Citation Nr: 20065027 Decision Date: 10/07/20 Archive Date: 10/07/20 DOCKET NO. 17-50 498 DATE: October 7, 2020 ORDER Entitlement to a disability rating of 70 percent for posttraumatic stress disorder (PTSD) is granted on and after September 24, 2014, subject to the laws and regulations governing the payment of monetary benefits. Service connection for neuropathy of the lower extremities is granted. Service connection for a gastrointestinal disability is granted. Service connection for erectile dysfunction is granted. REMANDED Service connection for hypertension is remanded. Service connection for a chronic skin disability is remanded. Service connection for sleep apnea is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran’s PTSD has been manifested by occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. 2. The probative evidence of record is at least in equipoise as to whether the Veteran’s neuropathy of the lower extremities is etiologically related to direct exposure to firefighting chemicals during his active duty service. 3. The probative evidence of record is at least in equipoise as to whether the Veteran’s gastrointestinal disability is etiologically related to his service-connected PTSD. 4. The probative evidence of record is at least in equipoise as to whether the Veteran’s erectile dysfunction is etiologically related to his service-connected PTSD. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the Veteran’s favor, on and after September 24, 2014, the criteria for a disability rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2019). 2. With resolution of reasonable doubt in the Veteran’s favor, the criteria for a grant of service connection for neuropathy of the lower extremities have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2019). 3. With resolution of reasonable doubt in the Veteran’s favor, the criteria for a grant of service connection for a gastrointestinal disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2019). 4. With resolution of reasonable doubt in the Veteran’s favor, the criteria for a grant of service connection for erectile dysfunction have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Air Force from June 1989 to February 1995, including service in the Persian Gulf War. These matters are on appeal from June 2015 and May 2017 rating decisions. The Veteran’s claims for service connection for a functional gastrointestinal disorder and acid reflux have been recharacterized as a gastrointestinal disability, to include acid reflux. The Veteran’s claims for service connection for a skin disability and the residuals of a staph infection have been recharacterized as a skin disability, to include the residuals of a staph infection. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In his June 2017 Notice of Disagreement (NOD) with regard to the rating assigned for the Veteran’s service-connected PTSD, the Veteran’s attorney raised the issue of entitlement to a TDIU. The Board therefore finds that the issue of entitlement to a TDIU has been raised in connection with the claim on appeal for an increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran’s attorney submitted an NOD in August 2015. Of the claims being decided below, this NOD pertains to the gastrointestinal, neuropathy, and erectile dysfunction claims. In this NOD, the Veteran’s attorney has generally raised the issue of the adequacy of the VA examinations. He does not raise any specific objection to any particular examination. He also refers to VA’s duty to assist by noting that VA “has been unable to obtain the Veteran’s service medical records,” but those records appear to be complete and the Veteran’s attorney has not identified any record that he contends is missing. In a June 2016 statement, the Veteran’s attorney specifically contends that the VA examination with regard to neuropathy did not consider the Veteran’s contentions with regard to chemical exposure and is therefore inadequate. Because the Board is granting service connection for a gastrointestinal disability, neuropathy, and erectile dysfunction, any alleged error is harmless and results in no prejudice to the Veteran. In his June 2017 NOD with regard to the rating assigned for PTSD, the Veteran’s attorney again generally raised the issue of the adequacy of the VA examinations. He does not raise any specific objection to any particular examination. He contends that VA examiners did not consider functional loss due to fatigue, pain, and weakness caused by repetitive use and movement and that examinations are inherently flawed because they reflect “an isolated snapshot of his physical condition in a pristine environment when he was under no ordinary, everyday physical stress.” Because this is an appeal of a rating for a psychiatric disability, these contentions are not pertinent to the Veteran’s appeal. He also again refers to VA’s duty to assist by noting that VA “has been unable to obtain the Veteran’s service medical records” but, as stated above, those records appear to be complete and the Veteran’s attorney has not identified any record that he contends is missing. With regard to this claim, because this a claim for an increased rating, not service connection, and for a period long after the Veteran’s active duty service, even if any additional service treatment records exist, those records are not pertinent to the issue on appeal. In addition, in the August 2015 and June 2017 NODs, the Veteran’s attorney contends, without explanation, that failures asserted in the NODs rise to the level of a denial of procedural due process protections. Because this is a boilerplate contention, the Board finds it does not raise any issue with the duty to notify or assist. The Board also notes that the Veteran’s attorney, in the October 2017 substantive appeal (VA Form 9), sought to preserve for appeal any “failure to discharge the duty to assist.” However, neither the Veteran nor his attorney have raised any specific issue with the duty to notify or duty to assist other than those referenced above. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). 1. PTSD The Veteran contends that his PTSD warrants a higher ratings than that currently assigned. It is currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, for PTSD, with a 30 percent rating on and after September 24, 2014. The full period of service connection is on appeal. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4 (2019). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. “Staged” ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Given the nature of the present claim for a higher initial evaluation, the Board has considered all evidence of severity from the effective date for the award of service connection. Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Under 38 C.F.R. § 4.130, psychiatric impairment is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130 provides that a 30 percent evaluation is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. 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; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful situations (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is in order when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, occupation, or own name. Id. When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant’s capacity for adjustment during periods of remission. See Vazquez–Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). A September 2014 VA treatment record notes the Veteran’s report of anger issues and his fear at times “of what he could possibly do.” The Veteran denied suicidal ideation but reported periodic passive death wishes. The United States Court of Appeals for Veterans Claims has held that “wishing that you were dead” constitutes “passive suicidal ideation,” that the rating criteria make no distinction between passive and active suicidal ideation, and that “a veteran’s thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas.” Bankhead v. Shulkin, 29 Vet. App. 10, 19-20 (2017). During a VA treatment appointment later in September 2014, the Veteran reported that he recently lost a job at a casino due to a panic attack and that he was having suicidal thoughts with a specific plan “but couldn’t do it.” The Veteran has submitted a September 2014 examination report by his VA treatment provider, who diagnosed PTSD, major depressive disorder, panic disorder, and generalized anxiety disorder. The treatment provider noted that the Veteran had recently been fired because of a panic attack and that he “[c]an’t hold a job.” The treatment provider listed the Veteran’s symptoms for rating purposes as depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, panic attacks more than once a week, near-continuous panic or depression affecting the 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 and social relationships, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control, grossly inappropriate behavior, persistent danger of hurting self or others, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living. The treatment provider characterized the Veteran’s overall level of occupational and social impairment as occupational and social impairment with deficiencies in most areas, which is consistent with a 70 percent rating. A VA treatment record from the day after this examination notes the Veteran’s report that his employer reconsidered suspending him after a coworker explained the situation. During an October 2014 VA treatment record, the Veteran reported that he was changing jobs to limit his direct contact with the public. He also reported that his attention and concentration were mildly impaired at times during periods of heightened anxiety. During a November 2014 VA treatment appointment, the Veteran reported that he had found a new job in security that provided fewer triggers for his PTSD symptoms. He denied a history of acting out but reported concern about his emotional and behavioral control. During a December 2014 VA treatment appointment, the Veteran reported considerable avoidance of social interaction in an attempt to avoid groups of people, which caused him to feel “like the walls are closing in on [him].” He also clarified that his security work was at night. During a VA treatment appointment later in December 2014, the Veteran reported that this job was less stressful because he did not have to be around people. During another VA treatment appointment later in December 2014, the Veteran reported that his two most significant recent anxiety attacks were when traveling as a passenger in a car with family after having been at social gatherings. The Veteran was afforded a VA examination in January 2015. The examiner diagnosed persistent depressive disorder with anxious distress. The Veteran reported that he had been married twice and was currently divorced. He also reported that he was single, had no children, and lived alone. He also reported that he had had approximately 20 jobs since 1995 and was currently working part-time as a night security guard for a construction company; he clarified that he worked alone. The examiner listed the Veteran’s symptoms for rating purposes as depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. No significant deficits in hygiene were noted, he was alert and oriented, his thought processes seemed logical, sequential and goal-directed, no frank delusional thinking was elicited, he denied hallucinations in all modalities other than two brief possible olfactory hallucinations of “rotten egg smell,” and no difficulties with attention or concentration were noted. He reported his mood as “dark” and denied suicidal or homicidal ideation. He also reported socializing with his spouse (presumably a reference to his former spouse) and a few friends. The examiner characterized the Veteran’s overall level of occupational and social impairment as not severe enough either to interfere with occupational social functioning or to require continuous medication, which is consistent with a noncompensable rating. In a February 2015 statement, the Veteran reported his symptoms as anxiety, chronic sleep problems, depression, difficulty making decisions, emotional numbing, flashbacks, isolation, lack of emotions, lack of self-esteem, neglect of personal hygiene, nervousness, panic attacks, sense of helplessness, and suspiciousness. Over the course of 2015, the Veteran submitted 25 statements by various friends and family members, including some who had served with him during his active duty service. One reported that the Veteran “has spoken of ending it all.” These statements collectively speak to the Veteran’s depression, anxiety, and social isolation, but their existence also demonstrates that the Veteran was in social contact with at least 25 people during this period. In a June 2016 statement, the Veteran reported that his depression was getting worse and that he was having “relationship issues because of the depression.” He also reported that he had been having suicidal thoughts. The Veteran has also submitted a July 2016 statement by a friend who is a Licensed Professional Counselor and listed his symptoms as increased impulse for isolation, a suspected incidence of dissociation when encountering a Middle Eastern couple having a verbal conflict, difficulty in maintaining intimate relationships, suicidal ideation with a plan, opportunity, and means for accomplishment, insomnia, often becoming triggered when working in an environment not trained in supporting individuals suffering from PTSD, and inability to maintain long term employment. During a July 2016 VA treatment appointment, the Veteran reported passive death wishes and that he was terribly depressed as well as having anxiety, panic, and rage. The treatment provider noted that the Veteran was “extremely flat” with “no emotion whatsoever.” The Veteran was afforded an additional VA examination in August 2016. The examiner diagnosed PTSD. The Veteran reported that he was still single, had no children, and lived alone; he added that he dating had not worked for him because it was difficult for him to leave his house due to hypervigilance and lack of trust. He also reported keeping in touch with some friends through social media. He also reported that he kept in touch with his two siblings but did not see them much, adding that he did not attend family gatherings and did not leave his home unless necessary because of his anxiety around people. He also reported that he had been working full time as a security guard and receptionist for the past three weeks and that it was difficult because he sometimes had to deal with more than one person at a time. The examiner listed the Veteran’s symptoms for rating purposes as depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, and suicidal ideation. The Veteran was alert and oriented, his dress was appropriate, his grooming and hygiene were good, his attention and concentration were good, his mood was dysthymic with tearful affect, his speech was fluent and productive, his thought process was clear, coherent, and goal-directed without evidence of formal thought disorder or psychosis, there were no psychotic symptoms, he denied suicidal and homicidal ideation, and his judgment and insight appeared average. The examiner characterized the Veteran’s overall level of occupational and social impairment as occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication, which is consistent with a 10 percent rating. In a June 2017 statement, the Veteran reported that he typically started his day by violently retching while trying to get ready for work and that he took a night job to avoid contact with people but often broke out into tears due to loneliness. He also reported that, at work, he would lose track of what he was doing after staring off into space for minutes at a time and that he did not feel safe leaving his apartment. During an October 2017 VA treatment appointment, the Veteran reported that his depression was interfering with his work performance and that he had been missing scheduled work shifts due to calling off. During a November 2017 VA treatment appointment, the Veteran reported that he did not know how much longer he could work given the number of days he was missing. The Veteran has also submitted a November 2017 examination report by the same VA treatment provider who provided the September 2014 examination report. The treatment provider noted that the Veteran was unable to maintain a relationship and that he missed a lot of work. The treatment provider listed the Veteran’s symptoms for rating purposes as depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, disturbances of motivation and mood, impaired judgment, impaired abstract thinking, gross impairment in thought processes or communication, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living. The treatment provider characterized the Veteran’s overall level of occupational and social impairment as occupational and social impairment with deficiencies in most areas, which is consistent with a 70 percent rating. During a January 2018 VA neuropsychological assessment, the Veteran reported that his employment was in eight hour shifts but that he was missing work “more and more” due to his neuropathy and that he did not receive paid leave because he was a contractor. He again reported that he was not in a relationship and had no children but had friends and positive relationships with his siblings. He reported trouble sustaining focus at work and had frequent word-finding difficulties. He denied any periods of confusion or disorientation. He also reported that his panic attacks impacted his driving. He reported generalized anxiety throughout the day and panic attacks typically lasting five minutes. He denied any history of suicide attempts. During a June 2019 VA treatment appointment, the Veteran reported that he was tolerating his job. During a March 2020 VA treatment appointment, the Veteran reported decreased stress at work because the pandemic had limited the number of people he encountered. Based on the evidence described above, the Board finds that, affording the Veteran the benefit of the doubt, his psychiatric symptoms and overall disability picture warrant an evaluation of 70 percent for PTSD throughout the period on appeal. During that period, the record contains evidence of near-continuous panic or depression, impaired impulse control, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, and frequent reports of suicidal ideation. The Veteran’s VA treatment provider, in two examination reports, has also characterized the overall severity of his symptoms as occupational and social impairment with deficiencies in most areas. For these reasons, the Board finds that Veteran’s symptoms most nearly approximate those that warrant a 70 percent rating throughout the period on appeal. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. The Board does not, however, find the criteria for a 100 percent evaluation are more nearly approximated by the Veteran’s symptoms at any point during the period on appeal. The record contains evidence of some of the symptoms listed in the criteria for a 100 percent rating, including gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting himself or others, and intermittent inability to perform activities of daily living. However, even the constant presence of some symptoms listed in the criteria for a 100 percent rating is insufficient because the overall guiding criterion for a 100 percent rating is that both total occupational and total social impairment be present. 38 C.F.R. § 4.130; see, e.g., Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). In this case, the Veteran’s symptoms have not been shown to be so severe that he has both total occupational and total social impairment. “Total” is defined as “whole, not divided; full; complete,” and “utter, absolute.” Black’s Law Dictionary, 1498 (7th ed. 1999). Although the Board is remanding the Veteran’s TDIU claim, it is unnecessary to resolve that claim before deciding this issue because, even if total occupational impairment is eventually found, total social impairment is not shown. The Veteran has been able to maintain some personal relationships, specifically with his siblings and a significant number of friends. The Board acknowledges that these relationships are sometimes strained or distant, but that is reflected in the current 70 percent rating for “deficiencies in most areas,” the criteria for which include inability to establish and maintain effective relationships and difficulty in adapting to stressful circumstances including work or a worklike setting. Because the Veteran is not totally socially impaired, a 100 percent rating is not warranted. The Board also notes that many of the Veteran’s reported symptoms throughout the period on appeal are included among those specifically contemplated in the General Rating Formula for Mental Disorders, pursuant to which a 70 percent disability rating has been assigned. See 38 C.F.R. § 4.130. Importantly, the Board notes that symptoms noted in the rating schedule 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 disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In other words, symptoms comparable to those listed in the General Rating Formula could be considered in evaluating the Veteran’s extent of occupational and social impairment. Accordingly, the existence and severity of the Veteran’s psychiatric symptoms are adequately contemplated by the 70 percent rating criteria. As noted above, many of the symptoms are specifically listed in the General Rating Formula for Mental Disorders, and the others are common psychiatric symptoms that-while not specifically listed-are comparable indicators of the type of occupational and social impairment contemplated in the Rating Formula. The Board has also considered the Veteran’s assertions and those in the other lay statements of record regarding his psychiatric symptoms, which they are competent to provide. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The lay evidence is also credible. The symptoms described in those lay statements comport with the 70 percent rating that has now been assigned. However, these lay statements do not provide any basis upon which to assign a higher rating because they do not reflect total social impairment. In sum, the Board finds that, resolving reasonable doubt in the Veteran’s favor, his impairment due to PTSD has been most consistent with a 70 percent disability rating throughout the period on appeal. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. 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); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Neuropathy of the Lower Extremities The Veteran has a current diagnosis of neuropathy of the lower extremities, which he contends is etiologically related to chemical exposure at Wurtsmith Air Force Base during his active duty service. His service personnel records indicate service at Wurtsmith Air Force Base. The Veteran has submitted an August 2015 private medical opinion by a clinician who opined that it is at least as likely as not that the Veteran’s peripheral neuropathy of the lower extremities is related to chemical exposure at Wurtsmith Air Force Base and cited literature in support of this conclusion. The Veteran was afforded a VA examination in May 2017. The nexus opinion discussed causation by exposure to contaminated water, but not direct exposure to firefighting chemicals. In a February 2018 statement, the Associate Director of Clinical Services at VA’s War Related Illness and Injury Study Center (WRIISC) noted the Veteran’s reports of direct exposure to firefighting foam. Based on these reports, the Associate Director ordered testing, which found elevated test results for one contaminant. In an additional February 2018 statement, the Associate Director clarified that there were many possible sources of exposures but that, given the Veteran’s direct exposure to foam known to contain the chemical in question, “it is likely that your exposure to this chemical in the military may have contributed to your overall exposure/elevated blood levels.” With regard to a nexus between this exposure and neuropathy, the Associate Director found that “[a]nimal studies may be suggestive, but applicability to humans is unclear.” The medical evidence of record includes a diagnosis of neuropathy of the lower extremities and a private opinion that chemical exposure at Wurtsmith Air Force Base was at least as likely as not to be among its causes. On examination, WRIISC found elevated levels of a contaminant present in firefighting foam in the Veteran’s blood and concluded that this likely reflected exposure but did not opine as to whether a nexus was at least as likely as not. In light of the totality of the circumstances, and after resolving all reasonable doubt in the Veteran’s favor, the evidence of record supports a finding that it is at least as likely as not that the Veteran’s neuropathy of the lower extremities was caused, at least in part, by direct exposure to chemicals present in firefighting foam during his active duty service. Accordingly, the Board finds that granting service connection for neuropathy of the lower extremities is the decision that is the most consistent with VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts of the case. 38 C.F.R. § 3.303(a). The Board notes that the Veteran has also contended that his neuropathy of the lower extremities was caused by exposure to contaminated water at Wurtsmith Air Force Base but, because the Board is granting his claim based on direct exposure to firefighting foam, it is unnecessary to discuss this additional theory of causation further. 3. Gastrointestinal Disability The Veteran contends that he has a gastrointestinal disability that is etiologically related to his service-connected PTSD. The Veteran has a current diagnosis of gastroesophageal reflux disease (GERD). The Veteran was afforded a VA examination in May 2015. The examiner did not include an explicit nexus opinion, but noted that the Veteran’s separation examination was “silent for a diagnosis of GERD.” To the extent that this can be construed as a negative nexus opinion, it pertains to direct but not secondary service connection. The Veteran has submitted an August 2015 private medical opinion by a clinician who opined that it is at least as likely as not that the Veteran’s GERD “is secondary to, related to, and/or aggravated by” his service-connected PTSD and cited literature in support of this conclusion. In August 2015, the Veteran also submitted an article regarding comorbidity between GERD and psychological disorders. The Veteran was afforded an additional VA examination in May 2017, with opinions regarding both direct and secondary service connection. With regard to secondary service connection, the examiner opined that a nexus was less likely than not because the medical literature cited in the private opinion was merely “[c]orrelational research” and that it is “incorrect to imply causation from correlation.” The record contains two medical opinions with regard to secondary service connection. A private clinician provided an opinion that is favorable to the Veteran’s claim, the VA examiner provided an opinion unfavorable to the Veteran’s claim, and both provided detailed rationales in support of their opinions. The Board finds that the evidence is in equipoise. In light of the totality of the circumstances, and after resolving all reasonable doubt in the Veteran’s favor, the evidence of record supports a finding that it is at least as likely as not that the Veteran’s GERD was caused or aggravated, at least in part, by his service-connected PTSD. Accordingly, the Board finds that granting service connection for a gastrointestinal disability is the decision that is the most consistent with VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts of the case. 38 C.F.R. §§ 3.303 (a), 3.310. 4. Erectile Dysfunction The Veteran contends that he has erectile dysfunction that is etiologically related to his service-connected PTSD. The Veteran has a current diagnosis of erectile dysfunction. The Veteran was afforded a VA examination in May 2015. The examiner did not include an explicit nexus opinion, but noted that the Veteran’s separation examination was “silent for a diagnosis of erectile dysfunction.” To the extent that this can be construed as a negative nexus opinion, it pertains to direct but not secondary service connection. The Veteran has submitted an August 2015 private medical opinion by a clinician who opined that it is at least as likely as not that the Veteran’s erectile dysfunction “is secondary to, related to, and/or aggravated by” his service-connected PTSD and cited literature in support of this conclusion. In August 2015, the Veteran also submitted articles regarding a relationship between erectile dysfunction and psychiatric disorders. The Veteran was afforded an additional VA examination in May 2017, with opinions regarding both direct and secondary service connection. With regard to secondary service connection, the examiner opined that a nexus was less likely than not because the medical literature cited in the private opinion was merely “[c]orrelational research” and that it is “incorrect to imply causation from correlation.” The record contains two medical opinions with regard to secondary service connection. A private clinician provided an opinion that is favorable to the Veteran’s claim, the VA examiner provided an opinion unfavorable to the Veteran’s claim, and both provided detailed rationales in support of their opinions. The Board finds that the evidence is in equipoise. In light of the totality of the circumstances, and after resolving all reasonable doubt in the Veteran’s favor, the evidence of record supports a finding that it is at least as likely as not that the Veteran’s erectile dysfunction was caused or aggravated, at least in part, by his service-connected PTSD. Accordingly, the Board finds that granting service connection for erectile dysfunction is the decision that is the most consistent with VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts of the case. 38 C.F.R. §§ 3.303 (a), 3.310. REASONS FOR REMAND 1. Service connection for hypertension is remanded. The Veteran was most recently afforded a VA examination for hypertension in May 2017. The examiner opined that it was less likely than not that the Veteran’s hypertension was incurred in or caused by active duty service because the “most likely cause” is “his unrelated medical conditions which are significant and severe especially his morbid obesity.” In 2017, VA’s General Counsel issued a precedent opinion which held that obesity is not subject to service connection on a direct basis, cannot qualify as an in-service disease or injury for the purposes of service connection, and generally cannot be service connected on a secondary basis as a disability directly resulting from a service-connected disability. VAOPGCPREC 1-2017 (Jan. 22, 2017). It was further held, however, that obesity can be an “intermediate step” between a service-connected disability and a current disability that may be service-connected on a secondary basis. Id. In order for obesity to be such an “intermediate step,” (1) a service-connected disability must have caused the Veteran to become obese, (2) obesity must have been a substantial factor in causing the disability in question and (3) the disability in question must have been one that would not have occurred but for obesity caused by the service-connected disability. Id; see also Marcelino v. Shulkin, 29 Vet. App. 155 (2018). The Veteran has submitted an August 2015 private medical opinion by a clinician who opined that it is at least as likely as not that the Veteran’s hypertension “is secondary to, related to, and/or aggravated by” his service-connected PTSD and cited literature in support of this conclusion. The clinician’s rationale used obesity as an intermediate step between the Veteran’s PTSD and his hypertension but did not find that his hypertension would not have occurred but for obesity caused by the service-connected PTSD. A remand is necessary to afford the Veteran an addendum opinion addressing obesity as an intermediate step. 2. Service connection for a chronic skin disability is remanded. Once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was afforded a VA examination in May 2015. The examiner did not include an explicit nexus opinion, but noted that the Veteran’s separation examination was “silent for a chronic skin condition.” To the extent that this can be construed as a negative nexus opinion, its rationale is inadequate. The Veteran was afforded an additional VA examination in May 2017, but the opinions focused entirely on secondary service connection. For these reasons, a remand is warranted to obtain an additional medical opinion. 3. Service connection for sleep apnea is remanded. The Veteran was afforded a VA examination in May 2015. The examiner found that the Veteran did not have a diagnosis of sleep apnea and so did not provide a nexus opinion. VA treatment records from January 2018 indicate that the Veteran has since been diagnosed with sleep apnea. For this reason, a remand is warranted to obtain an additional medical opinion. 4. Entitlement to a TDIU is remanded. Because the Veteran’s employment and income history during the period on appeal are unclear from the evidence of record, the Agency of Original Jurisdiction (AOJ) should request this information from the Veteran. The matters are REMANDED for the following action: 1. Provide the Veteran and his attorney with notice concerning how to substantiate the claim for a TDIU, to include providing him with a VA Form 21-8940. 2. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran’s hypertension. The entire claims file and a copy of this remand must be made available to the examiner for review. A new physical or telehealth examination is only required if deemed necessary by the clinician. The clinician must provide opinions as to the following: a. Whether it is as likely as not (a probability of 50 percent or greater) that any current hypertension had its origin in service or is related to the Veteran’s active service. b. Whether it is as least as likely as not that any current hypertension was caused by the Veteran’s service-connected PTSD. c. Whether it is as least as likely as not that any current hypertension was aggravated beyond its natural progression by the Veteran’s service-connected PTSD. d. Whether it is at least as likely as not that the Veteran’s service-connected PTSD caused him to become obese. e. Whether it is at least as likely as not that the Veteran’s obesity was a substantial factor in causing his hypertension. f. Whether it is at least as likely as not that the Veteran’s hypertension would not have occurred but for obesity caused by his service-connected PTSD. Although an independent review of the claims file is required, the Board calls the clinician’s attention to the following: a. Blood pressure readings from service treatment records on November 5, 1990, March 3, 1993, January 1, 1994, and January 20, 1995, as well as a finding of mildly elevated systolic blood pressure in a February 7, 1994 service treatment record. b. An April 1999 private treatment record noting the Veteran’s report of a history of hypertension for the past year and a half, with a diagnosis of hypertension. c. The Veteran’s contentions in a statement VA received in March 2015 regarding his symptoms and their etiology. d. An August 2015 private medical opinion ascribing the Veteran’s hypertension to his PTSD, with obesity as an intermediate step. e. The May 2017 VA examiner’s finding that the Veteran’s hypertension was most likely attributable to his obesity. f. A September 2017 statement by a member of the New Hampshire House of Representatives and environmental scientist regarding a relationship between contaminants present at Wurtsmith Air Force Base and hypertension. The rationale for any opinion expressed should be provided. Note that a lack of documented treatment in service, while probative, cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the examiner should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 3. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran’s chronic skin disability. The entire claims file and a copy of this remand must be made available to the examiner for review. A new physical or telehealth examination is only required if deemed necessary by the clinician. The clinician must provide opinions as to the following: a. Whether it is as likely as not (a probability of 50 percent or greater) that any current chronic skin disability had its origin in service or is related to the Veteran’s active service, including his service in the Persian Gulf War. b. Whether it is at least as likely as not that any current chronic skin disability was caused by the Veteran’s service-connected PTSD, including as a side effect of medication. c. Whether it is at least as likely as not that any current chronic skin disability was aggravated beyond its natural progression by the Veteran’s service-connected PTSD, including as a side effect of medication. Although an independent review of the claims file is required, the Board calls the clinician’s attention to the following: a. February 1991 service treatment records noting a rash, with a diagnosis of contact dermatitis. b. An August 1992 service treatment record noting scaly lesions, with a diagnosis of tinea versus nummular eczema. c. A February 1993 service treatment record noting an erythematous rash. d. Private treatment records from April 1999 regarding warts on the Veteran’s hands. e. A July 1999 private treatment record regarding a probable infected sebaceous cyst on the Veteran’s left thigh. f. A September 1999 private treatment record noting a probable wart on the Veteran’s right forearm. g. A January 2002 private treatment record noting an eczematous rash on the Veteran’s legs and post-inflammatory changes on his forearms. h. Private treatment records from April 2003 and July 2003 regarding an eczematous rash on the Veteran’s lower extremities. i. Private treatment records from August 2004, October 2004, and December 2004 noting psoriasis and probable shingles. j. An August 2008 private treatment record noting a wart on the Veteran’s forehead. k. An October 2009 private treatment record noting recurrence of warts on the Veteran’s forehead and hands. l. An August 2010 private treatment record noting eczema on the Veteran’s hands. m. A May 2012 private treatment record noting skin lesions, the nature of which were unclear to the treatment provider. n. VA treatment records from July 2014 describing the Veteran’s skin symptoms. o. VA treatment records from January 2015 and February 2015 regarding a cyst under the Veteran’s left armpit. p. The Veteran’s contentions in a statement VA received in March 2015 regarding his symptoms and their etiology. q. An April 2015 statement by a fellow Veteran, A.O, regarding contaminants at Wurtsmith Air Force Base and their possible effects. The rationale for any opinion expressed should be provided. Note that a lack of documented treatment in service, while probative, cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 4. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran’s sleep apnea. The entire claims file and a copy of this remand must be made available to the examiner for review. A new physical or telehealth examination is only required if deemed necessary by the clinician. The clinician must provide opinions as to the following: a. Whether it is as likely as not (a probability of 50 percent or greater) that any current sleep apnea had its origin in service or is related to the Veteran’s active service, including his service in the Persian Gulf War. b. Whether it is at least as likely as not that any current sleep apnea was caused by the Veteran’s service-connected PTSD. c. Whether it is at least as likely as not that any current sleep apnea was aggravated beyond its natural progression by the Veteran’s service-connected PTSD. Although an independent review of the claims file is required, the Board calls the clinician’s attention to the following: a. The Veteran’s contentions in a statement VA received in March 2015 regarding his symptoms and their etiology. b. Articles the Veteran submitted in August 2015 regarding a possible relationship between PTSD and sleep apnea. c. VA treatment records from January 2018 noting a diagnosis of severe obstructive sleep apnea. The rationale for any opinion expressed should be provided. Note that a lack of documented treatment in service, while probative, cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 5. Ensure that the directives specified in this remand have been implemented. If they have not, appropriate corrective action must be undertaken before readjudication. Stegall v. West, 11 Vet. App. 268 (1998). (Continued on the next page) 6. Then, readjudicate the claims. If any decision is unfavorable to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Ryan Frank, 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.