Citation Nr: 22067477 Decision Date: 12/07/22 Archive Date: 12/07/22 DOCKET NO. 18-45 530 DATE: December 7, 2022 ORDER The petition to reopen a claim for service connection for an acquired psychiatric disorder is granted. The petition to reopen a claim for service connection for an eye disorder is granted. The petition to reopen a claim for service connection for a skin disorder is granted. The petition to reopen a claim for service connection for hyperlipidemia is granted. The petition to reopen a claim for service connection for gastroesophageal reflux disease (GERD) is granted. The petition to reopen a claim for service connection for a headache disorder is granted. Entitlement to service connection for allergic rhinitis is granted. Entitlement to service connection for chronic bronchitis is granted pursuant to the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxins Act of 2022 (PACT Act). Entitlement to service connection for hyperlipidemia is denied. Entitlement to service connection for a dental disorder for compensation purposes is denied. REMANDED Entitlement to a rating in excess of 10 percent for right knee osteoarthritis is remanded. Entitlement to a rating in excess of 10 percent for left knee osteoarthritis is remanded. Entitlement to a compensable rating for fracture of the right third long finger distal phalangeal tuft is remanded. Entitlement to service connection for chronic bronchitis based on a claim dated February 2, 2011 is remanded. Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for a skin disorder is remanded. Entitlement to service connection for an eye disorder is remanded. Entitlement to service connection for a fungal disorder on the feet is remanded. Entitlement to service connection for bilateral osteoarthritis of the elbows is remanded. Entitlement to service connection for GERD is remanded. Entitlement to service connection for rheumatoid arthritis is remanded. Entitlement to service connection for a headache disorder is remanded. FINDINGS OF FACT 1. In an unappealed June 2008 rating decision, the Agency of Original Jurisdiction (AOJ) denied the Veteran's claim for entitlement to service connection an acquired psychiatric disorder, an eye disorder, a skin disorder, hyperlipidemia, GERD, and a headache disorder; no new and material evidence was received within one year of the notification of that decision. 2. Subsequent to the June 2008 rating decision, evidence was associated with the claims file that is neither cumulative nor redundant of the evidence of record; relates to an unestablished fact; and raises a reasonable possibility of substantiating the Veteran's claims of entitlement to service connection for an acquired psychiatric disorder, an eye disorder, a skin disorder, hyperlipidemia, GERD, and a headache disorder. 3. The Veteran served in the southwest Asia theater of operations on or after August 2, 1990 and has diagnoses of chronic bronchitis and allergic rhinitis current during the period on appeal. 4. The Veteran's hyperlipidemia does not constitute a disability for VA benefits purposes. 5. The evidence is persuasively against finding that the Veteran had during the period on appeal a dental disability for which compensation is payable. CONCLUSIONS OF LAW 1. The June 2008 rating decision that denied entitlement to service connection for an acquired psychiatric disorder, an eye disorder, a skin disorder, hyperlipidemia, GERD, and a headache disorder is final. 38 U.S.C. §§ 7105, 7252. 2. As evidence received since the June 2008 final rating decision is new and material, the criteria to reopen the claims for service connection for an acquired psychiatric disorder, an eye disorder, a skin disorder, hyperlipidemia, GERD, and a headache disorder have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for entitlement to service connection for chronic bronchitis and allergic rhinitis have been met. 38 U.S.C. §§ 1110, 1119, 1120, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for entitlement to service connection for hyperlipidemia have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for entitlement to service connection for a dental disorder for compensation purposes have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.381, 4.150, 17.161. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1983 to March 1992, from March to August 2002, and from August 2004 to November 2005. He also had additional periods of active duty service. He served honorably in the U.S. Army, including service in southwest Asia from January to May 1991 and in Iraq and Kuwait from January to October 2005 during the Persian Gulf War. The Board thanks the Veteran for his service to our country. The Veteran testified before the undersigned at a Board videoconference hearing in February 2022. A transcript of the hearing is of record. The Board observes that the issue service connection for a dental disorder for the purposes of treatment was not addressed in the April 2013 rating decision denying service connection for compensation purposes. The regulation relating to service connection of dental conditions for treatment purposes was amended, effective February 29, 2012, in order to clarify existing regulatory provisions and to reflect the respective responsibilities of the Veterans Health Administration (VHA) and Veterans Benefits Administration (VBA) in determinations concerning eligibility for dental treatment. See Proposed Rules, Dental Conditions, 76 Fed. Reg. 14,600 (Mar. 17, 2011); Final Rule, Dental Conditions, 77 Fed. Reg. 4469 (Jan. 30, 2012). The amended version of 38 C.F.R. § 3.381 now clarifies that VBA will adjudicate a claim for service connection of a dental condition for treatment purposes after VHA determines that a veteran meets the basic eligibility requirements of 38 C.F.R. § 17.161 and requests that VBA make a determination on relevant questions. 38 C.F.R. § 3.381(a). Accordingly, the matter of service connection for outpatient dental treatment is referred to the AOJ for appropriate action. Service Connection Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303. To substantiate a claim of service connection, there must be evidence of: (1) a current disability; (2) a disease, injury, or event in service; and (3) a nexus or causal relationship between the claimed disability and the disease, injury, or event in service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the evidence is persuasively against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. The petition to reopen a claim for service connection for an acquired psychiatric disorder is granted. 2. The petition to reopen a claim for service connection for an eye disorder is granted. 3. The petition to reopen a claim for service connection for a skin disorder is granted. 4. The petition to reopen a claim for service connection for hyperlipidemia is granted. 5. The petition to reopen a claim for service connection for GERD is granted. 6. The petition to reopen a claim for service connection for a headache disorder is granted. Claims are to be reopened when new and material evidence is submitted. 38 U.S.C. § 5108. "New" evidence means existing evidence not previously submitted to agency decision-makers. "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110 (2010). In determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. For purposes of determining whether VA has received new and material evidence sufficient to reopen a previously denied claim, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510 (1992). Within one year of the June 2008 denial of service connection for an acquired psychiatric disorder, an eye disorder, a skin disorder, hyperlipidemia, GERD, and a headache disorder, the Veteran did not submit additional evidence or appeal the decision. As the Veteran did not appeal the denial of service connection and no new and material evidence was received within one year of the denial, the June 2008 rating decision is final. At the February 2022 hearing, the Veteran testified that a recurring skin rash on his back had its onset during Desert Storm. He testified that he had GERD in service and went to sick call in 1991, where he was given Pepto Bismol and milk of magnesia. He testified that during service, a piece of metal chipped off of a tank and hit his eye and that he has had pain since then. He testified that his headaches began after a motor vehicle accident in Iraq and that he continued to have headaches since then. With respect to functional impairment as a result of high cholesterol, he testified that he passed out during duty and was medevacked from Iraq because of chest pains. In a June 2017 mental health note, a PTSD psychologist rendered a diagnosis of PTSD, specifically noting that Criterion A was met. Accordingly, the Board finds that the additional evidence is neither cumulative nor redundant, and it is material since the evidence raises the possibility of substantiating the claims of service connection for an acquired psychiatric disorder, an eye disorder, a skin disorder, hyperlipidemia, GERD, and a headache disorder. See 38 C.F.R. § 3.156(a). As new and material evidence has been presented for the claims, they are reopened. 7. Entitlement to service connection for allergic rhinitis is granted. 8. Entitlement to service connection for chronic bronchitis is granted pursuant to the PACT Act. Service connection for allergic rhinitis is granted. Service connection for chronic bronchitis is granted pursuant to the PACT Act. Effective August 5, 2021, VA amended its regulations to establish a presumption of service connection for veterans who have a qualifying period of service and certain respiratory conditions (i.e., asthma, rhinitis and sinusitis, to include rhinosinusitis). See Presumptive Service Connection for Respiratory Conditions Due to Exposure to Particulate Matter, 86 Fed. Reg. 148, 42725 (Aug. 5, 2021). A qualifying period of service exists if a veteran served on active duty in the Southwest Asia theater of operations (i.e., Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations) during the Persian Gulf War or in Afghanistan, Syria, Djibouti or Uzbekistan on or after September 19, 2001 during the Persian Gulf War. Id. at 41,732-33 (to be codified at 38 C.F.R. § 3.320). A veteran who has a qualifying period of service is presumed to have been exposed to fine, particulate matter during such service unless there is affirmative evidence establishing that the veteran had no such exposure. Id. In addition, the revisions amended VA's duty to assist to require obtaining an examination or medical opinion if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim but establishes that a veteran suffered an event, injury or disease in service, or has a disease or symptoms of a disease listed in 38 C.F.R. §§ 3.309, 3.313, 3.316, 3.317, and 3.320 manifesting during an applicable presumptive period provided the claimant has the required service or triggering event to qualify for that presumption. Id. at 41,732 (to be codified at 38 C.F.R. § 3.159(c)(4)(i)(B)). On August 10, 2022, the President signed into law the Honoring our PACT Act of 2022 which, in relevant part, expands the presumptions of service connection for diseases associated with exposures to burn pits and other toxins. Pub. L. 117-168, 136 Stat. 1759 (2022) (to be codified under 38 U.S.C. § 1120). Under the Honoring our PACT Act, service connection may also be established for a covered veteran with a disease associated with exposure to burn pits and other toxins. Under this Act, any enumerated disease, including chronic bronchitis, becoming manifest in a covered veteran shall be considered to have been incurred in or aggravated during active military, naval, air, or space service even though there is no record of such disease during the period of such service. Honoring our PACT Act of 2022, sec. 406, § 1120. A covered veteran means any veteran who performed active military, naval, air, or space service while assigned to a duty station in enumerated countries, including Iraq and Kuwait, on or after August 2, 1990. Honoring our PACT Act of 2022, sec. 302, § 1119(c). The Board recognizes that a claim based on a liberalizing law is a new claim requiring no new and material evidence to reopen a previous, final denial that preceded the liberalizing law. See Spencer v. Brown, 17 F.3d 368 (1994). While the Honoring our PACT Act establishes phased in applicability dates for presumptions to assist veterans in establishing service connection for disabilities, including those associated with exposure to burn pits and other toxins, in a September 2022 Executive Decision Memorandum, the Secretary approved a recommendation which has the effect of eliminating the phased¬ in applicability dates for such presumptions. Therefore, the Board may immediately apply any presumptions associated with exposure to burn pits and other toxins, which it will now proceed to do. Here, the Veteran served in Iraq and Kuwait from January to October 2005. He carries a diagnoses or assessments of allergic rhinitis, first noted in December 1992, and chronic bronchitis current during the period on appeal. Accordingly, service connection for the disorders is granted. 9. Entitlement to service connection for hyperlipidemia is denied. The Veteran contends that service connection for hyperlipidemia is warranted as it had its onset in service. The Board finds that service connection is not warranted for hyperlipidemia. Numerous VA active problem lists during the period on appeal reflect that the Veteran's medical history includes hyperlipidemia. However, the Board finds that hyperlipidemia, or high levels of lipids in the blood, does not constitute a disability in its own right, but is akin to a laboratory finding. Cf. 61 Fed. Reg. 20440, 20,445 (May 7, 1996) (supplementary information preceding Final Rule amending the criteria for evaluating endocrine system disabilities indicates that diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory test results, and are not, in and of themselves, disabilities). In this regard, the evidence does not show that the Veteran's hyperlipidemia is manifested by symptoms, causes functional impairment, or impairs earning capacity. See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018) (holding that the term "disability" for VA compensation purposes refers to functional impairment of earning capacity); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (holding that pursuant to 38 C.F.R. § 4.1, the term disability "should be construed to refer to impairment of earning capacity due to disease, injury, or defect, rather than to the disease, injury, or defect itself"). The Board acknowledges the Veteran's testimony as to functional limitations resulting from his elevated cholesterol: specifically, he testified that he passed out during duty and was medevacked from Iraq because of chest pains. The Board notes that an August 1997 statement of medical examination and duty status notes chest pain incurred in the line of duty while the Veteran was on active duty for training. The provider noted that he had chest pain and brief loss of consciousness when eating at chow. Days later, a provider noted that the Veteran had a 15-minute episode with chest pain and shortness of breath. The provider noted a normal exam and noted increased cholesterolemia and increased triglycerides. In an October 2005 service treatment record, the provider noted that the Veteran was referred for evaluation of chest pain. The provider noted that he was taking medication for cholesterol but had run out of Fenofibrate. The provider rendered separate diagnoses of atypical chest pain and hyperlipidemia. With respect to atypical chest pain, the provider noted that extreme lipids are a cardiac risk factor but, noting "excellent quality study" ESE with no evidence of ischemia, concluded that the chest pain is highly unlikely to be from obstructive coronary artery disease despite the risk factors. With respect to hyperlipidemia, the provider relayed concern about the Veteran's poor lipid control and ability to make any intervention, as Fenofibrate was not available and different medication could be dangerous in the environment. Later that day, in medical evacuation patient record, the provider noted that Fenofibrate was not available in theater and that alternative medication was dangerous in the environment in combination with Zocor; accordingly, the Veteran should go to Walter Reed's lipid clinic for evaluation and reinitiation of medication. In a December 2005 note, a VA provider noted chest pain in Iraq which was thought related to stress or GERD. While the Veteran's increased cholesterol and hyperlipidemia were noted concurrent with notations of chest pain, there is no evidence suggesting that chest pain or syncope is a manifestation of elevated cholesterol. The Board notes that lipids are noted as a cardiac risk factor; however, a cardiac risk factor does not suggest causation; further, there is no evidence that the Veteran's episodes of chest pain were cardiovascular in origin: the August 1997 examination was normal and the October 2005 provider noted that chest pain was highly unlikely to be related to coronary artery disease. Finally, a VA provider noted that the chest pain was thought to be related to stress or GERD rather than to cholesterol or a cardiovascular disorder. In the absence of a current disability, the criteria for establishing service connection for hyperlipidemia are not satisfied. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.310. 10. Entitlement to service connection for a dental disorder for compensation purposes is denied. The Veteran generally contends that service connection is warranted for in service dental extractions and periodontal disease. The Board finds that service connection for a dental disorder for compensation purposes is not warranted. A claim of service connection for a dental disability is also considered a claim for VA outpatient dental treatment. Mays v. Brown, 5 Vet. App. 302, 306 (1993). In dental claims, the Regional Office (RO) adjudicates the claim for service connection and the VA Medical Center adjudicates the claim for outpatient treatment. As the current issue of service connection for a dental disability stems from an adverse determination by the RO, the dental issue addressed herein must be limited to service connection for compensation purposes only. In the VA benefits system, dental disabilities are treated differently than medical disabilities. Disability compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150, including chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible; loss of the mandible; nonunion or malunion of the mandible; limited temporomandibular motion; loss of the ramus; loss of the condyloid or coronoid processes; loss of the hard palate; and loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150. Furthermore, dental conditions such as treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service-connected solely for the purpose of establishing eligibility for outpatient dental treatment but will not be considered for compensation. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 4.150. However, impacted or malposed teeth, and other developmental defects, will not be considered service-connected for treatment purposes. 38 C.F.R. § 3.381(f)(4). Dental care can also be provided in cases where a dental disability is due to combat wounds or other service trauma. 38 U.S.C. § 1712; 38 C.F.R. § 3.381. In this case, there is no evidence of teeth extracted during the Veteran's initial period of active service. A March 2000 dental examination notes existing missing teeth 8 through 10, 30, and 31 and notes that a partial upper was present. A June 2004 periodic examination notes existing missing teeth 7 through 10, 30, and 31 and noted that treatment was needed for periodontal disease. There is no evidence of anatomical loss or bony injury of the mandible or the maxilla. Furthermore, in a November 2013 statement, the Veteran attributed the extraction of teeth to gingivitis and at the hearing, he denied trauma to the teeth or gums but attributed the extraction to gum disease. To the extent that the Veteran had teeth extracted in service and to the extent that he had periodontal disease current during the period on appeal, the evidence is persuasively against finding that the Veteran has loss of teeth due to loss of substance of body of the maxilla or mandible without loss of continuity. Because the Veteran is not shown to have one of the dental disorders listed under 38 C.F.R. § 4.150, a compensable dental condition is not shown. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Service connection of a dental disorder for compensation purposes is, therefore, denied. Gilbert, 1 Vet. App. at 55; 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent for right knee osteoarthritis is remanded. 2. Entitlement to a rating in excess of 10 percent for left knee osteoarthritis is remanded. 3. Entitlement to a compensable rating for fracture of the right third long finger distal phalangeal tuft is remanded. A remand is warranted for a VA examination. At a March 2018 DRO hearing, the Veteran testified with respect to his knees that he had limited range of motion, instability, and trouble walking distances. With respect to his right third finger disability, he testified that he had a tendency to drop things, had limited range of motion, and a weakened grip. At the February 2022 Board hearing, he again testified that he had limitation of motion and that his knees give out. He testified that his knees had changed dramatically since a 2013 VA examination, including increased limitation of motion. He testified that sometimes he could fully flex his finger but sometimes it would be really painful to move it. He testified that sometimes he would pick things up and drop them. He testified that he had less strength and endurance. As there is evidence that the service connected disabilities may have worsened since the last VA examination in April 2013, a remand is necessary. 4. Entitlement to service connection for chronic bronchitis based on a claim dated February 2, 2011 is remanded. While the Board herein granted entitlement to service connection for chronic bronchitis pursuant to the PACT Act, a remand is warranted based the February 2, 2011 claim as an etiology opinion is necessary. In this case, the Veteran has documented active duty service at Ground Zero of the World Trade Center and a diagnosis of bronchitis at this time. He also has service in Southwest Asia, as noted above. In a December 2002 statement, he relayed having exposures to oil fires and chemicals from a bunker explosion during Desert Storm as well as exposures during his service at Ground Zero, which caused him to have trouble breathing. An October 2003 VA treatment record notes chronic bronchitis from 1991 exacerbated following duties at the World Trade Center site. At the February 2022 hearing, the Veteran testified that he started having problems with his breathing about a week after 9/11. As there is evidence indicating that the disorder may be related to service, a remand is warranted for an etiology opinion. 5. Entitlement to service connection for diabetes mellitus is remanded. 6. Entitlement to service connection for an acquired psychiatric disorder is remanded. 7. Entitlement to service connection for a skin disorder is remanded. 8. Entitlement to service connection for an eye disorder is remanded. 9. Entitlement to service connection for a fungal disorder on the feet is remanded. 10. Entitlement to service connection for bilateral osteoarthritis of the elbows is remanded. 11. Entitlement to service connection for GERD is remanded. 12. Entitlement to service connection for rheumatoid arthritis is remanded. 13. Entitlement to service connection for a headache disorder is remanded. Remands are necessary to afford the Veteran examinations for his disorders and obtain opinions as to their natures and etiologies. In an October 2003 treatment note, the Veteran reported a history of GERD from 1991 and rashes from 1991. At the February 2022 Board hearing, the Veteran testified that he first had fungus on his feet during Desert Storm. He testified that he had been prescribed a medication to put on his feet since then. He testified that a rash on his back also started during Desert Storm. He testified that severe heartburn started in 1991 during Desert Storm. He testified that he was diagnosed with rheumatoid arthritis in 2018 but that he had felt symptoms since returning from Iraq following a September 2005 motor vehicle accident. He testified that he injured his elbows in a motor vehicle accident and that his headaches began after the accident. As there are indications that the Veteran's GERD, fungus on the feet, skin rash, rheumatoid arthritis, elbow osteoarthritis, and a headache disorder may be related to service, an examination is necessary. With respect to service connection for diabetes, the Board observes that in an undated private medical record, a provider stated that, while the cause of diabetes is unknown, the tendency toward having it is partly inherited and that other factors include obesity. A May 2016 VA record notes that the Veteran's calculated BMI classification is obesity and that he was informed that being overweight is associated with health risks including diabetes. The Board further observes that an October 2003 VA treatment record noted that exercise was limited by knee weakness and that an October 2005 service treatment record noted that the Veteran was on a permanent profile for his knees and did not do physical training. Later, in an April 2013 knee examination, the Veteran reported that his condition had progressively worsened and that he had pain with prolonged standing, walking, climbing, squatting, and running. In a November 2013 statement, he relayed having limited standing and being unable to run due to his knee. As there is an indication that the Veteran's overweight/obesity may be related to his service connected knee disabilities and that his diabetes may be related to his overweight/obesity, an addendum opinion on obesity as an intermediate step is necessary. With respect to an eye disorder, in an April 2013 VA examination report, the examiner noted a diagnosis of macular drusen and concluded that it is less likely than not aggravated by service as drusen formation is likely genetic and not caused by ocular foreign body. The examiner also stated that it is possible that the drusen formed during service. However, the examiner did not identify whether the drusen is a congenital defect or disease; accordingly, a remand is necessary. Finally, with respect to an acquired psychiatric disorder, as noted above, in a June 2017 mental health note, a VA PTSD psychologist rendered a diagnosis of PTSD, specifically noting that Criterion A was met. However, the psychologist did not address whether the Veteran's symptoms were related to the claimed stressor or whether the stressor is related to a fear of hostile military or terrorist activity. Furthermore, as the Veteran's claimed stressor is a non-combat stressor, verification is required but there has been no attempt to develop and/or verify the Veteran's stressor. A remand is additionally necessary to associate outstanding records with the record. In a claim received in February 2006, the Veteran indicated that he was treated for a skin rash and headaches at a VAMC in Brooklyn, NY in 1993 and 1995, respectively. At the March 2018 DRO hearing, the Veteran testified that he was first diagnosed with GERD in 1994 or 1995 in Watertown, New York and afterward treated at the Manhattan VAMC. Further, in a November 2013 statement, the Veteran relayed that a private chiropractor told him that his headaches were possibly related to back pain and identified the practice. Accordingly, a remand is necessary to attempt to secure these private records. The Board makes no credibility determinations at this time. The matters are REMANDED for the following action: 1. Please secure for the record copies of complete updated clinical records (any not already of record) of all VA and non-VA treatment the Veteran has received for the disabilities on appeal. (a.) Please ask the Veteran to provide the releases necessary for VA to secure private treatment records, including A.H.C. as relayed by the Veteran in the November 21, 2013 Form 9. (b.) Please attempt to obtain VA treatment records from the Brooklyn and Manhattan VA treatment centers from 1993 to 1995 and document all requests for information as well as all responses in the claims file. 2. Please perform any necessary development to corroborate the Veteran's reported in service stressor, the death of a friend in Iraq. 3. After the action requested in paragraph 1 is complete, please schedule the Veteran for an examination to assess the current severity of his left and right knee disabilities and right third finger disability. The Veteran's claims-file must be made available to and reviewed by the examiner. Any indicated tests or studies should be conducted. Please indicate what the severity of the Veteran's service connected disabilities might be when discounting the ameliorative effects of medication. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The examiner should take into consideration that the Veteran is competent to report in service and post-service symptom experiences; other witnesses are competent to report observable symptoms. If the examiner cannot provide an opinion without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 4. After the action requested in paragraphs 1 and 2 are complete, please refer the claim to an appropriate clinician for an addendum opinion as to the nature and etiology of the Veteran's chronic bronchitis. The Veteran's claims-file must be made available to and reviewed by the clinician. The clinician is requested to respond to the following: a. Is the Veteran's chronic bronchitis at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service, to include service in Southwest Asia and at Ground Zero following 9/11? The clinician is requested to consider and address as appropriate the following: A January 21, 2002 treatment record noting that the Veteran was assigned to a team at the World Trade Center and noting a diagnosis of bronchitis. See Medical Treatment Record Government Facility received 2/16/06, pgs. 60, 62 of 132. The Veteran had Southwest Asia service from 1/3/91 to 5/20/91 and service in Iraq and Kuwait from 1/7/05 - 10/8/05. A December 2002 statement, in which the Veteran relayed having exposures to oil fires and chemicals from a bunker explosion during Desert Storm as well as exposures during his service at Ground Zero, which caused him to have trouble breathing. See 21 0781 received 12/5/02. An October 16, 2013 VA record noting chronic bronchitis from 1991 exacerbated following duties at the World Trade Center site. See Medical Treatment Record Government Facility received 1/07/04, pg. 18 of 121. At the February 2022 hearing, the Veteran testified that he started having problems with his breathing about a week after 9/11. b. Is the Veteran's bronchitis, alone, or when considered in combination with the Veteran's other disabilities, a medically unexplained chronic multisystem illness (MUCMI)? Please explain and address: (i) Is the Veteran's bronchitis without conclusive pathophysiology? (ii) Is the Veteran's bronchitis without conclusive etiology? (iii) Does the Veteran's sleep apnea have features such as fatigue, pain, disability out of proportion to physical findings, and/or inconsistent demonstration of laboratory abnormalities? Please note that chronic multisystem illnesses with partially understood etiology and pathophysiology are not considered MUCMIs. The clinician is advised that there is no legal requirement that the in-service event or injury must be the sole cause of the disorder claimed. The clinician must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The clinician should take into consideration that the Veteran is competent to report in service and post-service symptom experiences; other witnesses are competent to report observable symptoms. If the clinician cannot provide an opinion without resorting to speculation, the clinician should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 5. After the actions requested in paragraphs 1 and 2 are complete, please schedule the Veteran for examinations as to the nature and etiology of the GERD, fungus on the feet, skin rash, rheumatoid arthritis, elbow osteoarthritis, and headache disorders. The Veteran's claims-file must be made available to and reviewed by the examiner. Any indicated tests or studies should be conducted. The examiner(s) is requested to respond to the following: With respect to GERD: (a.) Is the Veteran's GERD at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service? In providing an opinion, please consider and address whether the Veteran's testimony of severe heartburn started in 1991 during Desert Storm, a December 8, 1992 report of medical history denying frequent indigestion, and a February 12, 2000 report of medical history endorsing frequent indigestion are consistent with how GERD is known to develop. (b.) Is the Veteran's GERD, alone, or when considered in combination with the Veteran's other disabilities, a medically unexplained chronic multisystem illness (MUCMI)? Please explain and address: (i) Is the Veteran's GERD without conclusive pathophysiology? (ii) Is the Veteran's GERD without conclusive etiology? (iii) Does the Veteran's GERD have features such as fatigue, pain, disability out of proportion to physical findings, and/or inconsistent demonstration of laboratory abnormalities? Please note that chronic multisystem illnesses with partially understood etiology and pathophysiology are not considered MUCMIs. With respect to a fungus on the feet: (c.) Is the Veteran's fungus on the feet at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service? In providing an opinion, please consider and address whether the Veteran's testimony that he first had fungus on the feet in 1991 during Desert Storm and had been prescribed medication for his feet since then is consistent with how the fungus is known to develop. (d.) Is the Veteran's fungus of the feet, alone, or when considered in combination with the Veteran's other disabilities, a medically unexplained chronic multisystem illness (MUCMI)? Please explain and address: (i) Is the Veteran's fungus of the feet without conclusive pathophysiology? (ii) Is the Veteran's fungus of the feet without conclusive etiology? (iii) Does the Veteran's fungus of the feet have features such as fatigue, pain, disability out of proportion to physical findings, and/or inconsistent demonstration of laboratory abnormalities? Please note that chronic multisystem illnesses with partially understood etiology and pathophysiology are not considered MUCMIs. With respect to a skin disorder: (e.) Please identify all skin rashes and disorders of the chest, arms, and back current during the period on appeal. (f.) For each disorder identified, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service? In providing an opinion, please address whether, the Veteran's lay statements as to the onset and recurrence of the disorder is consistent with how the disorder is known to develop. The examiner is requested to consider the following: At a March 30, 2018 hearing, the Veteran testified that he thought his skin disorder was diagnosed in 1994 or 1995 and that he has experienced it once or twice each year since returning from Desert Storm. The Veteran testified in February 2022 that the rash on his back started during Desert Storm and that he sought treatment but it could not be identified and he was given hydrocortisone. He testified that it went away but later progressed and that he went back to the doctor around 1994, where he was prescribed antibiotics. (g.) Is any identified skin disorder, alone, or when considered in combination with the Veteran's other disabilities, a medically unexplained chronic multisystem illness (MUCMI)? Please explain and address: (i) Is any identified skin disorder without conclusive pathophysiology? (ii) Is any identified skin disorder without conclusive etiology? (iii) Does any identified skin disorder have features such as fatigue, pain, disability out of proportion to physical findings, and/or inconsistent demonstration of laboratory abnormalities? Please note that chronic multisystem illnesses with partially understood etiology and pathophysiology are not considered MUCMIs. With respect to rheumatoid arthritis: (h.) Is the Veteran's rheumatoid arthritis at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service? The examiner is requested to consider the Veteran's testimony that he has felt symptoms since returning from Iraq. (i.) Is the Veteran's rheumatoid arthritis, alone, or when considered in combination with the Veteran's other disabilities, a medically unexplained chronic multisystem illness (MUCMI)? Please explain and address: (i) Is the Veteran's rheumatoid arthritis without conclusive pathophysiology? (ii) Is the Veteran's rheumatoid arthritis without conclusive etiology? (iii) Does the Veteran's rheumatoid arthritis have features such as fatigue, pain, disability out of proportion to physical findings, and/or inconsistent demonstration of laboratory abnormalities? Please note that chronic multisystem illnesses with partially understood etiology and pathophysiology are not considered MUCMIs. With respect to bilateral elbow osteoarthritis: (j.) Is the Veteran's bilateral elbow osteoarthritis at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service, to include a motor vehicle accident? The examiner is requested to consider the following: September 26, 2005 service treatment records noting the Veteran's complaint that he hurt his elbows, noting that he had been in a motor vehicle accident when his 5 ton truck skid into and rear ended another 5 ton truck, and noting that he was sent to his quarters for 24 hours. In a December 19, 2005 VA note, the Veteran complained of pain in both elbows for the past 4 months when picking something up. (k.) Is the Veteran's bilateral elbow osteoarthritis, alone, or when considered in combination with the Veteran's other disabilities, a medically unexplained chronic multisystem illness (MUCMI)? Please explain and address: (i) Is the Veteran's bilateral elbow osteoarthritis without conclusive pathophysiology? (ii) Is the Veteran's bilateral elbow osteoarthritis without conclusive etiology? (iii) Does the Veteran's bilateral elbow osteoarthritis have features such as fatigue, pain, disability out of proportion to physical findings, and/or inconsistent demonstration of laboratory abnormalities? Please note that chronic multisystem illnesses with partially understood etiology and pathophysiology are not considered MUCMIs. With respect to a headache disorder: (l.) Is the Veteran's headache disorder at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service, to include a motor vehicle accident? The examiner is requested to consider the following: In a December 19, 2005 VA note, the Veteran reported getting a headache behind the right eye for about one month which was relieved with Tylenol or by lying down. A February 3, 2009 VA record noting that the headache sounded like a migraine. The Veteran's February 2022 testimony that headaches began after the accident in Iraq and that he was given Motrin when he went to sick call. A September 26, 2019 VA note in which the Veteran reported the 2005 motor vehicle accident and relayed being disoriented with a headache and immediate back pain and the provider concluded that, based on the history of the injury and the course of clinical symptoms, the Veteran sustained a TBI during OEF/OIF/OND deployment. (m.) Is the Veteran's headache disorder, alone, or when considered in combination with the Veteran's other disabilities, a medically unexplained chronic multisystem illness (MUCMI)? Please explain and address: (i) Is the Veteran's headache disorder without conclusive pathophysiology? (ii) Is the Veteran's headache disorder without conclusive etiology? (iii) Does the Veteran's headache disorder have features such as fatigue, pain, disability out of proportion to physical findings, and/or inconsistent demonstration of laboratory abnormalities? Please note that chronic multisystem illnesses with partially understood etiology and pathophysiology are not considered MUCMIs. To the extent that the Veteran's reported in service treatment is not documented in his service treatment records (to include reported visits during his first tour of duty in Southwest Asia in 1991), the examiner is advised that complete service treatment records are unavailable and that no service treatment records from his deployment during Desert Storm have been associated with the record. For the purposes of rendering an opinion, the examiner should accept as fact the Veteran's reports of in service treatment during his 1991 Desert Storm deployment. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The examiner should take into consideration that the Veteran is competent to report in service and post-service symptom experiences; other witnesses are competent to report observable symptoms. If the examiner cannot provide an opinion without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 6. After the actions requested in paragraphs 1 and 2 are complete, please schedule the Veteran for an examination as to the nature and etiology of the Veteran's diabetes. The Veteran's claims-file must be made available to and reviewed by the examiner. Any indicated tests or studies should be conducted. The examiner is requested to respond to the following: (a.) Is the Veteran's obesity at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) caused by service-connected disabilities, to include the Veteran's service connected knee disabilities? (b.) Is the Veteran's obesity at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) aggravated by service-connected disabilities, to include the Veteran's service connected knee disabilities? (c.) If the answer to either (a.) or (b.) above is yes, is the Veteran's obesity at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) a substantial factor in causing his diabetes? (d.) If the answer to either (a.) or (b.) above is yes, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the diabetes would not have occurred but for obesity caused or aggravated by the service-connected disabilities? The examiner is requested to consider the following: A May 23, 2016 VA record notes that the Veteran's calculated BMI classification is obesity and that he was informed that being overweight is associated with health risks including diabetes. An October 16, 2003 VA treatment record noted that exercise was limited by knee weakness. An October 6, 2005 service treatment record noted that the Veteran was on a permanent profile for his knees and did not do physical training. In an April 19, 2013 knee examination, the Veteran reported that his condition had progressively worsened and that he had pain with prolonged standing, walking, climbing, squatting, and running. In a November 21, 2013 statement, the Veteran relayed having limited standing and being unable to run due to his knee. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The examiner should take into consideration that the Veteran is competent to report in service and post-service symptom experiences; other witnesses are competent to report observable symptoms. If the examiner cannot provide an opinion without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 7. After the actions requested in paragraphs 1 and 2 are complete, please schedule the Veteran for an examination as to the nature and etiology of the macular drusen. The Veteran's claims-file must be made available to and reviewed by the examiner. Any indicated tests or studies should be conducted. The examiner is requested to respond to the following: (a.) Is macular drusen, noted in the April 2013 VA examination report, a congenital disease or a congenital defect? A "congenital disease" is capable of improvement or deterioration. A "congenital defect" is more or less stationary in nature, and is generally incapable of improvement or deterioration. (b.) If macular drusen is a congenital defect, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any additional disability superimposed on macular drusen is a result of his in service right eye irritation secondary to a foreign body? (c.) If macular drusen is a congenital disease, (1) Is it clearly and unmistakably (obvious, manifest, undebatable) not aggravated beyond its natural progress during or as a result of service? (2) Alternatively, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that it first manifested in service? The examiner is requested to consider and address as appropriate October 31, 1990 service treatment records documenting a foreign body in the Veteran's right eye. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The examiner should take into consideration that the Veteran is competent to report in service and post-service symptom experiences; other witnesses are competent to report observable symptoms. If the examiner cannot provide an opinion without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 8. After the actions requested in paragraphs 1-3 are complete, please schedule the Veteran for an examination as to the nature and etiology of the acquired psychiatric disorder. The Veteran's claims-file must be made available to and reviewed by the examiner. Any indicated tests or studies should be conducted. The examiner is requested to respond to the following: (a.) Please identify all psychiatric disorders current during the period on appeal. (b.) For each psychiatric disorder, is the Veteran's disorder at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to service? The examiner is requested to consider and address as appropriate the following: A December 5, 2002 VAF 21-0781. An April 15, 2009 mental health E&M consultation in which the Veteran reported restless sleep since returning from Desert Storm which increased due to job loss and, while denying a history of domestic violence, he reported that there was an angry side of him since Iraq. A June 23, 2011 VAF 21-0781 and accompanying VAF 21-4138. A September 26, 2011 VA examination report in which the examiner noted that the Veteran was a reliable historian but concluded in an October 27, 2011 addendum that the DSM-IV criteria for PTSD were not met. A June 27, 2017 mental health note, in which a VA PTSD psychologist rendered a diagnosis of PTSD based on CAPS-5. The Veteran's February 2022 testimony. During the Veteran's second period of Southwest Asia service, he received hostile fire/imminent danger pay. As a heavy vehicle driver, his daily duties included organizing and participating in convoys and his appointed duties included participating in combat logistical patrols and performing force protection. He was noted to have completed more than 50 convoys and traveled more than 7000 miles during OIF. (c.) Is the Veteran's psychiatric disorder, alone, or when considered in combination with the Veteran's other disabilities, a medically unexplained chronic multisystem illness (MUCMI)? Please explain and address: (i) Is the Veteran's psychiatric disorder without conclusive pathophysiology? (ii) Is the Veteran's psychiatric disorder without conclusive etiology? (iii) Does the Veteran's psychiatric disorder have features such as fatigue, pain, disability out of proportion to physical findings, and/or inconsistent demonstration of laboratory abnormalities? Please note that chronic multisystem illnesses with partially understood etiology and pathophysiology are not considered MUCMIs. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The examiner should take into consideration that the Veteran is competent to report in service and post-service symptom experiences; other witnesses are competent to report observable symptoms. If the examiner cannot provide an opinion without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Vashaw, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.