411, 9435 (2021). 3. The criteria for entitlement to a TDIU are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16(a), (b) (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1975 to January 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2014 rating decision of a Department of Veterans' Affairs (VA) Regional Office, the agency of original jurisdiction (AOJ). Unfortunately, the Veteran died in February 2019. The appellant is his surviving spouse and has been properly substituted for the Veteran with respect to the claims addressed herein pursuant to 38 U.S.C. § 5121A. See VA Appeal Process Request Letter dated July 1, 2020. In October 2021, the appellant testified during a virtual Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record and has been reviewed. Preliminary Matter 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). Increased Ratings Applicable Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the low rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several DC; however, the critical element in doing so is that none of the symptomatology is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. The assignment of a particular DC is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One DC may be more appropriate than another based on such factors as an individual's relevant medical history, the DC, and the demonstrated symptomatology. Any change in a DC by VA must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for any initial rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). A claimant is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through their senses. See Layno v. Brown, 6 Vet. App. 465 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a claimant prevailing in either event. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The claimant is entitled to the benefit of the doubt when there is an "approximate" (meaning nearly equal) balance of positive and negative evidence regarding any material determination. See Lynch v. McDonough, 999 F.3d 1391 (2021); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The claimant bears the burden of presenting and supporting his or her claim for benefits. 38 U.S.C. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). Pulmonary Sarcoidosis The AOJ assigned a 60 percent disability rating for the Veteran's pulmonary sarcoidosis with decreased pulmonary function, granuloma, chronic fatigue, headaches, and joint pain under Diagnostic Code (DC) 6600-6846 based on medical evidence showing a forced expiratory volume in one second (FEV-1) of 40 to 55 percent of predicted value. See Rating Decision dated August 4, 2007. The appellant claims that a maximum rating is warranted. See Appeal Memorandum received January 13, 2021. Under DC 6600, a 60 percent rating is warranted for a FEV-1 of 40 to 55 percent predicted, or; an FEV-1/forced vital capacity (FVC) ratio of 40 to 55 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A maximum 100 percent rating is warranted for an FEV-1 of less than 40 percent predicted, or; an FEV-1/FVC ratio of less than 40 percent, or; DLCO (SB) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy. 38 C.F.R. § 4.97, DC 6600. Under DC 6846, a 60 percent rating is warranted for pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control. A maximum 100 percent rating is warranted for Cor pulmonale, or; cardiac involvement with congestive heart failure, or; progressive pulmonary disease with fever, night sweats, and weight loss despite treatment. 38 C.F.R. § 4.97, DC 6846. Post-bronchodilator results must be applied when evaluating a respiratory disability based on PFTs unless post-bronchodilator results are poorer than the pre-bronchodilator results. 38 C.F.R. § 4.96(d)(5). Regardless, post-bronchodilator studies are required when PFTs are done for disability evaluation purposes except when the results of pre-bronchodilator pulmonary function tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. 38 C.F.R. § 4.96(d)(4). When there is a disparity between the results of different PFTs (FEV-1 (Forced Expiratory Volume in one second), FVC (Forced Vital Capacity), etc.), so that the level of evaluation would differ depending on which test result is used, the test result indicated by the examining clinician to most accurately reflect the level of disability should be used. 38 C.F.R. § 4.96(d)(6). Rating Analysis Turning to the record, private pulmonary function testing (PFT) in January 2014 revealed pre-bronchodilator FVC ranging from 36 percent to 43 percent predicted, FEV-1 ranging from 33 percent to 37 percent predicted, and FEV-1/FVC ranging from 86 percent to 95 percent. The interpretation was severe airway obstruction with low vital capacity. The report reflects that each test was administered three times; however, the clinician who administered the tests did not indicate which results most accurately reflected the level of the Veteran's disability. See Spirometry Report dated January 22, 2014. Acute exacerbation of chronic obstructive airway disease was noted in late January 2014. Private chest x-rays dated February 2014 revealed findings concerning for mediastinal and right hilar lymphadenopathy. A February 2014 private chest CT indicated hilar and mediastinal lymphadenopathy consistent with sarcoidosis. There was positive honeycombing in the right lower lob superior segment and positive emphysematous and fibrotic type changes in the bilateral lungs. February 2014 private treatment records note an abnormal PFT indicating moderately severe obstruction with low vital capacity. The PFT results were not included with the notes. The Veteran was short of breath, had a fever, and was dehydrated. In March 2014, the Veteran was seen at a private hospital emergency room due to fever, chills, rigors, and shortness of breath. He was admitted for suspected pneumonia, but cultures were negative. A chest x-ray showed right hilar enlargement, and a chest CT showed bibasilar bronchiectasis with associated scarring, minimal air space disease posterior right lung, and multiple mediastinal and hilar adenopathy with several calcified lymph nodes. Fungal cultures were negative. The Veteran's condition was noted to have improved significantly from treatment with Ceftriaxone, Azithromycin, and systemic steroid. On examination at discharge four days after being admitted, there was good air entry into the lungs bilaterally with fine bibasilar crepitation, and he was negative for wheezing. See Discharge Summary dated March 15, 2014. Private treatment notes reflect that the Veteran was hospitalized again in August 2014 after an abnormal echocardiogram. The Veteran endorsed chronic exertional dyspnea, which had become worse in recent months. On examination, his lungs were clear to auscultation, except for a few basilar rales. PFT revealed post-bronchodilator FVC of 59 percent predicted (pre-bronchodilator 60 percent), FEV-1 of 38 percent predicted (pre-bronchodilator 35 percent), and FEV-1/FVC of 65 percent predicted (pre-bronchodilator 45 percent). The interpretation was a severe obstructive lung defect. The clinician who administered the tests did not indicate which results most accurately reflected the level of the Veteran's disability. See Spirometry Report dated August 12, 2014. A September 2014 Social Security Administration (SSA) disability determination found the Veteran was disabled as of June 2014 due to chronic pulmonary/heart disease, back, hypertension, anxiety, and affective disorders. See SSA Determination dated September 22, 2014. An SSA medical examination included February 2014 chest CT and x-rays indicating hilar and mediastinal lymphadenopathy consistent with sarcoidosis, and February 2014 pulmonary testing revealed pre-bronchodilator FVC ranging from 52 percent to 60 percent predicted, FEV-1 ranging from 50 percent to 52 percent predicted, and FEV-1/FVC ranging from 67 percent to 75 percent. The interpretation was moderately severe obstruction, with low vital capacity. The report reflects that each test was administered three times; however, the clinician who administered the tests did not indicate which results most accurately reflected the level of the Veteran's disability. The Board notes that while Social Security Administration (SSA) determinations and/or findings are not binding on the Board, they are, however, relevant and the records relied upon to make SSA determinations are probative evidence specifically in consideration of the appellant's claim for entitlement to an increased rating for the Veteran's service-connected pulmonary sarcoidosis. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991) (observing that while SSA decisions are relevant, there are significant differences between SSA and VA recognition of disabilities and SSA decisions are not binding on VA). Here, while SSA pulmonary testing does not reflect which results most accurately reflected the level of the Veteran's disability, the Board finds the examination probative based on the nature of the testing and the findings noted by the physician. In coming to this conclusion, the Board only considers the evidence as it pertains to the service-connected pulmonary disorder, which is the subject of the instant claim. In October 2014, the Veteran underwent a VA respiratory conditions examination, at which time the examiner rendered a diagnosis of sarcoidosis. X-ray imagery obtained for the examination revealed probable Stage 1 bilateral hilar lymphadenopathy. The Veteran reported experiencing shortness of breath and fatigue. The examiner noted that it was unclear if the Veteran had other lung conditions. The Veteran's sarcoidosis did not require the use of oral or parenteral corticosteroid medications but did require the use of the inhaled medication Albuterol on an as needed basis. His condition did not require the use of oral bronchodilators, antibiotics, or outpatient oxygen therapy. The examiner found that the Veteran was negative for ophthalmologic, renal, cardiac, neurologic or other organ system involvement due to sarcoidosis. The Veteran was negative for pulmonary vascular disease, bacterial lung infection, mycotic lung disease, pneumothorax, cardiopulmonary complications, tumors and neoplasms, respiratory failure. PFT revealed post-bronchodilator FVC of 50 percent predicted, FEV-1 of 37 percent predicted, and FEV-1/FVC of 59.2 percent. The examiner indicated that the FEV-1/FVC test result most accurately reflected the level of the Veteran's pulmonary function at that time; DLCO testing was not conducted. The examiner noted that it was unclear whether the Veteran's current level of pulmonary function as indicated by PFT testing was directly attributable to his sarcoidosis or an underlying process. Lastly, the examiner concluded that the Veteran's sarcoidosis impacted his ability to work in that it resulted in moderate impairment of stamina. See VA Respiratory Conditions examination dated October 3, 2014. March 2015 VA outpatient PFT results indicated FVC of 49 percent predicted and FEV-1 of 32 percent predicted. Whether the data was pre- or post-bronchodilator was not noted and the FEV-1/FVC ratio percentage was not specifically noted. DLCO was noted as 32 percent. The VA clinician did not indicate which test results most accurately reflected the level of the Veteran's pulmonary function. In an October 2015 statement, the Veteran described shortness of breath on minimal exertion, even moving from sitting to standing and walking, lack of energy, and only being able to walk short distances due to shortness of breath. VA outpatient PFT results dated August 2017 indicated FVC of 52 percent predicted and FEV-1 of 33 percent predicted. Whether the data was pre- or post-bronchodilator was not noted and the FEV-1/FVC ratio percentage was not specifically noted. DLCO was noted as 29 percent. The VA clinician did not indicate which test results most accurately reflected the level of the Veteran's pulmonary function. Private treatment notes dated March 2018 reflect that the Veteran was seen at an emergency room, at which time he reported losing consciousness for about 45 minutes the previous day while assisting someone putting up a fence. He denied nausea, vomiting, chest discomfort, shortness of breath, and dizziness at that time, and he said after he drank fluids and rested, he felt better. On examination, his chest was clear to auscultation, normal expansion bilaterally, and his respiration was non-labored. The impression was unchanged bibasilar subsegmental atelectasis/scarring, unchanged mild bilateral lobe bronchiectasis, right greater than left, unchanged partially calcified moderate mediastinal and mild bilateral hilar adenopathy in setting of chronic granulomatous disease such as sarcoidosis, and new moderate cardiomegaly with findings suggestive of pulmonary hypertension. VA outpatient PFT results dated March 2018 indicated FVC of 54 percent predicted and FEV-1 of 34 percent predicted. Whether the data was pre- or post-bronchodilator was not noted and the FEV-1/FVC ratio percentage was not specifically noted. DLCO was noted as 34 percent. The VA clinician did not indicate which test results most accurately reflected the level of the Veteran's pulmonary function. Private treatment notes dated October 2015 show that the Veteran was prescribed home oxygen therapy. In April 2018, Prednisone was restarted for increased shortness of breath and declining FVC. It was noted that the Veteran had had had three to four episodes of syncope. A transthoracic echocardiogram showed worsening pulmonary hypertension. A VA pulmonary follow up in June 2018 included an echocardiogram which indicated worsening pulmonary hypertension. July VA CT imagery indicated apical pleural-parenchymal scarring, linear opacities within the bilateral lower lobes, likely atelectasis or scarring, and bronchial wall thickening within the bilateral lower lobes. VA treatment notes from August 2018 reflect that the Veteran was negative for congestive heart failure. December 2018 VA treatment records show that the Veteran was taking Prednisone daily for shortness of breath. He required oxygen above 90 percent to alleviate shortness of breath. He had hypoxemia with exertion. It was noted that findings were suggestive of pulmonary hypertension. Congestive heart failure was indicated. The Veteran underwent abdominal and pelvic CT scans in January 2019 due to a possible inguinal hernia. The imagery indicated appendicitis and hernia as well as linear densities at the lung bases thought to be scarring or subsegmental atelectasis. Private treatment records reflect the Veteran's admission to a non-VA hospital in January 2019 for an appendectomy and inguinal hernia repair. The Veteran's spouse reported that the Veteran had been using supplemental oxygen for about a year. Chest CT imagery indicated consolidated atelectasis of the dependent bilateral lower lobes and indications of cardiomegaly. The Veteran suffered cardiogenic and septic shock and remained hospitalized. However, he died on February [REDACTED], 2019. In July 2019, a VA examiner opined, in part, that the Veteran had pulmonary hypertension and it can be related to sarcoidosis, placing strain on the heart and resulting in congestive heart failure, the Veteran also had infective tricuspid endocarditis and infected heart valves, which can lead to congestive heart failure. See VA Medical Opinion dated July 15, 2019. November 2020 correspondence from I.N., M.D. submitted in support of the appeal, reflects his opinion that the Veteran's cardiac involvement at death was more likely than not the result of his service-connected sarcoidosis. Doctor I.N. concluded that the February 2014 chest x-rays and chest CT indicating mediastinal and right hilar lymphadenopathy, honeycombing in the right lower lobe superior segment, and emphysematous and fibrotic type changes in the bilateral lungs were characteristic of Stage IV sarcoidosis. Notably, Doctor I.N. opined, that FEV1 most accurately reflects the overall level of the Veteran's pulmonary disability. Additionally, Doctor I.N. opined that it is "at least as likely as not that the Veteran met the 100 percent criteria set forth in DC 6600 based upon PFT results," explaining that symptoms of cardiac sarcoidosis include shortness of breath, chest pain, syncope, fatigue, edema, and congestive heart failure. See Correspondence from I.N., M.D. received November 3, 2020. The November 2020 medical opinion of Doctor I.N. is competent, credible and probative: It was authored by a licensed physician who reviewed the Veteran's treatment records and was therefore familiar with the Veteran's symptoms, diagnoses, and treatment of his pulmonary sarcoidosis; the opinion also considered lay statements of the Veteran regarding symptoms associated with his sarcoidosis as well as medical literature relevant to sarcoidosis and pulmonary hypertension. The opinion is consistent with the medical evidence of record and contains clear conclusions with supporting data connected by a reasoned medical explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-02 (2008). Notably, there are no medical opinions or other competent medical evidence of record that weighs against Doctor I.N.'s opinion. Accordingly, the Board finds the November 2020 medical opinion probative, competent and persuasive medical evidence in this case. On appeal, the appellant's representative's emphasizes Doctor I.N.'s opinion that FEV-1 data obtained through PFT evaluations rather than the FEV-1/FVC ratio most accurately reflected the overall level of the Veteran's pulmonary disability. See Correspondence from C.M. received January 13, 2021; Board hearing transcript dated October 4, 2021 at pg. 6. On review of all the evidence, both lay and medical, and resolving reasonable doubt in favor of the appellant, the Board finds that a maximum rating of 100 percent is warranted under DC 6600 for pulmonary sarcoidosis from the commencement of the rating period on appeal. The record demonstrates that throughout the rating period, PFT evaluations reflected FEV-1 results ranging from 32 to 38 percent. While the February 2014 SSA FEV-1 results were higher and the October 2014 VA examiner indicated that the FEV-1/FVC results of 59.2 percent most accurately reflected the level of the Veteran's pulmonary function at that time, these higher results must be weighed against the other multiple FEV-1 readings below 40 percent. Although the clinicians who recorded the PFT results reflecting FEV-1 readings lower than 40 percent predicted did not indicate which results more accurately reflected the level of the Veteran's disability, weighing these results with Doctor I.N.'s opinion and the Veteran's overall symptomology throughout the rating period, including difficulty breathing, shortness of breath, and limited physical activities as competently described by the Veteran and his spouse, see Layno, supra, and with resolution of doubt in favor of the appellant, the Board finds that the Veteran's pulmonary sarcoidosis predominantly manifested as reflected in PFT FEV-1 test results of less than 40 percent indicated. The Board also considers whether a rating higher than 60 percent is warranted under DC 6846, which requires heart involvement. Although the Veteran was service-connected for arrythmia associated with sarcoidosis, in terms of the rating criteria under DC 6846, the record is negative for evidence of cor pulmonale, congestive heart failure is not indicated until later in the rating period, and the treatment records reflect only infrequent episodes of fever. At any rate, the rating of the same disability, or the same manifestation of a disability, under different DCs, "pyramiding," is to be avoided. 38 C.F.R. § 4.14. As such, it is appropriate here to assign the maximum rating under DC 6600. For these reasons, and resolving reasonable doubt in the appellant's favor, the Board finds that a rating of 100 percent for pulmonary sarcoidosis with decreased pulmonary function, granuloma, chronic fatigue, headaches, and joint pain is warranted for the entire rating period on appeal. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7, 4.97, DC 6600. Depressive Disorder and PTSD The AOJ assigned a 50 percent disability rating for the Veteran's PTSD under DCs 9411-9435 based on occupational and social impairment, with reduced reliability and productivity based on difficulty adapting to stressful circumstances, difficulty in establishing and maintaining effective work relationships, disturbances of motivation and mood, flattened affect, panic attacks more than once a week, anxiety, chronic sleep impairment, depressed mood, mild memory loss, and suspiciousness. 38 C.F.R. § 4.130, DC 9411-9435; Rating Decision dated May 4, 2012. The appellant claims that a higher rating is warranted. See Representative's appeal brief received January 13, 2021. Under the General Rating Formula for Mental Disorders, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent rating is warranted if the evidence establishes there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating (total occupational and social impairment) is warranted due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact a Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Board recognizes that the United States Court of Appeals for Veterans Claims (Court) in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA's general Rating Formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; however, the Court further indicated that, without those examples, differentiating between rating evaluations would be extremely ambiguous. In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that, given that the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the Global Assessment of Functioning (GAF) scale, and that VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating in cases where the DSM-5 applies when the appeal was certified after August 4, 2014. Here, the Veteran's claim for an increased rating was certified to the Board in April 2017, and as such, only DSM-5 applies. Rating Analysis For the reasons expressed below, the Board finds that a 70 percent rating is warranted for depressive disorder and PTSD. Turning to the record, VA treatment notes dated November 2013 reflect that the Veteran presented with symptoms of anxiety, depression, increased irritability, low energy, disturbing memories, and at risk drinking he said was only on weekends. Diagnostic screening indicated mild depression and mild anxiety. He described vivid memories, flashbacks, and hypervigilance. He said his anxiety symptoms made it very difficult for him to do his work, take care of things at home, and get along with others. On examination, the Veteran was alert and oriented to all spheres, and his speech was fluent and goal-directed. His mood was appropriate, and his insight and judgment were intact. His thought process was free of abnormal content, and he denied suicidal and homicidal ideations. May 2014 VA treatment notes reflect that the Veteran endorsed feeling sad or depressed, which he said was caused by his being sick since January. He denied worry or increased stress, personal or family problems, alcohol or drug use. The clinician noted a history of anxiety disorder but noted that the Veteran was stable. VA treatment records dated July 2014 reflect that the Veteran denied feeling depressed, increased stress, personal or family problems, alcohol or drug use, and mental or emotional illness. He endorsed episodes of anxiety and said he avoided people when experiencing PTSD symptoms. The clinician noted a history of anxiety disorder but noted that the Veteran was stable. Undated correspondence from licensed professional counselor W.W. received in July 2014 reflects that a comprehensive clinical assessment of the Veteran in June 2014 demonstrated that the Veteran suffered from PTSD and should not be working. W.W. explained that the Veteran suffered from dissociative reactions (flashbacks), feelings of detachment or estrangement from others, persistent negative emotional state, and persistent inability to experience happiness, satisfaction, or loving feelings. In a statement from the Veteran received in August 2014, he described feeling detached from others, persistent negative emotional state, persistent inability to experience happiness or loving feelings toward others. He said he was irritable and withdrawn from society. Also in August 2014, several statements were submitted by the Veteran's family members and friends in support of his claim. His spouse B.W. said the Veteran was becoming more irritable and withdrawn and he had mentioned to B.W. that he was unable to perform his job due to his PTSD. His son L.W. said the Veteran did not have a close fatherly relationship with him, that he tended to be isolated and withdrawn from their family, especially L.W. He had become more irritable and isolated from the people who loved him. L.W. noted that the Veteran's PTSD affected his daily activities and his ability to work. Friend and neighbor W.H. said the Veteran was withdrawn, did not socialize like he once did, his attention span was very short, and he sometimes forgot what he was talking about and started talking about a different subject, and this behavior was becoming worse. Friend and neighbor D.J. said the Veteran related that he had become isolated and withdrawn from his family and friends, and that the Veteran attributed his shortened work career to his PTSD, which he said made it difficult to handle issues on the job. Friend R.M. said he had noticed that the Veteran did not have a close relationship with his son, and over the years the Veteran had become isolated and withdrawn from family and friends. He observed that the Veteran was irritable and isolated from people in general. R.M. said the Veteran tended to become upset more quickly than he had before and had become more withdrawn and less communicative with friends than in past years. A September 2014 Social Security Administration (SSA) disability determination found the Veteran was disabled as of June 2014 due to anxiety and affective disorders, chronic pulmonary/heart disease, back, and hypertension. See SSA Determination dated September 22, 2014. A September SSA psychological evaluation, upon which the determination was, in part, based, reflects that the Veteran was alert, well-oriented, and appropriately dressed. His speech was normal, and he denied feeling anxious or depressed daily, but noted that every day he was upset about something. His affect was flat but otherwise appropriate to content and conversational shifts. He said he felt anxious all the time. He said he was still interested but not as active in things he liked to do in the past. He endorsed nightmares and flashbacks related to in-service trauma. He denied avoidant behaviors and exaggerated startle response but endorsed hypervigilance. He said he preferred to be by himself, and he seemed to endorse being detached and numb to things around him. He was functioning in the average or high average range, intellectually. He denied paranoia and suspiciousness but admitted he was withdrawn socially, and he said he was irritable most of the time. He denied ever having suicidal or homicidal ideation. He denied experiencing auditory or visual hallucinations. The diagnostic impression was major depressive disorder, current, moderate; and unspecified anxiety disorder and PTSD and generalized symptoms. The psychologist noted that the Veteran appeared capable of understanding instructions adequately to perform, simple, routine, and repetitive tasks. Although the Veteran demonstrated adequate social skills and the ability to interact appropriately with others, it was noted that he had trouble tolerating stress. See SSA Comprehensive Clinical Psychological Evaluation dated September 30, 2014. As discussed above, SSA determinations and/or findings are not binding on the Board, they are, however, relevant and the records relied upon to make SSA determinations are probative evidence specifically in consideration of the appellant's claim for entitlement to an increased rating for the Veteran's service-connected PTSD and depression. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991) (observing that while SSA decisions are relevant, there are significant differences between SSA and VA recognition of disabilities and SSA decisions are not binding on VA). Here, the Board finds the SSA decision probative based on its analysis of the evidence, which included an analysis of pertinent medical evidence in the Veteran's claims file, and thus it is entitled to probative value. In coming to this conclusion, the Board only considers the evidence as it pertains to the service-connected depressive disorder and PTSD, which is the subject of the instant claim. In October 2014, the Veteran was afforded a VA PTSD examination, at which time the VA examiner diagnosed PTSD and depressive disorder. In terms of social impairment, the examiner noted that the Veteran had been married for over 36 years. He said his stepfather died a month earlier, but the Veteran said at the funeral he did not react as deeply as he would have in the past. He said he avoided visiting his mother to reduce interaction with his brother. He said most of his interaction with others was through his spouse. She noted that the Veteran was very grouchy. In terms of occupational impairment, the examiner noted that the Veteran had earned two master's degrees and was employed at a school district as an early childhood teacher for twelve years but quit working in June 2014 at the end of the school year, after experiencing unexplained fevers for several months. On examination, the Veteran was appropriately dressed and groomed. His mood was depressed, and his affect was restricted. His speech was normal in tone, rate, and content. His thoughts appeared organized and logical. However, some mild psychomotor retardation was indicated. There was no evidence of psychosis. He denied suicidal and homicidal thoughts. He denied violent behavior and panic attacks. The examiner identified symptoms of depressed mood; anxiety; chronic sleep impairment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting. Additional symptoms were withdrawal from other people, lack of enjoyment of activities, and increased irritability. The examiner concluded that the Veteran's PTSD and depressive disorder resulted in occupational and social impairment with reduced reliability and productivity. See VA PTSD examination report dated October 9, 2014. During an April 2015 VA outpatient appointment, the Veteran reported that he was doing well. He said he had attended stress management classes through VA and learned coping skills to deal with anger and frustration. He endorsed day to day feelings of depression and irritation that would come and go. He denied feeling hopeless or helpless, and he denied suicidal and homicidal ideation, plan or intent. October 2015 VA treatment notes reflect that the Veteran complained of anxiety and occasional agitation and insomnia. The VA physician noted that the Veteran's PTSD was stable. July 2016 VA treatment notes show that the Veteran endorsed anxiety, agitation, and insomnia. He said he became upset over little things and expressed dissatisfaction over having to explain himself to a family member. He emphasized that he needed time for himself. He denied worry or increased stress. It was noted that the Veteran's PTSD was stable at that time. The Veteran said he was feeling down or depressed nearly every day and had little interest or pleasure in doing things. A depression screening was positive. March 2018 VA treatment records note the Veteran's endorsement of symptoms consistent with major depression and moderate to severe anxiety. On examination, the Veteran oriented in all spheres, mood was anxious, with congruent affect. His thought process was coherent and goal-directed. He was negative for delusions and there was no evidence of internal stimuli. He denied suicidal and homicidal ideation. During June 2018 and August 2018 VA outpatient appointments for joint pain, the Veteran said the pain affected his mood. VA treatment notes dated December 2018 reflect that the Veteran was worried about his health, and PTSD and depression screenings were positive. In January 2019, the Veteran underwent an appendectomy and inguinal hernia repair. However, he suffered cardiogenic and septic shock and remained hospitalized. Mental status was noted as improving with ongoing disorientation and attention deficits attributed to deficits from a stroke. The Veteran died on February [REDACTED], 2019. In the January 2021 appeal memorandum, the appellant's representative asserted that the Veteran's PTSD warrants at least a 70 percent rating, asserts he suffered from occupational and social impairment, with deficiencies in most areas work, family relations, judgment, thinking, and mood. During the October 2021 Board hearing, the appellant stated that the Veteran was depressed all the time, his memory and concentration seemed to fail, and overall, his health seemed to go downhill starting in 2014. See Board hearing transcript dated October 4, 2021 at pgs. 8-9. On review of all the evidence, both lay and medical, and resolving reasonable doubt in favor of the appellant, the Board finds that a 70 percent rating for depressive disorder and PTSD is warranted for the entire period on appeal. In so finding, the Board notes that the Veteran endorsed symptoms indicating near-continuous depression, inability to establish and maintain effective relationships as demonstrated by being withdrawn from his family members, friends, and neighbors, his avoidance of interaction with family, and difficulty adapting to stressful circumstances, indicated by an inability to function in the employment setting. The Veteran, his spouse and other family members, as well friends and neighbors, are capable of reporting all of these symptoms as lay persons. See Layno, supra. The Board recognizes that the SSA psychologist observed that the Veteran demonstrated adequate social skills and the ability to interact appropriately with others. However, the psychologist also observed that the Veteran had trouble tolerating stress and was capable of understanding instructions adequately only to perform, simple, routine, and repetitive tasks. While the October 2014 VA examiner found that the Veteran's psychiatric symptoms resulted in occupational and social impairment with only reduced reliability and productivity, the examiner also observed psychomotor retardation and found deficiencies in the Veteran's ability to maintain effective work and social relationships and concluded that the Veteran had difficulty in adapting to stressful circumstances, including work or a worklike setting, which is contemplated by the criteria for a 70 percent rating. Throughout the rating period, the treatment records, examinations, and assessments reflect ongoing depression. Although it appears that the Veteran's symptoms may have fluctuated in severity throughout the claim period, he overall continued to endorse near-continuous depressive symptoms, which are contemplated by the criteria for a 70 percent rating. In terms of occupational impairment, the Board specifically considered evidence suggestive that the Veteran's psychiatric symptoms impacted his ability to work. The Board also considers whether a higher rating is warranted; however, the higher rating of 100 percent is not warranted here because the evidence of record does not show total occupational and social impairment due to the Veteran's depressive disorder and PTSD symptoms. For these reasons, and resolving reasonable doubt in the appellant's favor, the Board finds that a rating of 70 percent for depressive disorder and PTSD is warranted for the entire rating period on appeal. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. TDIU It is the established policy of VA that all veterans who are unable to secure and maintain substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. § 3.340(a)(1). Controlling laws provide that a TDIU may be assigned when a veteran has one service-connected disability rated at 60 percent or more, or two or more service-connected disabilities where at least one disability is rated at 40 percent or more and the combined rating is at least 70 percent. 38 C.F.R. § 4.16(a). The record must also show that the service-connected disabilities alone result in such impairment of mind or body that the average person would be precluded from securing or maintaining a substantially gainful occupation. Id. See 38 U.S.C. § 1155. The Board recognizes that the Court has held that the receipt of a 100 percent schedular rating for a service-connected disability does not necessarily render moot any pending claim for a TDIU. Bradley v. Peake, 22 Vet. App. 280 (2008). Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, the Court's decision in Bradley recognizes that a separate award of a TDIU predicated on a single disability may form the basis for an award of special monthly compensation (SMC). In the Bradley case, the Court found that TDIU was warranted in addition to a schedular 100 percent evaluation where the TDIU had been granted for a disability other than the disability for which a 100 percent rating was in effect. Under those circumstances, there was no "duplicate counting of disabilities." Bradley, 22 Vet. App. at 293. The Veteran in this case is in receipt of service connection for pulmonary sarcoidosis with decreased pulmonary function, granuloma, chronic fatigue, headaches, and joint pain, rated at 60 percent disabling from January 29, 2007, and at 100 percent from July 9, 2014 as granted herein; depressive disorder and posttraumatic stress disorder, rated at 50 percent disabling from June 30, 2010, and 70 percent from July 9, 2014 as granted herein; skin condition due to undiagnosed illness, rated at 30 percent disabling from June 30, 2010; lumbar spine strain, rated at 10 percent from July 1, 2001; tinnitus, rated at 10 percent from July 1, 2001; gastroesophageal reflux disease with dysphagia, bowel irregularity, and weight fluctuation associated with pulmonary sarcoidosis with decreased pulmonary function, granuloma, chronic fatigue, headaches, and joint pain, rated at 10 percent from January 29, 2007; arrhythmia associated with pulmonary sarcoidosis with decreased pulmonary function, granuloma, chronic fatigue, headaches, and joint pain, rated noncompensable from July 1, 2001; and salivary gland stone, rated noncompensable from June 30, 2010. Thus, the Veteran met the schedular requirement for a TDIU under 38 C.F.R. § 4.16(a) as of January 29, 2007. The Board notes that the rating period on appeal commenced in July 2014. The remaining question is whether any of the service-connected disabilities precluded the Veteran from securing and following a substantially gainful occupation. See 38 C.F.R. § 4.16(b). The fact that a veteran is unemployed or has difficulty finding employment does not alone warrant assignment of a TDIU, as a high rating itself establishes that her disability makes it difficult for her to obtain and maintain employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Rather, the evidence must show that she is incapable "of performing the physical and mental acts required" to be employed. Id. at 363. Thus, the central question is whether a veteran's service-connected disabilities alone are of sufficient severity to produce unemployability, and not whether a veteran could find employment. Id. Consideration may be given to a veteran's education, training, and special work experience, but not to her age or to impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The claimant is entitled to the benefit of the doubt when there is an "approximate" (meaning nearly equal) balance of positive and negative evidence regarding any material determination. See Lynch v. McDonough, 999 F.3d 1391 (2021); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The appellant asserts on appeal that the Veteran was entitled to a TDIU mainly because his service-connected sarcoidosis rendered him unable to obtain and follow substantially gainful employment. See Board hearing transcript dated October 4, 2021 (Hearing Transcript) at pg. 12. Prior to his death, the Veteran asserted that his service-connected PTSD and non-service connected chronic bronchitis rendered him unable to obtain and follow substantially gainful employment. See Veteran's Application for Increased Compensation Based on Unemployability (TDIU application) received July 9, 2014; See Veteran's statement received January 13, 2021. The Veteran's DD Forms 214 reflects that his Air Force military occupational specialty (MOS) was Aircraft Fabrication Superintendent for 17 years, then First Sergeant for nearly three years. The Veteran's July 2014 TDIU application form indicates that after his separation from the Air Force he earned a four year college degree and worked as an elementary school teacher for 12 years until June 2014, leaving this job because of chronic bronchitis and service-connected PTSD. The Veteran's service-connected physical disabilities are reflected in his post-service VA medical records and VA examinations, which have been reviewed by VA examiners and adjudicators in past years. Undated correspondence from licensed professional counselor W.W. received in July 2014 reflects that a comprehensive clinical assessment of the Veteran in June 2014 demonstrated that the Veteran suffered from PTSD and should not be working. W.W. explained that the Veteran suffered from dissociative reactions (flashbacks), feelings of detachment or estrangement from others, persistent negative emotional state, and persistent inability to experience happiness, satisfaction, or loving feelings. The Veteran's July 2014 TDIU application reflects that he completed at least four years of college and worked as schoolteacher for 12 years, that his chronic bronchitis and service-connected PTSD affected full-time employment by January 2014 and rendered him too disabled to work by June 2014. In a statement from the Veteran received in August 2014, he described experiencing detachment from others, persistent negative emotional state, persistent inability to experience happiness or loving feelings toward others. He said he was irritable and withdrawn from society. He emphasized that these symptoms made it impossible for him to work. Also in August 2014, the Veteran's spouse said the Veteran had become more irritable and withdrawn and he had told B.W. that he was unable to perform his job due to his PTSD. In an August 2014 statement, the Veteran's friend R.M. said the Veteran tended to become upset more quickly than he had before and had become more withdrawn and less communicative with others in past years. A September 2014 Social Security Administration (SSA) disability determination found the Veteran was disabled as of June 2014 due to anxiety and affective disorders, chronic pulmonary/heart disease, back, and hypertension. The diagnostic impression was major depressive disorder, current, moderate; and unspecified anxiety disorder with PTSD and generalized symptoms. The psychologist noted that the Veteran appeared capable of understanding instructions adequately to perform, simple, routine, and repetitive tasks. Although the Veteran demonstrated adequate social skills and the ability to interact appropriately with others, it was noted that he had trouble tolerating stress. See SSA Determination dated September 22, 2014. As discussed above, SSA findings are not binding on the Board, they are, however, relevant and the records relied upon to make SSA determinations are probative evidence specifically in consideration of the appellant's claim. The October 2014 VA examiner noted that while evaluating the Veteran some mild psychomotor retardation was indicated, his mood was depressed, and there was evidence of anxiety, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner concluded that while the Veteran was able to handle his financial affairs, his depressive disorder and PTSD resulted in occupational and social impairment with reduced reliability and productivity. See VA PTSD examination report dated October 9, 2014. In an October 2015 statement, the Veteran said he was unable to work even in a job in which he would be sitting all day. He described, in part, back pain, lack of concentration, anger issues, and an inability to be around other people. In a January 2021 appeal brief, the appellant's representative stressed that the Veteran was unable to work, in part, because he was mentally and emotionally incapable of handling duties requiring constant interaction with other people. See Representative's appeal brief received January 13, 2021 at pg. 3 During the October 2021 Board hearing, the appellant's representative stated that the Veteran was unable to work mainly because of sarcoidosis. Board hearing transcript dated October 4, 2021 at pg. 12. Nevertheless, the Veteran's spouse B.W. indicated that because the Veteran had memory problems, trouble concentrating, and anger and frustration over his mental deficiencies, he was unable to work. Id. at pgs. 8-9. The Board notes that in a relatively recent precedent decision, the Court defined the term "unable to secure and follow a substantially gainful occupation" to have two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of the Veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. See Ray v. Wilkie, 31 Vet. App. 58, 72-73 (2019). Here, the Veteran's active duty service involved the repair and maintenance of aircraft, and his post-service civilian work experience was that of an early childhood or elementary school teacher. Both occupations reasonably required a considerable amount of mobility, alertness, and concentration. Indeed, the Veteran's treatment records and evaluations reflect that throughout the rating period, he was irritable and withdrawn, had trouble tolerating stress, was quick to anger, and as early as October 2014, the VA examiner observed psychomotor retardation. The lay statements of the Veteran, his spouse, and family and friends regarding his behavior and physical symptoms in this regard are competent. See Layno, supra. Indeed, the licensed professional counselor W.W. concluded in July 2014 that the Veteran should not work because of his PTSD symptoms. In other words, the Veteran's limitations due to his service-connected PTSD, and to some degree his service-connected lumbar spine strain, not only precluded physical employment but sedentary employment as well. Therefore, the Board resolves all doubt in the Veteran's favor, finding that he was unemployable by reason of his service-connected depressive disorder and PTSD, and lumbar spine strain disabilities. Entitlement to a TDIU is granted. For these reasons, and resolving reasonable doubt in the appellant's favor, the Board finds that the Veteran was unemployable by reason of his service-connected depressive disorder and PTSD, and back disabilities. 38 U.S.C. § 5107; 38 C.F.R. § 4.16. Finally, neither the appellant nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND To date, no etiology opinion has been obtained in the development of the appellant's claim of service connection for chronic bronchitis. VA is obligated to provide an examination and/or obtain a medical opinion in an initial claim of service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d) (2012); McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). Here, while the Veteran's service treatment records do not reflect a diagnosis of chronic bronchitis per se, they include numerous references to coughing, chest pain, shortness of breath, and diagnoses of upper respiratory infections, restrictive lung disease, and sarcoidosis. Notably, a post-service non-VA hospital discharge summary reflects a diagnosis of chronic bronchitis which appears to be a distinct disorder from sarcoidosis. See Hospital Discharge Summary dated August 25, 2014. Accordingly, remand is necessary to obtain a VA opinion addressing the likely etiology of the Veteran's chronic bronchitis. 38 C.F.R. § 3.303; See McLendon, supra. The matter is REMANDED for the following action: 1. Implement the Board's decision herein granting increased ratings for pulmonary sarcoidosis and depressive disorder and PTSD, and entitlement to a TDIU. 2. Ensure that all outstanding VA treatment records are associated with the claims file. 3. Then, obtain an opinion as to the nature and etiology of the late Veteran's chronic bronchitis. Access to the Veteran's electronic claims file, which shall include a copy of this Remand, must be made available to the examiner for review, and be reviewed, in connection with the examination. After a complete review of the claims file, the examiner is asked to respond to the following: (a) Provide an opinion as to whether it is at least as likely as not that the Veteran's chronic bronchitis onset during service or is otherwise etiologically related to service, to include coughing, chest pain, shortness of breath, upper respiratory infections, and/or restrictive lung disease noted in the service treatment records. *Please differentiate symptoms of chronic bronchitis from symptoms of service-connected pulmonary sarcoidosis. (Continued on the next page) The examiner must provide a complete rationale for each opinion provided. 4. Then, readjudicate the remanded claim. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Farrell, 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. Department of Veterans Affairs YOUR RIGHTS TO APPEAL OUR DECISION The attached decision by the Board of Veterans' Appeals (Board) is the final decision for all issues addressed in the "Order" section of the decision. The Board may also choose to remand an issue or issues to the local VA office for additional development. If the Board did this in your case, then a "Remand" section follows the "Order." However, you cannot appeal an issue remanded to the local VA office because a remand is not a final decision. The advice below on how to appeal a claim applies only to issues that were allowed, denied, or dismissed in the "Order." If you are satisfied with the outcome of your appeal, you do not need to do anything. Your local VA office will implement the Board's decision. However, if you are not satisfied with the Board's decision on any or all of the issues allowed, denied, or dismissed, you have the following options, which are listed in no particular order of importance: Appeal to the United States Court of Appeals for Veterans Claims (Court) File with the Board a motion for reconsideration of this decision File with the Board a motion to vacate this decision File with the Board a motion for revision of this decision based on clear and unmistakable error. Although it would not affect this BVA decision, you may choose to also: Reopen your claim at the local VA office by submitting new and material evidence. There is no time limit for filing a motion for reconsideration, a motion to vacate, or a motion for revision based on clear and unmistakable error with the Board, or a claim to reopen at the local VA office. Please note that if you file a Notice of Appeal with the Court and a motion with the Board at the same time, this may delay your appeal at the Court because of jurisdictional conflicts. If you file a Notice of Appeal with the Court before you file a motion with the Board, the Board will not be able to consider your motion without the Court's permission or until your appeal at the Court is resolved. How long do I have to start my appeal to the court? You have 120 days from the date this decision was mailed to you (as shown on the first page of this decision) to file a Notice of Appeal with the Court. If you also want to file a motion for reconsideration or a motion to vacate, you will still have time to appeal to the court. As long as you file your motion(s) with the Board within 120 days of the date this decision was mailed to you, you will have another 120 days from the date the Board decides the motion for reconsideration or the motion to vacate to appeal to the Court. You should know that even if you have a representative, as discussed below, it is your responsibility to make sure that your appeal to the Court is filed on time. Please note that the 120-day time limit to file a Notice of Appeal with the Court does not include a period of active duty. If your active military service materially affects your ability to file a Notice of Appeal (e.g., due to a combat deployment), you may also be entitled to an additional 90 days after active duty service terminates before the 120-day appeal period (or remainder of the appeal period) begins to run. How do I appeal to the United States Court of Appeals for Veterans Claims? Send your Notice of Appeal to the Court at: Clerk, U.S. Court of Appeals for Veterans Claims 625 Indiana Avenue, NW, Suite 900 Washington, DC 20004-2950 You can get information about the Notice of Appeal, the procedure for filing a Notice of Appeal, the filing fee (or a motion to waive the filing fee if payment would cause financial hardship), and other matters covered by the Court's rules directly from the Court. You can also get this information from the Court's website on the Internet at: http://www.uscourts.cavc.gov, and you can download forms directly from that website. The Court's facsimile number is (202) 501-5848. To ensure full protection of your right of appeal to the Court, you must file your Notice of Appeal with the Court, not with the Board, or any other VA office. How do I file a motion for reconsideration? You can file a motion asking the Board to reconsider any part of this decision by writing a letter to the Board clearly explaining why you believe that the Board committed an obvious error of fact or law, or stating that new and material military service records have been discovered that apply to your appeal. It is important that your letter be as specific as possible. A general statement of dissatisfaction with the Board decision or some other aspect of the VA claims adjudication process will not suffice. If the Board has decided more than one issue, be sure to tell us which issue(s) you want reconsidered. Issues not clearly identified will not be considered. Send your letter to: Litigation Support Branch Board of Veterans' Appeals P.O. Box 27063 Washington, DC 20038 VA FORM DEC 2016 4597 Page 1 CONTINUED ON NEXT PAGE Remember, the Board places no time limit on filing a motion for reconsideration, and you can do this at any time. However, if you also plan to appeal this decision to the Court, you must file your motion within 120 days from the date of this decision. How do I file a motion to vacate? You can file a motion asking the Board to vacate any part of this decision by writing a letter to the Board stating why you believe you were denied due process of law during your appeal. See 38 C.F.R. § 20.904. For example, you were denied your right to representation through action or inaction by VA personnel, you were not provided a Statement of the Case or Supplemental Statement of the Case, or you did not get a personal hearing that you requested. You can also file a motion to vacate any part of this decision on the basis that the Board allowed benefits based on false or fraudulent evidence. Send this motion to the address on the previous page for the Litigation Support Branch, at the Board. Remember, the Board places no time limit on filing a motion to vacate, and you can do this at any time. However, if you also plan to appeal this decision to the Court, you must file your motion within 120 days from the date of this decision. How do I file a motion to revise the Board's decision on the basis of clear and unmistakable error? You can file a motion asking that the Board revise this decision if you believe that the decision is based on "clear and unmistakable error" (CUE). Send this motion to the address on the previous page for the Litigation Support Branch, at the Board. You should be careful when preparing such a motion because it must meet specific requirements, and the Board will not review a final decision on this basis more than once. You should carefully review the Board's Rules of Practice on CUE, 38 C.F.R. § 20.1400-20.1411, and seek help from a qualified representative before filing such a motion. See discussion on representation below. Remember, the Board places no time limit on filing a CUE review motion, and you can do this at any time. How do I reopen my claim? You can ask your local VA office to reopen your claim by simply sending them a statement indicating that you want to reopen your claim. However, to be successful in reopening your claim, you must submit new and material evidence to that office. See 38 C.F.R. § 3.156(a). Can someone represent me in my appeal? Yes. You can always represent yourself in any claim before VA, including the Board, but you can also appoint someone to represent you. An accredited representative of a recognized service organization may represent you free of charge. VA approves these organizations to help veterans, service members, and dependents prepare their claims and present them to VA. An accredited representative works for the service organization and knows how to prepare and present claims. You can find a listing of these organizations on the Internet at: http://www.va.gov/vso/. You can also choose to be represented by a private attorney or by an "agent." (An agent is a person who is not a lawyer, but is specially accredited by VA.) If you want someone to represent you before the Court, rather than before the VA, you can get information on how to do so at the Court's website at: http://www.uscourts.cavc.gov. The Court's website provides a state-by-state listing of persons admitted to practice before the Court who have indicated their availability to the represent appellants. You may also request this information by writing directly to the Court. Information about free representation through the Veterans Consortium Pro Bono Program is also available at the Court's website, or at: http://www.vetsprobono.org, mail@vetsprobono.org, or (855) 446-9678. Do I have to pay an attorney or agent to represent me? An attorney or agent may charge a fee to represent you after a notice of disagreement has been filed with respect to your case, provided that the notice of disagreement was filed on or after June 20, 2007. See 38 U.S.C. § 5904; 38 C.F.R. § 14.636. If the notice of disagreement was filed before June 20, 2007, an attorney or accredited agent may charge fees for services, but only after the Board first issues a final decision in the case, and only if the agent or attorney is hired within one year of the Board's decision. See 38 C.F.R. § 14.636(c)(2). The notice of disagreement limitation does not apply to fees charged, allowed, or paid for services provided with respect to proceedings before a court. VA cannot pay the fees of your attorney or agent, with the exception of payment of fees out of past-due benefits awarded to you on the basis of your claim when provided for in a fee agreement. Fee for VA home and small business loan cases: An attorney or agent may charge you a reasonable fee for services involving a VA home loan or small business loan. See 38 U.S.C. § 5904; 38 C.F.R. § 14.636(d). Filing of Fee Agreements: If you hire an attorney or agent to represent you, a copy of any fee agreement must be sent to VA. The fee agreement must clearly specify if VA is to pay the attorney or agent directly out of past-due benefits. See 38 C.F.R. § 14.636(g)(2). If the fee agreement provides for the direct payment of fees out of past-due benefits, a copy of the direct-pay fee agreement must be filed with the agency of original jurisdiction within 30 days of its execution. A copy of any fee agreement that is not a direct-pay fee agreement must be filed with the Office of the General Counsel within 30 days of its execution by mailing the copy to the following address: Office of the General Counsel (022D), Department of Veterans Affairs, 810 Vermont Avenue, NW, Washington, DC 20420. See 38 C.F.R. § 14.636(g)(3). The Office of the General Counsel may decide, on its own, to review a fee agreement or expenses charged by your agent or attorney for reasonableness. You can also file a motion requesting such review to the address above for the Office of the General Counsel. See 38 C.F.R. § 14.636(i); 14.637(d). VA FORM DEC 2016 4597 Page 2 SUPERSEDES VA FORM 4597, APR 2015, WHICH WILL NOT BE USED