Citation Nr: 23002628 Decision Date: 01/17/23 Archive Date: 01/17/23 DOCKET NO. 17-23 275 DATE: January 17, 2023 ORDER Service connection for sleep apnea, is granted. Service connection for acid reflux is granted. Service connection for a heart disorder, diagnosed as hypertensive heart disease, is granted. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. REMANDED Entitlement to service connection for a deviated septum is remanded. Entitlement to service connection for restless leg syndrome of the right leg is remanded. Entitlement to service connection for restless leg syndrome of the left leg is remanded. FINDINGS OF FACT 1. The Veteran's sleep apnea is caused, at least in part, by his service-connected PTSD, with an alcohol use disorder and a cannabis use disorder. 2. The Veteran's acid reflux is caused, at least in part, by his service-connected PTSD, with an alcohol use disorder and a cannabis use disorder. 3. The Veteran's heart disorder, diagnosed as hypertensive heart disease, cannot be disassociated from his hypertension, a disability of service origin. 4. The Veteran's service-connected disabilities are of such severity so as to preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 2. The criteria for service connection for acid reflux have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 3. The criteria for service connection for a heart disorder, diagnosed as hypertensive heart disease, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 4. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from January 1966 to January 1968, including service in the Republic of Vietnam. This matter is before the Board of Veterans' Appeals (Board) on appeal of a November 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), that denied service connection for sleep apnea; acid reflux; a heart disorder; a deviated septum; restless leg syndrome of the right leg; and for restless leg syndrome of the left leg. By this decision, the RO also denied entitlement to a TDIU. In May 2021, the Board remanded this appeal for further development. 1. Service Connection for Sleep Apnea and Acid Reflux Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). The term "active military, naval, or air service" includes active duty, any period of active duty for training during which the individual was disabled or died from a disease or injury incurred in or aggravated in the line of duty, and any period of inactive duty training during which the individual was disabled or died from an injury incurred in or aggravated in the line of duty. 38 U.S.C. § 101(24). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 C.F.R. § 3.310 (2015); see also Allen v. Brown, 7 Vet. App. 439 (1995). A veteran who served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed during such service to certain herbicide agents (e.g., Agent Orange). In the case of such a veteran, service incurrence for the following diseases will be presumed if they are manifest to a compensable degree within specified periods, even if there is no record of such disease during service: chloracne or other acneform diseases consistent with chloracne, type 2 diabetes, Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and sub-acute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, and trachea), and soft-tissue sarcomas. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). Effective August 31, 2010, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), is included as a disease associated with herbicide exposure under 38 C.F.R. § 3.309 (e). (Under 38 C.F.R. § 3.309 (e), the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. 38 C.F.R. § 3.309 (e) (Note 3.). On January 1, 2021, the National Defense Authorization Act for Fiscal Year 2021 has added three disorders to the list of diseases presumptively associated with exposure to herbicide agents. Specifically, it amended 38 U.S.C. § 1116(a)(2), to include parkinsonism, bladder cancer and hypothyroidism. 38 C.F.R. §§ 3.307(a)(6)(ii), 3.309(e). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Service connection is in effect for PTSD, with an alcohol use disorder and a cannabis use disorder; a right eye injury, status post removal of a foreign object; bilateral hearing loss; and for tinnitus. The Veteran contends that he has sleep apnea and acid reflux that are related to service, to include as due to Agent Orange exposure, or, more specifically, that are related to his service-connected PTSD, with an alcohol use disorder and a cannabis use disorder. The Veteran served on active duty in the Army from January 1966 to January 1968. His DD Form 214 indicates that he served for eleven months in Vietnam, and that his occupational specialty was listed as an armor crewman. As such, his exposure to Agent Orange is presumed. The service treatment records do not show treatment for any sleep problems, to include sleep apnea, or for any gastrointestinal problems, to include acid reflux. Post-service private and VA treatment records, including VA examination reports, show treatment, including sleep studies, for sleep apnea and obstructive sleep apnea. Such records also show treatment for acid reflux and for gastroesophageal reflux disease (GERD). The Board notes that the evidence of record includes opinions, as to the etiology of the Veteran's claimed sleep apnea, pursuant to a June 2021 VA sleep apnea examination report, and a January 2022 addendum opinion, and an April 2022 statement from B. S., M.D. Additionally, the Board observes that the evidence of record includes opinions, as to the etiology of the Veterans' claimed acid reflux, pursuant to a June 2021 VA esophageal conditions examination report, and an April 2022 statement from B. S., M.D. An April 2022 statement from Dr. B. S., indicates that he was an otolaryngologist, and that he was also board certified to practice in his specialty of ear, nose, and throat (ENT), and sleep medicine. Dr. B. S., reported that the Veteran had been under his care since 2005, and that he was diagnosed with obstructive sleep apnea, which required the use of a continuous positive airway pressure (CPAP) machine. Dr. B. S., stated that he was familiar with the Veteran's history, and that he had examined the Veteran often while he had been under his care. It was noted that an all-night comprehensive sleep study was performed on the Veteran in October 2009. Dr. B. S. maintained that he had reviewed the Veteran's medical history, his history of PTSD, and his medals and citations as a result of his military service in Vietnam combat situations. Dr. B. S. reported that the Veteran had no other known risk factors that may have precipitated his current condition of obstructive sleep apnea. Dr. B. S., stated that, in his personal experience, as well as in the medical literature, it was known that there was a connection between sleep dysfunction, obstructive sleep apnea, and PTSD. Dr. B. S., indicated that it was more likely than not that the Veteran's condition of obstructive sleep apnea was aggravated by his PTSD. An April 2022 statement from Dr. B. S., indicates he was an otolaryngologist, and that he was also board certified to practice in his specialty of ear, nose, and throat (ENT), and sleep medicine. Dr. B. S., reported that the Veteran was under his care since 2005, and that he was diagnosed with acid reflux. Dr. B. S., stated that he had reviewed the Veteran's medical history, his history of PTSD, and his medals and citations as a result of his military service in Vietnam combat situations. Dr. B. S., stated that he was familiar with the Veteran's history, and that he had examined the Veteran often while he was under his care. Dr. B. S., stated that the Veteran had no other known risk factors that may have precipitated his acid reflux. Dr. B. S., noted that, in his personal experience, as well as in the medical literature, it was known that there was a connection between acid reflux, stress, and PTSD. Dr. B. S., indicted that it was more likely than not that the Veteran's condition of acid reflux was aggravated by his PTSD. The Board notes that the Veteran is currently diagnosed with sleep apnea. The Board observes that, Dr. B. S., in an April 2022 statement, specifically indicated that the Veteran's sleep apnea was aggravated by his service-connected PTSD, with an alcohol use disorder and a cannabis use disorder. Additionally, the Board notes that the Veteran is currently diagnosed with acid reflux. The Board observes that, in an additional April 2022 statement, Dr. B. S. also found that the Veteran's condition of acid reflux was aggravated by his service-connected PTSD, with an alcohol use disorder and a cannabis use disorder. The Board finds that the respective opinions provided by Dr. B. S., pursuant to the April 2022 statements, are the most probative in this matter. The Board therefore finds that the Veteran's sleep apnea, and his acid reflux, are due to, or the result of, at least in part, his service-connected PTSD, with an alcohol use disorder and a cannabis use disorder. Thus, the evidence at least approximates and thus supports secondary service connection for sleep apnea, and for acid reflux. See 38 C.F.R. § 3.310. As the Board has granted secondary service connection it need not address direct service connection, or any other theories for service connection, in this matter. 2. Service Connection for a Heart Disorder Service connection is in effect for PTSD, with an alcohol use disorder and a cannabis use disorder; a right eye injury, status post removal of a foreign object; bilateral hearing loss; and for tinnitus. As discussed above, service connection is also now in effect for sleep apnea and for acid reflux. The Veteran contends that he has a heart disorder that is related to service, to include as due to Agent Orange exposure. He also asserts that his claimed heart disorder is secondary to his service-connected PTSD, with an alcohol use disorder and a cannabis use disorder, and his now service-connected sleep apnea. The service treatment records do not show treatment for any heart problems. Post-service private and VA treatment records, including VA examination reports, show that the Veteran has been diagnosed with heart disorders, including an irregular heartbeat; congestive heart failure; supraventricular arrythmia; heart block; valvular heart disease; and hypertensive heart disease, and that he has an implanted automatic implantable cardioverter defibrillator (AICD). The Board notes that service connection is not in effect for hypertension but the Veteran's hypertension is a disease of service origin as his exposure to Agent Orange is conceded. The Board notes that there is positive evidence within VA's possession to support a finding that the Veteran's hypertension is a disability of service origin. A 2014 National Academy of Sciences (NAS) Report (2014 NAS Update) found "limited or suggestive evidence of association" between hypertension and herbicide agent exposure. In a 2018 NAS Update, hypertension was elevated from the "limited or suggestive evidence" category to the "sufficient evidence of an association" category. See Veterans and Agent Orange: Update 11 (2018), available at https://www.nap.edu/read/25137/chapter/1, pages 465, 560, 565. According to NAS, the "sufficient evidence of an association" category indicates that there is enough epidemiologic evidence "to conclude that there is a positive association" between hypertension and herbicide agent exposure. Id. at 565. The 2018 Update has been held to be constructively before the Board. See Euzebio v. McDonough, 989 F.3d 1305, 1323 (Fed. Cir. 2021). In this case, the Veteran is currently diagnosed with hypertension, he has conceded exposure to herbicide agents (Agent Orange), and a NAS report establishing a causal relationship between hypertension and herbicide agents (Agent Orange). Therefore, the Board will consider the Veteran's hypertension as a disability of service origin. The Veteran is currently diagnosed with multiple heart disorders, including hypertensive heart disease. Additionally, as noted above, the Board considers the Veteran's hypertension as a disability of service origin. While there is no etiological opinion provided addressing whether the Veteran's hypertensive heart disease is related to his hypertension, the Board notes that hypertensive heart disease refers to heart problems that occur because of high blood pressure that is present over a long time. See "Hypertensive Heart Disease," MEDLINEPLUS, U.S. National Library of Medicine, NIH, available at https://medlineplus.gov/ency/article/000163.htm (last updated January 2022). The Board notes that the medical treatment reports of record note a significant history of hypertension, at least as of October 2014. (See an October 2014 echocardiogram report from Mid Valley Cardiology). Accordingly, the Board finds that the Veteran's heart disorder, diagnosed as hypertensive heart disease, cannot be disassociated from his hypertension, a disability of service origin, and that service connection for a heart disorder, diagnosed as hypertensive heart disease, is warranted on a secondary basis. See 38 C.F.R. § 3.310; see also Clemons v. Shinseki, 23 Vet. App. 1 (2009). Entitlement to a TDIU A total disability rating may be assigned, where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as the result of service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to a veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Todd v. McDonald, 27 Vet. App. 79, 85-86 (2014). To qualify for a total rating for compensation purposes, the evidence must show: (1) a single disability rated as 100 percent disabling; or (2) that the veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities and there is one disability ratable at 60 percent or more, or, if more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent. 38 C.F.R. § 4.16(a). For the purpose of establishing one 60 percent disability, or one 40 percent disability in combination, disabilities affecting a single body system are considered as one disability. Id. Disabilities that are not service connected cannot serve as a basis for a total disability rating. 38 C.F.R. §§ 3.341, 4.19. Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to TDIU is based on an individual's particular circumstance." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009) (quoting Thun v. Peake, 22 Vet. App. 111, 116 (2008)); see also Todd, 27 Vet. App. at 85-86. Therefore, in adjudicating a TDIU claim, VA must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering veteran's master's degree in education and his part-time work as a tutor). In determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to: the veteran's history, education, skill, and training; whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The Veteran essentially contends that his service-connected disabilities prevent gainful employment, warranting a TDIU. He specifically reports that his service-connected PTSD, with an alcohol use disorder and a cannabis use disorder, prevents him from securing or following any substantially gainful employment. He has also asserted that his service-connected PTSD, with an alcohol use disorder and a cannabis use disorder, bilateral hearing loss and tinnitus, as well as his now service-connected sleep apnea, acid reflux, and heart disorder, diagnosed as hypertensive heart disease, and non-service-connected disabilities of bilateral restless leg syndrome and insomnia, have prevented him from securing or following any substantially gainful employment. The Veteran's service-connected disabilities are PTSD, with an alcohol use disorder and a cannabis use disorder (rated 70 percent); a right eye injury, status post removal of a foreign object (rated 0 percent); bilateral hearing loss (rated 30 percent); and tinnitus (rated 10 percent). The combined disability rating is 80 percent. As discussed above, the Board has also granted service connection for sleep apnea; acid reflux; and for a heart disorder, diagnosed as hypertensive heart disease. Therefore, the Veteran clearly satisfies the schedular criteria for a TDIU. The remaining question is whether the Veteran is unemployable due to his service-connected disabilities alone, taking into consideration his educational and occupational background. The record reveals that the Veteran completed four years of college and that he reported that he last worked full-time in December 2008. The Veteran has also maintained that he became too disabled to work in December 2008. He indicates that he last worked as a civil engineer. The Board observes that there are multiple VA examination reports of record addressing the Veteran's unemployability. After a review of the evidence, the Board finds, resolving any reasonable doubt as mandated by law (38 U.S.C. § 5107; 38 C.F.R. § 3.102), that the evidence supports the conclusion that the Veteran's service-connected disabilities prevent him from securing and following substantially gainful employment. In reaching this determination, the Board notes that the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that a determination of whether a Veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the RO. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). Thus, an award of a TDIU is warranted. REASONS FOR REMAND The remaining issues on appeal are entitlement to service connection for a deviated septum; restless leg syndrome of the right leg; and for restless leg syndrome of the left leg. As discussed above, the Board has granted service-connection for sleep apnea; acid reflux; and for a heart disorder, diagnosed as hypertensive heart disease. Given this change in circumstances, and to accord the Veteran due process, the RO should readjudicate the issues of entitlement to service connection for a deviated septum; restless leg syndrome of the right leg; and restless leg syndrome of the left leg. This case was remanded in May 2021, partly to schedule the Veteran for VA examinations to determine the nature and etiology of his claimed deviated septum; restless leg syndrome of the right leg; and restless leg syndrome of the left leg. As to the Veteran's claimed deviated septum, the examiner was to state whether it was as likely as not that his current deviated septum had its onset in service or was otherwise etiological related to active service. The examiner was to consider the Veteran's statements regarding his in-service physical assault, and to address those statements in a rationale for the opinion. As to the Veteran's claimed restless leg syndrome of the right leg and restless leg syndrome of the left leg, Board finds that another VA examination is necessary to adjudicate this appeal. Pursuant to the May 2021 Board remand, the Veteran was afforded a VA sinusitis/rhinitis and other conditions of the nose, throat, larynx, and pharynx, examination in June 2021. The Veteran was also afforded a VA central nervous system and neuromuscular diseases examination in June 2021. The Board notes that the same examiner conducted the above examinations and provided etiological opinions. The same examiner also provided addendum opinions, as to the Veteran's claimed deviated septum; restless leg syndrome of the right leg, and restless leg syndrome of the left leg, in January 2022. The Board finds that the opinions provided by the examiner, pursuant to the respective examination reports above, are inadequate. For example, the etiological opinions provided do not address the claimed disorders, pursuant to the Veteran's presumed exposure to Agent Orange during service. Additionally, the examiner was not able to address whether the Veteran's now service-connected sleep apnea caused or aggravated his claimed deviated septum, and/or whether the Veteran's now service-connected heart disorder, diagnosed as hypertensive heart disease caused or aggravated his claimed restless leg syndrome of the right leg and restless leg syndrome of the left leg. In El-Amin v. Shinseki, 26 Vet. App. 136 (2013), a decision issued by the United States Court of Appeals for Veterans Claims (Court), the Court vacated a decision of the Board where a VA examiner did not specifically opine as to whether a disability was aggravated by a service-connected disability. In light of the above, the Board finds that the Veteran should be afforded VA examinations, with the opportunity to obtain responsive etiological opinions, following a thorough review of the record, as to his claims for service connection for a deviated septum; restless leg syndrome of the right leg; and restless leg syndrome of the left leg. Such examinations must be accomplished on remand. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006); Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007); see also Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Ask the Veteran to identify all medical providers who have treated him for a deviated septum; restless leg syndrome of the right leg; and for restless leg syndrome of the left leg, since January 2022. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service symptomatology regarding his claimed deviated septum; restless leg syndrome of the right leg; and restless leg syndrome of the left leg. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Schedule the Veteran for an appropriate VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the onset and/or etiology of his claimed deviated septum. The examiner must specifically indicate if the Veteran has a deviated septum. The examiner must then opine as to whether it is at least as likely as not that any diagnosed deviated septum is related to, or had its onset during, the Veteran's period of service, to include his presumed exposure to Agent Orange during service. The examiner must specifically acknowledge and discuss the Veteran's reports regarding an in-service physical assault which he maintains caused his deviated septum, as well as any reports by the Veteran of symptoms he thought were due to a deviated septum during service and since service. The examiner must state whether it is at least as likely as not that any diagnosed deviated septum is caused or aggravated by the Veteran's service-connected disabilities, to specifically include his service-connected sleep apnea, and PTSD, with an alcohol use disorder and cannabis uses disorder. 4. Schedule the Veteran for an appropriate VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the onset and/or etiology of his claimed eustachian tube dysfunction of the right ear. The examiner must specifically indicate if the Veteran has currently diagnosed restless leg syndrome of the right leg and restless leg syndrome of the left leg The examiner must then opine as to whether it is at least as likely as not that any diagnosed restless leg syndrome of the right leg and restless leg syndrome of the left leg are related to, or had their onset during, the Veteran's period of service, to include his presumed exposure to Agent Orange during service. The examiner must specifically acknowledge and discuss any reports by the Veteran of symptoms he thought were due to restless leg syndrome of the right leg and/or left leg during service and since service. The examiner must state whether it is at least as likely as not that any diagnosed restless leg syndrome of the right leg and restless leg syndrome of the left leg are caused or aggravated by the Veteran's service-connected disabilities, to specifically include his service-connected PTSD, with an alcohol use disorder and cannabis use disorder, and heart disorder, diagnosed as hypertensive heart disease. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. D. Regan, 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.