Citation Nr: 22055779 Decision Date: 09/30/22 Archive Date: 09/30/22 DOCKET NO. 17-48 280A DATE: September 30, 2022 ORDER The appeal with respect to entitlement to a disability rating in excess of 30 percent for irritable bowel syndrome is dismissed. The previously denied claim of entitlement to service connection for a sinus disorder is reopened. Service connection for chronic sinusitis and allergic rhinitis is granted. The previously denied claim of entitlement to service connection for gastroesophageal reflux disease (GERD), originally claimed as dyspepsia, is reopened. Service connection for GERD is granted. The previously denied claim of entitlement to service connection for hysterectomy, originally claimed as fibroid tumors, is reopened; to this limited extent, the appeal of that issue is granted. Service connection for an acquired psychiatric disability, diagnosed as posttraumatic stress disorder (PTSD) and adjustment disorder with mixed anxiety and depression, is granted. Service connection for alopecia (hair loss) is granted. REMANDED Entitlement to service connection for hysterectomy is remanded. Entitlement to service connection for a disorder claimed as herpes zoster (shingles) and/or herpes simplex is remanded. FINDINGS OF FACT 1. By correspondence received in April 2022, prior to the promulgation of an appellate decision on the matter, the Veteran indicated that she wished to withdraw her appeal with respect to entitlement to a disability rating in excess of 30 percent for irritable bowel syndrome. 2. The Veteran's claims of entitlement to service connection for a sinus condition, dyspepsia, and fibroid tumors were last denied in a June 2001 rating decision, which became final. 3. Evidence received since the June 2001 rating decision is not cumulative or redundant of the evidence previously of record and raises a reasonable possibility of substantiating the claims for service connection for a sinus condition, GERD, and hysterectomy (previously claimed as fibroid tumors). 4. The evidence reasonably establishes the occurrence of stressors related to an in-service personal assault. 5. It is at least as likely as not that the Veteran has PTSD that is related to corroborated in-service stressors. 6. It is at least as likely as not that the Veteran's adjustment disorder with mixed anxiety and depression is secondary to her service-connected irritable bowel syndrome. 7. It is at least as likely as not that the Veteran's GERD and alopecia are secondary to her psychiatric disability, diagnosed as PSTD and adjustment disorder with anxiety and depression. 8. It is at least as likely as not that the Veteran's claimed sinus disorder, diagnosed as allergic rhinitis and chronic sinusitis, is related to service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal of the issue of entitlement to a disability rating in excess of 30 percent for irritable bowel syndrome have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The June 2001 rating decision denying service connection for a sinus condition, dyspepsia, and fibroid tumors is final. 38 U.S.C. § 7105 (2000); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103 (2000). 3. New and material evidence has been received to reopen the claim of entitlement to service connection for a sinus disorder. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 4. New and material evidence has been received to reopen the claim of entitlement to service connection for GERD. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 5. New and material evidence has been received to reopen the claim of entitlement to service connection for hysterectomy, previously claimed as fibroid tumors. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 6. Resolving reasonable doubt in the Veteran's favor, the criteria for an award of service connection for PTSD and adjustment disorder with mixed anxiety and depression have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 7. Resolving reasonable doubt in the Veteran's favor, the criteria for an award of service connection for GERD have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 8. Resolving reasonable doubt in the Veteran's favor, the criteria for an award of service connection for alopecia have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 9. Resolving reasonable doubt in the Veteran's favor, the criteria for an award of service connection for chronic sinusitis and allergic rhinitis have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from July 1979 to December 1987. These matters come to the Board of Veterans' Appeals (Board) on appeal from December 2013 and December 2017 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office. In April 2022, the Veteran testified at a virtual Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. The Board notes that the Veteran submitted a VA Form 20-0996 (Decision Review Request: Higher-Level Review)) in July 2022, in response to a September 2021 rating decision that determined that no new and relevant evidence had been submitted to warrant readjudication of the claim for service connection for a sinus disorder. It appears that the agency of original jurisdiction (AOJ) is currently conducting additional development on this issue in response to the Veteran's VA Form 20-0996, despite the legacy appeal pending before the Board. See September 2022 rating decision ("The issue of sinus condition was returned for correction of a duty to assist error in the prior decision. We failed to get an examination(s) and/or medical opinion(s). We will develop for VA exam and medical opinion."). However, the Veteran had previously submitted a timely legacy notice of disagreement (VA Form 21-0958) with the December 2013 rating decision that reopened and disallowed the previously denied claim for service connection for a sinus disorder. Because the Veteran perfected her appeal of this issue to the Board from a rating decision entered prior to February 19, 2019 (the effective date of the Appeals Improvement and Modernization Act of 2017 (AMA)), and she has not indicated that it is her intent to opt into the AMA from a statement of the case (SOC) issued on or after February 19, 2019, the legacy appeal has not been withdrawn and is properly before the Board for appellate consideration. 1. The appeal with respect to entitlement to a disability rating in excess of 30 percent for irritable bowel syndrome is dismissed. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. Id. Appeal withdrawals must include the name of the veteran, the name of the claimant or appellant if other than the veteran (e.g., a veteran's survivor, a guardian, or a fiduciary appointed to receive VA benefits on an individual's behalf), the applicable VA file number, and a statement that the appeal is withdrawn. If the appeal involves multiple issues, the withdrawal must specify that the appeal is withdrawn in its entirety or list the issue(s) withdrawn from the appeal. Id. By correspondence received in April 2022, prior to the promulgation of an appellate decision, the Veteran's representative indicated that the Veteran wished to withdraw the appeal with respect to entitlement to a disability rating in excess of 30 percent for irritable bowel syndrome. The correspondence included her name and VA file number. Under the circumstances, the Board finds that the requirements for a proper withdrawal have been satisfied. As the Veteran, through her representative, has withdrawn the appeal of this issue, there remain no allegations of error of fact or law for appellate consideration as to this issue. Accordingly, the appeal with respect to entitlement to a disability rating in excess of 30 percent for irritable bowel syndrome must be dismissed. 2. The previously denied claim of entitlement to service connection for a sinus disorder is reopened. 3. The previously denied claim of entitlement to service connection for GERD, originally claimed as dyspepsia, is reopened. 4. The previously denied claim of entitlement to service connection for hysterectomy, originally claimed as fibroid tumors, is reopened. The Veteran's claims for service connection for a sinus condition, dyspepsia (claimed as an ulcer), and fibroid tumors were first denied in a December 1999 rating decision. Following the issuance of a letter pursuant to the Veterans' Claims Assistance Act of 2000, with no response from the Veteran, the claims were again denied in June 2001 on the basis that "[t]here was no record of a sinus condition or fibroid tumors" and that the "noted evidence failed to establish any relationship between [] dyspepsia [] and any disease or injury during military service." June 2001 rating decision. The Veteran did not appeal the June 2001 decision within a year. Nor was any new and material evidence received within that time. As a result, that decision became final. 38 U.S.C. § 7105 (2000); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103 (2000). Accordingly, the Board must make an initial determination as to the threshold issue of whether new and material evidence has been received to reopen the claims. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Evidence is considered "new" if it was not previously submitted to agency decision makers. "Material" evidence is 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. 38 C.F.R. § 3.156(a). For purposes of determining whether new and material evidence has been received, the credibility of the evidence is to be presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992); Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King v. Brown, 5 Vet. App. 19, 21 (1993). Here, the evidence received since the time of the June 2001 rating decision includes, among other things, evidence of a current diagnosis of sinusitis and hysterectomy, as well as a private medical opinion linking GERD and sinusitis to service, and the Veteran's statements regarding the presence of fibroids, which is the purported basis for her hysterectomy, in service. See, e.g., February 2018 VA treatment record (sinusitis); August 2017 private treatment record ("Hysterectomy; Date: August 1, 1989 (Severe Fibroid Tumors)"; April 2022 private medical opinion from S.B., M.D., PhD. (providing favorable nexus opinions regarding sinusitis and GERD); April 2022 Board hearing transcript, pp. 32-34 (discussing the onset of fibroid symptoms). The Board concludes that this evidence is new, in that it was not before the AOJ when the Veteran's claims were previously denied. It is also material in that it relates to unestablished facts necessary to substantiate the claims (i.e., that of a current disability and a nexus to service), and, presuming its credibility for new and material evidence purposes, raises a reasonable possibility of substantiating the claims. See, e.g., Shade v. Shinseki, 24 Vet. App. 110 (2010). Accordingly, the claims for service connection for a sinus disorder, GERD, and hysterectomy (previously adjudicated as fibroid tumors) are reopened. 5. Service connection for an acquired psychiatric disability, including PTSD and adjustment disorder with mixed anxiety and depression, is granted. The Veteran maintains that she should be service connected for PTSD due to in-service stressors, some of which are based on in-service personal assault. She has cited several stressors, including two military sexual assaults, as well as an attack on two female servicemembers (resulting in one fatality) who were well-known to her. Because she has two psychiatric diagnoses, the Board will address each diagnosis separately under the governing regulations. Turning first to the requirements for establishing service connection for PTSD, service connection requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). If a PTSD claim is based on in-service personal assault, evidence from sources other than a veteran's service records may corroborate the veteran's account of the stressor incident. 38 C.F.R. § 3.304(f)(5). Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Id. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Id. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. Id. The Board notes that VA has updated references in its regulations to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). See 38 C.F.R. § 4.125(a). The provisions of the final rule apply to all applications for benefits that are received by VA or that are pending before the AOJ on or after August 4, 2014. See Schedule for Rating Disabilities Mental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14,308 (March 19, 2015). Regarding the first element under 38 C.F.R. § 3.304(f), the Board finds that the evidence establishes that the Veteran has a current diagnosis of PTSD. See April 2022 Disability Benefits Questionnaire (DBQ) and private medical opinion by Dr. A.B., PsyD. See also Cohen v. Brown, 10 Vet. App. 128, 140 (1997) ("[A] clear (that is, unequivocal) PTSD diagnosis by a mental-health professional must be presumed (unless evidence shows to the contrary) to have been made in accordance with the applicable DSM criteria as to both the adequacy of the symptomatology and the sufficiency of the stressor."). Thus, this element has been satisfied. Regarding the second element, there is also evidence in the record which tends to corroborate the Veteran's stressor. In this regard, the April 2022 private psychologist evaluated the Veteran and found the presence of military sexual trauma markers following the claimed stressors. These markers included, but are not limited to, the Veteran's "self-reported lowered performance valuations starting after the first incident of [military sexual trauma]." Other potential markers identified included the Veteran's development of a variety of gastro-intestinal symptoms and entering into an emotionally abusive relationship with her husband shortly after experiencing the traumatic stressors. See April 2022 private opinion ("Research have shown that a prior history of abuse may lead someone to enter a repetitive abusive cycle and may chose relationship with abusive partners."). The Board has reviewed the Veteran's personnel records and there indeed was a marked decline in her performance evaluations following the claimed stressors of being sexually assaulted. Notably, there was a marked and steady decline in her performance evaluations from 1986 onward, ultimately leading to the Veteran not being recommended for reenlistment. See service personnel records (contrasting positive performance reviews for the first period of service with her poor performance reviews in her later years in the military). Additionally, the Veteran's abusive relationship with her husband is also well documented in VA treatment reports and is consistent with the identified marker identified by the April 2022 private psychologist. See September 2018 VA treatment report (emphasis added); see also Menegassi v. Shinseki, 638 F.3d 1379, 1382, (Fed. Cir.2011), (under § 3.304(f)(5), medical opinion evidence may be submitted for use in determining whether the occurrence of a personal assault stressor is corroborated); Patton v. West, 12 Vet. App. 272, 277 (1999) (holding that Moreau v. Brown, 9 Vet. App. 389 (1996), is not applicable to cases of alleged personal assault); 38 C.F.R. § 3.304(f)(5) (indicating that VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred). Given the Veteran's consistent and credible reporting of her personal assault stressors, the supporting evidence of behavioral changes in the form of poor performance evaluations and entering into an abusive relationship with her husband, as well as VA treatment records discussing the occurrence of a military sexual trauma, the Board finds that the stressor is sufficiently corroborated under 38 C.F.R. § 3.304(f)(5). Turning to the third and final element needed to establish service connection, that of a causal connection to service, the April 2022 private examiner linked the Veteran's DSM-5 diagnosis of PTSD to her claimed stressors. This evidence establishes the necessary link. In light of the evidence supporting the occurrence of an in-service stressors based on personal assault, a diagnosis of PTSD, and a link between the PTSD symptoms and in-service stressors, the Board finds that service connection is warranted. The evidence, at a minimum, gives rise to a reasonable doubt on the matter. 38 C.F.R. § 3.102. The appeal with respect to service connection for PTSD is granted. In regard to psychiatric disorders other than PTSD, as to secondary service connection, VA regulations provide that establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Here, the Board notes that the Veteran has a separate DSM-5 diagnosis of adjustment disorder with mixed anxiety and depression. See April 2022 private medical opinion. Additionally, she is service connected for irritable bowel syndrome. In ascertaining whether there is any relationship between the Veteran's adjustment disorder with anxiety and depression and IBS, the Board notes that no VA psychiatric or psychological examination or opinion has been sought in this appeal. In April 2022, however, a private mental health professional evaluated the Veteran. See April 2022 DBQ and private medical opinion. As a result of that psychiatric evaluation, the private examiner, A.B., PsyD., concluded, "It is my professional opinion that the Veteran's Adjustment Disorder with mixed anxiety and depression, chronic, is at least as likely as not (50% or greater probability) caused by her service-connected condition (IBS)." The private examiner explained that "the Veteran continued to have difficulty adjusting to or coping with the stress related to living with a chronic health condition (IBS)." In that regard, it was reported that the Veteran stated she had "experienced decades of a constant cycle of bathroom breaks and embarrassing soiling of [her] clothing." The private examiner further explained that "[t]he chronic nature of this condition remains stressful, continues to affect her quality of life, and impacts her mental health." Given the favorable medical nexus evidence in the record that the Veteran's adjustment disorder with anxiety and depression is related to her service-connected IBS, the Board finds that service connection is warranted on a secondary basis. Accordingly, the appeal with respect to service connection for an adjustment disorder with anxiety and depression is also granted. 6. Service connection for GERD is granted. The Veteran primarily asserts that her GERD is caused and aggravated by stress stemming from service. See April 2022 Board hearing transcript, p. 27 (asserting that her provider has told her that her GERD symptoms are linked to stress). As an initial matter, the Board notes that the Veteran has been diagnosed with GERD. See November 2013 VA examination report; April 2022 private opinion. Also, as discussed in detail above, she is now service connected for an acquired psychiatric disorder, diagnosed as PTSD and adjustment disorder with anxiety and depression. In ascertaining whether there is a relationship between the Veteran's GERD and her now service-connected psychiatric disorders, the Board notes that a VA examination was provided to the Veteran in November 2013. The examiner at that time concluded there was no causal connection with service. By way of rationale, the November 2013 VA examiner explained, "I do not find the evidence in the service medical record to support her verbal claim that GERD and gastritis are due to military service beyond speculation." This opinion is rather conclusory in that it does not address the Veteran's in-service and post-service complaints documented in the record. Additionally, because service connection for a psychiatric disorder had not yet been established, it does it address the likelihood that the Veteran's GERD may have been caused or aggravated by her PTSD and adjustment disorder with anxiety and depression. In April 2022, a private doctor reviewed the evidence of record and evaluated the Veteran. See April 2022 private medical opinion by S.B., M.D., PhD. The private examiner concluded that the Veteran's GERD "is a result and is exacerbated by her cognitive illness." The examiner explained: N]umerous reports in the literature show an interplay in the psychological stress and release of cortisol which may cause release of elevated gastric secretions. There is established research showing GERD is commonplace in Veterans and abnormal cortisol levels have been shown repeatedly to have a strong nexus to the release of gastritis and GERD[]. Years of abnormal cognitive stress indeed had a strong influence on the development of this Veteran's GERD . . . and in my medical opinion this Veterans' GERD is at least as likely as not secondary to her [major depressive disorder] and PTSD." See April 2022 private medical opinion. Given the favorable medical nexus evidence in the record that the Veteran's GERD is related to her now service-connected acquired psychiatric disability, the Board resolves reasonable doubt in favor of the Veteran and finds that service connection is warranted on a secondary basis. The appeal with respect to service connection for GERD is granted. 7. Service connection for alopecia is granted. The Veteran also primarily asserts that her alopecia is aggravated by stress and is related to her military service. See April 2022 Board hearing transcript, pp. 11, 19-22 (asserting that her alopecia began in service and that her dermatologist has said that her alopecia is linked to stress). As an initial matter, the Board notes that the Veteran has been diagnosed with alopecia. See private dermatology treatment records. Also, as discussed in detail above, the Veteran is now service-connected for an acquired psychiatric disorder, diagnosed as PTSD and adjustment disorder with anxiety and depression. In ascertaining the nature and etiology of the Veteran's alopecia, the Board notes that a VA skin disorders examination was provided to the Veteran in August 2017. Notably, the examiner incorrectly stated that the Veteran had not ever had a skin condition. See, e.g., May 1987 service treatment records (diagnosing alopecia); November 1998 VA treatment record ("seeing a dermatologist privately for recurrence of patchy alopecia"); private treatment records from 2013 (diagnosing "alopecia areata") and 2015 (diagnosing "alopecia (unspec[ified]"); April 2022 private medical opinion. In April 2022, a private doctor reviewed the evidence of record and conducted an in-person interview with the Veteran. See April 2022 private medical opinion by S.B., M.D., PhD. The examiner concluded that the Veteran's alopecia "is a result and is exacerbated by her cognitive illness." The examiner explained: [The Veteran] repeatedly suffers from alopecia which is generally around a time when she has high episodes of extreme stressors. She has suffered hair loss since 1987. . . . There is a strong link between hair loss and cognitive deficits. [Her] anxiety and depression can cause hair loss leading to different patches of hair and baldness. It develops when your immune system attacks your hair follicles. This may be triggered by stress, and it can result in hair loss. . . . [Her] episodic hair loss in my medical opinion is at least as likely as not secondary to enlistment activities." See April 2022 private medical opinion. This opinion is consistent with the service treatment records and post-service treatment records documenting the Veteran's periodic hair loss and is found to be highly probative. Given the favorable medical nexus evidence in the record that the Veteran's alopecia is related to her now service-connected acquired psychiatric disability, the Board resolves reasonable doubt in favor of the Veteran and finds that service connection is warranted on a secondary basis for this diagnosis. The appeal with respect to service connection for alopecia is granted. 8. Service connection for allergic rhinitis and chronic sinusitis is granted. The Veteran claims that she developed sinus problems in service and that she currently has chronic sinusitis and allergic rhinitis that are related to the problems she had in service. See April 2011 Board hearing transcript, pp.28-29. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove direct 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. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom., Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998). However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it pertains to the readily observable features or symptoms of injury or illness and may provide sufficient support for a claim of service connection. Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Thus, medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C. § 1154(a). See Davidson, supra. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Turning to the first criterion for such an award, that of a current disability, the Board notes that the Veteran was provided a VA examination in November 2013. As a result of that examination, the examiner concluded that the Veteran "has rhinitis but her history, physical exam and imaging do not support a diagnosis of chronic sinusitis." See November 2013 VA opinion. Notably, however, the Veteran was assessed with "chronic sinusitis" in an August 1996 VA treatment report, as well as by Dr. S.B. in the April 2022 private medical opinion (noting that the Veteran "has a chronic disease" of allergic rhinitis and chronic sinusitis that she has been suffering from [] since her discharge and noting that the "argument of chronicity is futile as the symptoms have progressively worsened."). Resolving doubt in the Veteran's favor, the Board finds that a current disability has been established for both allergic rhinitis and chronic sinusitis. As to the matter of an in-service disease or injury, the evidence is consistent with the Veteran's reports of first experiencing sinus-related symptoms during service. See generally service treatment reports (noting multiple occurrences of upper respiratory disorders, as well as a diagnosis of sinusitis in April 1985); see also February 1987 dental health questionnaire (answering "yes" to "sinus trouble"). Based on this evidence, the Board finds that the second criterion, that of an in-service event, injury, or disease, has also been met. As to whether the evidence establishes that the Veteran's allergic rhinitis and sinusitis are related to service, the Board notes that the November 2013 VA examiner provided a negative nexus opinion. The VA examiner stated that "[t]here is no evidence in the service medical record of rhinitis or chronic/recurrent sinusitis." However, the Board finds the opinion to be of limited probative value in that it does not address the sinus-related complaints documented in the Veteran's service treatment records, or the recurrences noted in the Veteran's post-service treatment records. See, e.g., August 1996 VA treatment record ("chronic sinusitis"); August 2017 VA treatment report ("allergic rhinitis"); May 2018 ("She had a recent sinus infection for which she took a Z-Pak" and assessing "rhinitis"); February 2018 VA treatment report ("follow up of sinusitis," and assessing a history of sinusitis "improved may have allergies now"). In April 2022, a private examiner took into account the Veteran's lay statements and documented history and provided the following favorable nexus opinion: There are episodes while enlisted that are consistent with allergic rhinitis and chronic sinusitis. In my medical opinion, the Veteran has valid disability claims and is at least as not secondary to enlistment activities. Sinusitis is an inflammation of the sinuses. . . . Chronic sinusitis often presents with protracted nasal congestion, nasal discharge, and facial pain. Sinusitis is often preceded by a viral upper respiratory infection. Local edema, allergic rhinitis, and nasal polyps may obstruct the sinus osteium, leading to acute or chronic disease. . . . Chronic sinusitis is diagnose when at least two of the following four symptoms are present and occur for more than 12 weeks: (1) purulent drainage, (2) facial and/or dental pain, (3) nasal obstruction, (4) hyposmia. . . . The actual cause of the Veteran's allergic rhinitis/chronic sinusitis has not been ascertained. However, it is certain, this is a chronic disease that she has been suffering from [] since her discharge. An argument of chronicity is futile as the symptoms have progressively worsened. The symptoms began in service and have progressively worsened over the years. Thus, I am convinced without any reservation, the Veteran's chronic sinusitis is at last as likely as not secondary to her episodes of allergic rhinitis and sinusitis while enlisted." See April 2022 private medical opinion. As this opinion is supported by a reasoned rationale and is supported by the pertinent facts, the Board finds it to be highly probative. In light of the foregoing, the Board resolves reasonable doubt in the Veteran's favor and finds that the criteria for an award of service connection for allergic rhinitis and chronic sinusitis have been met on a direct basis. The appeal of these issues is granted. REASONS FOR REMAND 1. Entitlement to service connection for a hysterectomy is remanded. 2. Entitlement to service connection for a disorder claimed as herpes zoster (shingles) and/or herpes simplex is remanded. Although the Board sincerely regrets the additional delay, additional development of the claims for service connection for a hysterectomy and herpes zoster (shingles) and/or herpes simplex is needed to ensure that there is a complete record upon which to decide the Veteran's claims and to afford her every possible consideration. As to both of these issues, the Veteran testified at the April 2022 Board hearing that she previously received private treatment through TriCare. See April 2022 Board hearing transcript, p. 15; see also April 2000 VA treatment records (noting treatment, including from an outside dermatologist, through TriCare). Additionally, the Veteran's medical history reflects that a hysterectomy was conducted in New Orleans in August 1989. See June 1997 VA treatment record. Because the records of such treatment, if obtained, could bear on the outcome of her appeal, efforts must be made to procure them. See, e.g., 38 C.F.R. § 3.159(e)(2) (if VA becomes aware of the existence of relevant records before deciding a claim, VA will, among other things, request that the claimant provide a release for the records). With respect to the Veteran's claim for service connection for a hysterectomy, the Board finds that a remand is needed to provide the Veteran with a VA examination and opinion regarding the nature and etiology of her claimed uterine fibroids/cysts. In that regard, VA treatment records and private treatment records reflect the Veteran's history of a hysterectomy for fibroids conducted in 1989, and the service treatment records reflect that the Veteran experienced clotting and abnormal bleeding in service. See, e.g., November 1982 service treatment record (noting "heavy menstrual flow [with] clots"); April 1986 service treatment record ("heavy vaginal flow [with] menses"); November 1982 service treatment record (complaining of irregular menses with clotting, noting that blood clots were unusual for her, and assessing menorrhagia"). This evidence is sufficient to trigger VA's duty to obtain a VA examination and opinion regarding the etiology of the Veteran's hysterectomy. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Additionally, as to the Veteran's claim for service connection for herpes zoster (shingles) and herpes simplex, the Board notes that neither of these conditions were addressed in the August 2017 VA skin disorders examination report. See August 2017 VA examination report (checking "no" for whether the Veteran has ever had a skin condition). However, VA treatment and private treatment records reflect that the Veteran has had herpes simplex on her left buttocks, as well as a history of shingles. In light of the Veteran's skin-related complaints during service, the Board finds that a new VA examination is needed. As there are indications that this condition may be worsened by stress, an opinion should also be sought to ascertain whether her herpes zoster or herpes simplex is secondary to her now service-connected psychiatric disability. See April 2022 Board hearing testimony (reporting that the Veteran was told by her doctor that the condition was worsened by stress). These matters are REMANDED for the following action: 1. Ask the Veteran to provide a release for non-duplicative and relevant records of private treatment through Tri-Care and from the facility that conducted her August 1989 hysterectomy in New Orleans, and any other non-VA care providers who may possess new or additional evidence pertinent to her claims for service connection for a hysterectomy and/or herpes zoster or herpes simplex. If she provides the necessary release(s), assist her in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. The evidence received should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact, and the Veteran and her representative should be notified. 2. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 3. After the foregoing development has been completed to the extent possible, arrange to have the Veteran scheduled for a new VA examination to ascertain the presence and etiology of any diagnosed herpes zoster (shingles) or herpes simplex. The examiner should review the record. All indicated tests should be conducted and the results reported. After examining the Veteran and reviewing the record, together with the results of any testing deemed necessary, the examiner should offer an opinion as to whether the Veteran has herpes zoster and/or herpes simplex. For each diagnosed condition, the examiner should offer a further opinion as to whether it is at least as likely as not (i.e., whether the likelihood is at least approximately balanced or nearly equal, if not higher) that the disorder had its onset in, or is otherwise related to service. In doing so, the examiner is directed to consider the Veteran's service treatment records from February 1982 ("c/o fever blisters on her lips") and April 1982 (noting a rash and assessing "Not chicken pox, vesicles of undetermined origin"), as well as current private and VA treatment records noting both shingles and herpes simplex, type II. See, e.g., November 1999 VA treatment report ("r/o herpes simplex, type 2"); September 2016 private treatment records (assessing "herpes simplex" on the left buttocks and noting a skin history of "shingles"). The examiner is also requested to provide an opinion as to whether it is at least as likely as not that the condition (a) was caused or (b) has been aggravated (i.e., worsened beyond natural progression) by the Veteran's now service-connected psychiatric disability. A complete medical rationale for all opinions expressed must be provided. 4. Also arrange to have the Veteran scheduled for a VA examination to ascertain the etiology of her hysterectomy. The examiner should review the record. All indicated tests should be conducted, and the results reported. After examining the Veteran and reviewing the record, to include the results of any necessary testing, the examiner should indicate whether it is at least as likely as not (i.e., whether the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's hysterectomy and/or any related condition of fibroid tumor/fibroid cysts had its onset in, or is otherwise attributable to, service. In doing so, the examiner is directed to consider the service treatment reports reflecting abnormal bleeding and clotting, as well as the Veteran's in-service use of birth control pills. See, e.g., November 1982 service treatment record (noting "heavy menstrual flow [with] clots"); April 1986 service treatment record ("heavy vaginal flow [with] menses"); November 1982 service treatment record (complaining of irregular menses with clotting, noting that blood clots were unusual for her, and assessing menorrhagia"). 5. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issues remaining on appeal should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, the Veteran and her representative should be issued a supplemental SOC. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Gielow, 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.