Citation Nr: 23003503 Decision Date: 01/19/23 Archive Date: 01/19/23 DOCKET NO. 19-06 352A DATE: January 19, 2023 ORDER The previously denied claim of entitlement to service connection for erectile dysfunction is reopened. The previously denied claim of entitlement to service connection for bronchitis (claimed as allergies) is reopened. The previously denied claim of entitlement to service connection for right shoulder disability is reopened. The previously denied claim of entitlement to service connection for left shoulder disability is reopened. The previously denied claim of entitlement to service connection for flat feet is reopened. Entitlement to service connection for chronic bronchitis is granted pursuant to the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act). Entitlement to service connection for rhinitis is granted pursuant to the PACT Act. Entitlement to service connection for sinusitis is granted pursuant to the PACT Act. Entitlement to service connection for asthma is granted pursuant to the PACT Act. Entitlement to service connection for flat feet is granted. Entitlement to service connection for plantar fasciitis is granted. Entitlement to service connection for the Veteran's right upper extremity neuropathy disability, including right median nerve palsy with complete atrophy of thenar eminence, is granted. REMANDED Entitlement to service connection for heart condition as secondary to asthma is remanded. Entitlement to service connection for right ventricle deviation as secondary to sinus condition is remanded. Entitlement to service connection for right ventricle hypertrophy as secondary to sinus condition is remanded. Entitlement to service connection for foot spurs is remanded. Entitlement to service connection for weak ankles is remanded. Entitlement to service connection for hip pain is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to April 13, 2017, is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for right shoulder disability is remanded. Entitlement to service connection for left shoulder disability is remanded. Entitlement to service connection for left wrist disability is remanded. Entitlement to service connection for right hand disability is remanded. Entitlement to service connection for sleep apnea is remanded. FINDINGS OF FACT 1. In an August 2015 rating decision, the Regional Office (RO) denied service connection for erectile dysfunction based on the finding that there was no connection to service. In an unappealed January 2016 rating decision, the RO found no new and material evidence to reopen the Veteran's claim for service connection for erectile dysfunction. 2. Additional evidence received since the January 2016 rating decision is not cumulative or redundant of the evidence of record at the time of that decision, relates to an unestablished fact necessary to substantiate the claim for service connection for erectile dysfunction, and raises a reasonable possibility of substantiating the claim. 3. In an unappealed August 2015 rating decision, the RO denied service connection for allergies based on the finding that there was no connection to service. 4. Additional evidence received since the August 2015 rating decision is not cumulative or redundant of the evidence of record at the time of that decision, relates to an unestablished fact necessary to substantiate the claim for service connection for allergies, and raises a reasonable possibility of substantiating the claim. 5. In an unappealed January 2016 rating decision, the RO denied service connection for right and left shoulder disability based on the finding that there was no connection to service. 6. Additional evidence received since the January 2016 rating decision is not cumulative or redundant of the evidence of record at the time of that decision, relates to an unestablished fact necessary to substantiate the claims for service connection for right and left shoulder disability, and raises a reasonable possibility of substantiating the claims. 7. In an unappealed January 2016 rating decision, the RO denied service connection for flat feet based on the finding that there was no connection to service. 8. Additional evidence received since the January 2016 rating decision is not cumulative or redundant of the evidence of record at the time of that decision, relates to an unestablished fact necessary to substantiate the claim for service connection for flat feet, and raises a reasonable possibility of substantiating the claim. 9. The Veteran served in Kuwait from July 1991 to September 1991 and was diagnosed with chronic bronchitis, allergic rhinitis, sinusitis, and asthma after service. 10. Resolving doubt in favor of the Veteran, his bilateral flat foot and plantar fasciitis disabilities are related to in-service injuries. 11. Resolving doubt in favor of the Veteran, his right upper extremity neuropathy disability, including right median nerve palsy with complete atrophy of thenar eminence, is related to an in-service injury. CONCLUSIONS OF LAW 1. The Regional Office's January 2016 rating decision continuing the denial of service connection for erectile dysfunction is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.200, 20.201, 20.1103. 2. New and material evidence has been received to reopen the Veteran's claim for service connection for erectile dysfunction. 38 U.S.C. §§ 1110, 5108; 38 C.F.R. §§ 3.303, 3.156. 3. The Regional Office's August 2015 rating decision denying service connection for allergies is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.200, 20.201, 20.1103. 4. New and material evidence has been received to reopen the Veteran's claim for service connection for allergies. 38 U.S.C. §§ 1110, 5108; 38 C.F.R. §§ 3.303, 3.156. 5. The Regional Office's January 2016 rating decision denying service connection for right and left shoulder disability is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.200, 20.201, 20.1103. 6. New and material evidence has been received to reopen the Veteran's claims for service connection for right and left shoulder disability. 38 U.S.C. §§ 1110, 5108; 38 C.F.R. §§ 3.303, 3.156. 7. The Regional Office's January 2016 rating decision denying service connection for flat feet is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.200, 20.201, 20.1103. 8. New and material evidence has been received to reopen the Veteran's claim for service connection for flat feet. 38 U.S.C. §§ 1110, 5108; 38 C.F.R. §§ 3.303, 3.156. 9. The criteria for service connection for chronic bronchitis, allergic rhinitis, sinusitis, and asthma have been met. 38 U.S.C. §§ 1110, 1119, 1120, 5107; 38 C.F.R. §§ 3.102, 3.303. 10. The criteria for service connection for bilateral flat foot and plantar fasciitis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 11. The criteria for service connection for right upper extremity neuropathy disability, including right median nerve palsy with complete atrophy of thenar eminence, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1985 to May 1992, including service in Southwest Asia during the Persian Gulf War. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2017, December 2017, and January 2018 rating decisions. In March 2022, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is in the claims file. As to the Veteran's claim for service connection for left wrist disability, the claim was denied in a January 2016 rating decision for lack of connection to service. However, in an April 2016 examination, the Veteran reported that he injured his left wrist during a fall from an armored personnel carrier during service. As such evidence is new and material (connection to service) and was received within a year of the January 2016 rating decision, the January 2016 rating decision did not become final as to the Veteran's claim for service connection for left wrist disability. Accordingly, the Veteran's claim for service connection for left wrist disability will be reviewed de novo. See 38 C.F.R. § 3.156(b). In an October 2018 statement, the Veteran requested to withdraw his right hand/right upper extremity claim. However, the statement also indicates that he has submitted new evidence and requests readjudication of the claim. The withdrawal is unclear and the Veteran continued to pursue the claim. Therefore, the Board will consider the claim in the decision below. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the appellant and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). New and Material Evidence 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 and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). 1. The previously denied claim of entitlement to service connection for erectile dysfunction is reopened. In an August 2015 rating decision, the RO denied service connection for erectile dysfunction based on the finding that there was no connection to service. In a January 2016 rating decision, the RO found no new and material evidence to reopen the Veteran's claim for service connection for erectile dysfunction. The RO notified the Veteran of its decision, and of his appellate rights, but he did not initiate an appeal of the RO's decision within one year nor was any new and material evidence received within a year. As a result, the RO's decision became final. Accordingly, the claim may now be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. At the time of the January 2016 rating decision, the record contained service treatment records, VA treatment records, and private treatment records. The evidence received since the time of the January 2016 rating decision includes the Veteran's assertion that his erectile dysfunction is secondary to medications for his service-connected back disability along with materials listing drugs that can cause erectile dysfunction, including one prescribed for his back. See September 2017 Notice of Disagreement; December 2017 Submission. This evidence was not before adjudicators when the Veteran's claim was last finally denied and it is not cumulative or redundant of the evidence of record at the time of that decision. The new evidence relates to an unestablished fact necessary to substantiate the claim for service connection for erectile dysfunction and raises a reasonable possibility of substantiating the claim. Accordingly, the claim is reopened. 2. The previously denied claim of entitlement to service connection for bronchitis (claimed as allergies) is reopened. In an August 2015 rating decision, the RO denied service connection for allergies based on the finding that there was no connection to service. The RO notified the Veteran of its decision, and of his appellate rights, but he did not initiate an appeal of the RO's decision within one year nor was any new and material evidence received within a year. As a result, the RO's decision became final. Accordingly, the claim may now be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. The Board notes that in a January 2016 rating decision, the RO reopened the claim for service connection for bronchitis previously claimed as allergies but confirmed the denial of the claim based on the finding that there was no connection to service. However, within a year after this rating decision, new and material evidence was submitted by the Veteran. In a private treatment record submitted in September 2016, the Veteran reported that his symptoms have been present since service. Accordingly, the January 2016 rating decision did not become final. Accordingly, the Board will evaluate whether new and material evidence has been received since the August 2015 rating decision. At the time of the August 2015 rating decision, the record contained service treatment records and private treatment records. As noted above, the evidence received since the time of the August 2015 rating decision includes a private treatment record in which the Veteran reported that his symptoms of postnasal drip and allergies have been present since service. See September 2016 Submission. This evidence was not before adjudicators when the Veteran's claim was last finally denied and it is not cumulative or redundant of the evidence of record at the time of that decision. The new evidence relates to an unestablished fact necessary to substantiate the claim for service connection for allergies (link to service) and raises a reasonable possibility of substantiating the claim. Accordingly, the claim is reopened. 3. The previously denied claim of entitlement to service connection for right shoulder disability is reopened. 4. The previously denied claim of entitlement to service connection for left shoulder disability is reopened. In a January 2016 rating decision, the RO denied service connection for right and left shoulder disability based on the finding that there was no connection to service. The RO notified the Veteran of its decision, and of his appellate rights, but he did not initiate an appeal of the RO's decision within one year nor was any new and material evidence received within a year. As a result, the RO's decision became final. Accordingly, the claims may now be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. At the time of the January 2016 rating decision, the record contained service treatment records, VA treatment records, and private treatment records. The evidence received since the time of the January 2016 rating decision includes the Veteran's reports that he has had shoulder pain since service. See March 2022 Hearing Transcript. This evidence was not before adjudicators when the Veteran's claims were last finally denied and it is not cumulative or redundant of the evidence of record at the time of that decision. The new evidence relates to an unestablished fact necessary to substantiate the claims for service connection for right and left shoulder disability and raises a reasonable possibility of substantiating the claims. Accordingly, the claims are reopened. 5. The previously denied claim of entitlement to service connection for flat feet is reopened. In a January 2016 rating decision, the RO denied service connection for flat feet based on the finding that there was no connection to service. The RO notified the Veteran of its decision, and of his appellate rights, but he did not initiate an appeal of the RO's decision within one year nor was any new and material evidence received within a year. As a result, the RO's decision became final. Accordingly, the claim may now be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. At the time of the January 2016 rating decision, the record contained service treatment records, VA treatment records, VA examination, and private treatment records. The evidence received since the time of the January 2016 rating decision includes the Veteran's assertion that his flat feet are related to the required footwear and running activities in service. See September 2017 Notice of Disagreement. This evidence was not before adjudicators when the Veteran's claim was last finally denied and it is not cumulative or redundant of the evidence of record at the time of that decision. The new evidence relates to an unestablished fact necessary to substantiate the claim for service connection for flat feet (connection to service) and raises a reasonable possibility of substantiating the claim. Accordingly, the claim is reopened. Service Connection Generally, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). In addition, service connection may be granted for a Persian Gulf Veteran with objective indications of a qualifying chronic disability that manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom chronic illness (MUCMI); and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. Effective August 5, 2021, VA promulgated an interim final rule regarding presumptive service connection for Gulf War veterans for three chronic respiratory health conditions, including asthma, rhinitis, and sinusitis, in association with exposure to fine particulate matter. Under the interim final rule, these shall be service connected even though there is no evidence of such disease during the period of service if it manifests within 10 years from the date of separation from military service that included active-duty service during the Gulf War in the Southwest Asia. 38 C.F.R. § 3.320(a). Exposure is presumed unless there is affirmative evidence to establish that the veteran was not exposed to fine particulate matter during service. 38 C.F.R. § 3.320(a). The interim final rule applies to all claims received by the VA on or after August 5, 2021, and that were pending before the VA, the United States Court of Appeals for Veterans' Claims, or the United States Court of Appeals for the Federal Circuit on August 5, 2021. See 86 Fed. Reg. 42724, 42724 (August 5, 2021). Under the PACT Act, unless affirmative evidence proves otherwise, any covered veteran is presumed to have been exposed to certain substances, chemicals, and airborne hazards during their service. A "covered veteran" means any veteran who on or after August 2, 1990, performed active military, naval, air, or space service while assigned to a duty station in Bahrain, Iraq, Kuwait, Oman, Qatar, Saudi Arabia, Somalia, or United Arab Emirates; or on or after September 11, 2001, performed active military, naval, air, or space service while assigned to a duty station in Afghanistan, Djibouti, Egypt, Jordan, Lebanon, Syria, Yemen, Uzbekistan, or any other country determined relevant by the Secretary. When a covered veteran manifests certain diseases, including chronic bronchitis, chronic rhinitis, chronic sinusitis, and asthma diagnosed after service, such disability shall be considered to have been incurred in or aggravated during active military, naval, air, or space service, notwithstanding that there is no record of evidence of such disease during the period of service. See 38 U.S.C. §§ 1119, 1120. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence showing that a current disability exists and that the disability was caused by or aggravated by a service-connected disability. 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. 6. Entitlement to service connection for chronic bronchitis is granted pursuant to the PACT Act. 7. Entitlement to service connection for rhinitis is granted pursuant to the PACT Act. 8. Entitlement to service connection for sinusitis is granted pursuant to the PACT Act. 9. Entitlement to service connection for asthma is granted pursuant to the PACT Act. The Veteran seeks service connection for bronchitis, rhinitis, sinusitis, and asthma, asserting that such conditions began during service and are related to Gulf War exposures. The Veteran's VA and private treatment records show current diagnoses of chronic bronchitis, allergic rhinitis, sinusitis, and asthma. Turning to the evidence, the Veteran's service treatment records show treatment for bronchitis and seasonal allergies. The Veteran and his friend reported that the Veteran was treated for bronchitis, rhinitis, sinusitis, and asthma from separation from service in 1992 to 2002 but that the private treatment records for that time period are not available. The private treatment records in the claims file begin in 2002, approximately 10 years after separation from service, along with VA treatment records from 2014 forward. These treatment records show treatment for bronchitis throughout the years with notations that the Veteran has bronchitis once or twice a year with a current diagnosis of chronic bronchitis. These treatment records also show treatment for allergic rhinitis, sinusitis, and asthma. While a July 2005 private treatment record notes no history of asthma, the subsequent private treatment records show medication for asthma beginning at least by February 2006. A December 2015 VA contract examiner noted that the Veteran did not have and had never been diagnosed with a respiratory condition, to include asthma and chronic bronchitis, but then noted that the Veteran's respiratory condition required the use of corticosteroid medications and antibiotics. The examiner opined that it is less likely than not that the Veteran has a diagnosis of chronic bronchitis incurred in or caused by service. The examiner explained that the medical records attached show nonspecific upper respiratory complaints and repeated diagnoses of acute bronchitis which is different than chronic bronchitis which was not diagnosed in the attached records. However, the examiner then noted that the Veteran's symptoms and the findings upon examination of the Veteran were actually consistent with chronic bronchitis. The Board finds the December 2015 opinion is internally inconsistent and not probative on the question of whether the Veteran's bronchitis is related to service. Moreover, the opinion relies on the lack of a chronic bronchitis diagnosis in treatment records, and VA treatment records subsequent to the December 2015 examination report note that the Veteran has an active diagnosis of chronic bronchitis. See April 2019 VA Treatment Record. The Board finds that service connection for chronic bronchitis, allergic rhinitis, sinusitis, and asthma is warranted pursuant to the PACT Act. The Veteran's service personnel records show service in Kuwait from July 1991 to September 1991. Accordingly, pursuant to the PACT Act, he is presumed to have been exposed to certain substances, chemicals, and airborne hazards during his service. The PACT Act provides a presumption that certain diseases, including chronic bronchitis, chronic rhinitis, chronic sinusitis, and asthma diagnosed after service, becoming manifest in a covered veteran are considered to have been incurred in service. The Veteran was diagnosed with asthma after service. The Veteran has a current diagnosis of chronic bronchitis in his VA treatment records. According to Merriam Webster, "chronic" means "continuing or occurring again and again for a long time." See www.merriam-webster.com/dictionary/chronic. Resolving doubt in favor of the Veteran, his rhinitis and sinusitis are repeatedly occurring for a long time and therefore considered chronic. See, e.g., April 2013 Private Treatment Record; June 2016 VA, April 2018, April 2019, January 2022, and September 2022 Treatment Records. In light of the above, the Board finds that service connection for chronic bronchitis, rhinitis, sinusitis, and asthma is warranted. 38 U.S.C. §§ 1119, 1120. The Board's grant herein is considered a full grant of the benefit sought (service connection) and should not be construed as limiting the Veteran's ability from pursuing higher ratings or an earlier effective date with the Agency of Original Jurisdiction (AOJ) once the grant is implemented. See Grantham v. Brown, 114 F.3d 1156, 1158-59); see also Evan v. West, 12 Vet. App. 296 (1999) (effective date is a "downstream matter" to be addressed after the benefit has been awarded). In other words, the Board is not assigning an initial rating or an effective date in the first instance, but rather only finding the evidence warrants a grant of service connection. Id. The Board notes that an August 2021 interim final rule provides presumptive service connection for rhinitis, sinusitis, and asthma manifested within 10 years from separation from the period of service which included Gulf War service. Here, viewing the lay and medical evidence as a whole, including the variety of respiratory illnesses the Veteran experienced throughout the years and the lack of treatment records prior to 2002 to confirm the diagnoses, the record is unclear as to whether the Veteran manifested rhinitis, sinusitis, and asthma within 10 years from separation of service (i.e., by May 2002). However, these diseases are covered by the PACT Act without any such limitation. Once again, the grant of service connection under the PACT Act set forth above is a full grant of the Veteran's claim. 10. Entitlement to service connection for flat feet is granted. 11. Entitlement to service connection for plantar fasciitis is granted. The Veteran seeks service connection for flat feet and plantar fasciitis, asserting that such conditions began during service and are related to in-service injuries, including his bilateral foot fractures. The Veteran is already service connected for residuals of his bilateral foot fractures. Turning to the evidence, the Veteran's service treatment records show treatment for bilateral foot complaints, including bilateral foot fractures, with a notation that 6 months after fracture the Veteran was unable to get a full arch and with an assessment of plantar fasciitis in April 1992 (a month before separation). The Veteran underwent VA contract examination in September 2015. The Veteran reported that his condition began with multiple cold weather injuries and foot fractures in service and that his condition worsened and his arches dropped. The examiner diagnosed bilateral flat foot and bilateral plantar fasciitis and noted status post bilateral foot fractures associated with his flat foot and plantar fasciitis conditions. The examiner opined that the Veteran's current bilateral foot condition is at least as likely as not incurred in or caused by service. The examiner noted the Veteran was treated in service for foot fracture and foot pain problems and that the current diagnosis may represent residuals and sequelae of the foot injuries sustained in service. The examiner reviewed the record, examined the Veteran, and discussed the Veteran's in-service injuries and service treatment records in support of the opinion. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no contrary medical opinion in the record. The October 2016 VA contract examiner again noted that the Veteran had diagnoses of bilateral flat foot and bilateral plantar fasciitis and status post bilateral foot fractures associated with the flat foot and plantar fasciitis conditions. Viewing the lay and medical evidence as a whole, the Board finds the evidence is at least in approximate balance as to whether the Veteran's current bilateral flat foot and plantar fasciitis disabilities are related to service. While the September 2015 examiner noted that the Veteran's condition "may" represent residuals of in-service injuries, the examiner also explicitly opined that the Veteran's current conditions (diagnosed as plantar fasciitis and flat feet along with associated status post foot fractures) are at least as likely as not incurred in service or related to his in-service injuries and noted service treatment records in support, including one diagnosing plantar fasciitis at the end of the Veteran's service following his foot fractures. While the positive nexus opinion is not perfect, it is supported by a rationale and citation to the evidence. The Board finds that the evidence as a whole is at least in approximate balance as to whether the Veteran's flat foot and plantar fasciitis disabilities are related to service. Accordingly, service connection for bilateral flat foot and plantar fasciitis is warranted. 12. Entitlement to service connection for the Veteran's right upper extremity neuropathy disability, including right median nerve palsy with complete atrophy of thenar eminence, is granted. The Veteran seeks service connection for right upper extremity neuropathy disability, asserting that such disability is related to an in-service injury. The Veteran reported that he injured his right arm in the antecubital fossa region while jumping off of an armored personnel carrier during service in Germany and that it has progressed into his current disability. The Veteran reported that his injury occurred during a field exercise which may explain the lack of documentation of treatment for the injury. Turning to the evidence, the Veteran's February 1985 entrance examination does not show any scars. The Veteran's service personnel records show service in Germany from January 1986 to January 1988. A February 1988 examination shows a one-inch scar on the right antecubital. An October 1989 service treatment record shows abrasions to both arms from football, including mild abrasions to the right arm. An April 1990 examination shows scars on the Veteran's right elbow and bilateral forearms. In an August 2015 scar examination, the examiner noted a right antecubital fossa scar which is now service connected. The Veteran reported that he injured his right arm in the joint between the forearm and bicep while jumping off of an armored personnel carrier during service in Germany. An April 2016 peripheral nerves examination noted right upper extremity radiculopathy but a March 2017 peripheral nerves examiner noted the Veteran's right upper extremity symptoms were subjective and did not warrant a diagnosis. An October 2017 private examiner completed a back examination report and noted that the Veteran has right hand/thumb atrophy due to his back disability. However, no rationale was provided. In December 2017 treatment, the Veteran reported a serious puncture injury in service with difficulty gripping and tingling since that time which worsened in the last 5 years. A January 2018 electromyography and nerve conduction study report shows a diagnosis of chronic, proximal right median neuropathy at the antecubital fossa from prior injury with evidence of anoxal loss. A May 2018 private examiner noted that the Veteran sustained a deep laceration at his right upper extremity antecubital fossa during service leading to right-sided median nerve injury. The examiner opined that it is more likely than not that there is a nexus between the Veteran's service and his right upper extremity pathology, with significant diminution in functional capacity. However, the opinion lacks an adequate rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). An October 2018 VA contract examination notes the Veteran's report of right thumb disability as a result of nerve injury to the antecubital fossa which has worsened over the years. However, the examiner did not provide a diagnosis for the Veteran's right hand disability or opine regarding whether it is related to service. A December 2018 VA contract examiner diagnosed the Veteran with right upper extremity radiculopathy, right carpal tunnel syndrome, right hand thenar atrophy, right thumb ankylosis, and right hand arthritis. The examiner specifically noted that the Veteran did not have a diagnosis of right claw hand. The Veteran reported that he had an antecubital injury in service and has had problems since which worsened over time. The examiner opined that the Veteran's right upper extremity neuropathy is at least as likely as not due to the Veteran's right antecubital scar. The examiner noted the Veteran's service treatment records showed a right antecubital area scar measuring one inch and that the Veteran now had a more decreased grip and constant pain. Records showed severe right median neuropathy at the antecubital fossa. The examiner explained that the scar may be pressing on cutaneous nerves resulting in radiculopathy. The examiner also opined that the Veteran's right hand condition is at least as likely as not due to the right antecubital scar. However, the examiner then explained that the scar is not a recognized cause of the Veteran's right hand condition. In a February 2019 addendum, the examiner clarified that the Veteran's right hand condition is not due to his scar. The December 2018 examiner also opined that the Veteran's right hand carpal tunnel syndrome and right hand thenar atrophy are less likely than not due to the Veteran's right antecubital scar. The examiner explained that the scar is not a recognized cause of carpal tunnel syndrome and thenar atrophy. The examiner opined that the Veteran's right thumb ankylosis is less likely than not due to his right upper extremity radiculopathy. The examiner noted that ankylosis of the thumb occurs when there are adhesions or muscle or cartilage damage causing stiffness to the joint. However, the examiner provided an inadequate rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). A July 2019 VA contract examiner reviewed the evidence but did not examine the Veteran. The examiner opined that the Veteran's right hand and arm disabilities (including carpal tunnel syndrome, claw hand, right thenar atrophy, right thumb ankylosis, and right upper extremity radiculopathy) are less likely than not due to the Veteran's service-connected condition or service. The examiner explained that the Veteran's current conditions and his service conditions are not medically related. The examiner noted an October 1986 service treatment record noting an injury to the left index finger and a July 1989 service treatment record noting abrasion of the bilateral arms which were acute and resolved. The examiner noted that these in-service complaints were not consistent with the Veteran's current conditions. The examiner's reference to a July 1989 service treatment record appears to actually be a reference to the October 1989 service treatment record noting arm abrasions from football and the referenced October 1986 service treatment record regarding ain jury to the left index finger also involved a football injury. The July 2019 examiner failed to address the Veteran's reports that he injured his right arm around the antecubital fossa area when jumping off of an armored personnel carrier during service or the later in-service examinations that confirm an injury resulting in a scar in that area. See Miller v. Wilkie, 32 Vet. App. 249 (2020). Accordingly, the Board finds the July 2019 opinions less probative. A May 2022 private examiner reviewed evidence and examined the Veteran and diagnosed right median nerve palsy with complete atrophy of thenar eminence. The examiner opined that the Veteran's disability is more likely than not the result of the laceration over his lateral antecubital fossa in service in the 1980s. The examiner noted the Veteran's reports that he was trying to step off a military transport vehicle during service in Germany and a sharp metal edge cut his forearm and he began noticing progressive paresthesias 2-4 weeks after the injury and then several years after the injury developed weakness in his hand. The Veteran reported that he was treated privately with physical therapy after the military but when his symptoms became severe he started treatment with a hand surgeon who was concerned about median nerve palsy. The examiner noted that electrodiagnostic studies showed chronic proximal right median neuropathy at the level of the antecubital fossa with evidence of anoxal loss. The examiner explained that given the somewhat delayed onset of symptoms, it is reasonable to assume that the laceration resulted in either a partial laceration that was fairly well compensated for but has since developed a neuroma in situ or a scar entrapment of the median nerve that developed as a consequence of the laceration. The examiner explained that the Veteran has developed complete atrophy of his thenar eminence and some mild weakness of median nerve innervated muscles in his forearm as a result of the injury. The opinion attached articles in support, including materials noting that median nerve palsy is often caused by deep, penetrating injuries to arm, forearm, or wrist or direct trauma at the wrist and elbow joints and an article noting that carpal tunnel syndrome (compression or pinching of median nerve) and trauma to the forearm may affect the thenar eminence. The Board finds the examiner's opinion highly probative, because it is based on the complete record including the Veteran's reports and the treatment records with an accurate medical history and an explanation that contains supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Viewing the lay and medical evidence as a whole, the Board finds the evidence is at least in approximate balance as to whether the Veteran has a current right upper extremity neuropathy disability related to service. The Veteran reported an in-service deep laceration to his right antecubital fossa area while jumping off of an armored personnel carrier during service in Germany in the 1980s. The Veteran's service personnel records confirm that the Veteran served in Germany at that time and an examination immediately upon return to the United States in February 1988 confirms a one-inch right antecubital scar. The Veteran reported that he has experienced some problems since then which worsened over the last several years. The most probative medical opinion in the record, the private May 2022 opinion, links the Veteran's current right upper extremity neuropathy disability with his in-service injury. The opinion is based on the medical records in the claims file, including a recent electrodiagnostic studying showing the Veteran has chronic proximal right median neuropathy at the level of the antecubital fossa, as well as the Veteran's reports regarding the in-service incident and his symptomatology. The opinion is supported by a rationale. The Board finds the other opinions in the claims file are less probative. The December 2018 examiner did not address whether the Veteran's current disability is related to his in-service injury but rather only whether it is related to his scar from the injury. The July 2019 examiner opined that the Veteran's right upper extremity disabilities are less likely than not due to service but only referenced service treatment records discussing abrasions from playing football. The July 2019 examiner failed to address the Veteran's reports that he injured his right arm around the antecubital fossa area when jumping off of an armored personnel carrier during service or the later in-service examinations that confirm an injury resulting in a scar in that area and therefore the July 2019 examiner's opinions are less probative. Viewing the evidence as a whole, and resolving doubt in favor of the Veteran, the Board finds that the Veteran's right upper extremity neuropathy disability is related to service. Accordingly, service connection for the Veteran's right upper extremity neuropathy disability, including right median nerve palsy with complete atrophy of thenar eminence, is warranted. REASONS FOR REMAND Remand of these matters is warranted to obtain outstanding treatment records. Review of the Veteran's VA treatment records in the claims file show that non-VA treatment records, including orthopedic, physical therapy, and respiratory treatment records, were scanned into the Veteran's VA medical file. See, e.g., February 2015, March 2015, August 2019, September 2019, October 2019, November 2019, February 2020, January 2021, February 2021, December 2021, and May 2022 VA Treatment Records. However, it does not appear that all of these treatment records are in the claims file. Accordingly, remand is appropriate to obtain these potentially relevant outstanding treatment records. 1. Entitlement to service connection for heart condition as secondary to asthma is remanded. 2. Entitlement to service connection for right ventricle deviation as secondary to sinus condition is remanded. 3. Entitlement to service connection for right ventricle hypertrophy as secondary to sinus condition is remanded. 4. Entitlement to service connection for foot spurs is remanded. 5. Entitlement to service connection for weak ankles is remanded. 6. Entitlement to service connection for hip pain is remanded. 7. Entitlement to a TDIU prior to April 13, 2017 is remanded. The Veteran disagrees with the December 2017 and January 2018 denials of service connection for heart condition, right ventricle deviation, right ventricle hypertrophy, foot spurs, weak ankles, and hip pain, and with the assigned effective date for TDIU. The Veteran filed a timely Notice of Disagreement (NOD) to these issues in March 2018. However, no statement of the case (SOC) has been issued addressing these claims. Therefore, the Board finds these matters should be remanded for the issuance of a SOC. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). 8. Entitlement to service connection for erectile dysfunction is remanded. The Veteran seeks service connection for erectile dysfunction, asserting that such disability is caused by medications for his service-connected back disability. The Veteran has a diagnosis of erectile dysfunction. The Veteran submitted online materials listing drugs that can cause erectile dysfunction, including medication prescribed for his back. See December 2017 Submission. Accordingly, remand is appropriate to obtain VA medical opinion regarding whether the Veteran's erectile dysfunction is secondary to a service-connected disability. See McLendon v. Nicholson, 20 Vet. App. 79, 85-86 (2006). 9. Entitlement to service connection for right shoulder disability is remanded. 10. Entitlement to service connection for left shoulder disability is remanded. The Veteran seeks service connection for bilateral shoulder disability, asserting that such disability began during service or is related to his service-connected left upper extremity radial nerve disability. He reports continuous pain since service and his service treatment records show right and left shoulder complaints, including a notation of left shoulder pain relating to a left collar bone fracture. A December 2017 private examiner opined that the Veteran's bilateral shoulder disability is more likely than not connected to his service but did not provide a rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Accordingly, remand is appropriate to obtain VA medical opinion regarding whether the Veteran's bilateral shoulder disability had an onset in service or is otherwise related to service or secondary to his service-connected left upper extremity radial nerve disability. See McLendon v. Nicholson, 20 Vet. App. 79, 85-86 (2006). 11. Entitlement to service connection for left wrist disability is remanded. The Veteran seeks service connection for left wrist disability, asserting that such disability began during service or is related to injuries in service or to his service-connected left upper extremity radial nerve disability. The Veteran has a diagnosis of left wrist arthritis and his service treatment records show complaints of left wrist pain and limited motion, left arm pain, and a scar on his left forearm. Accordingly, remand is appropriate to obtain VA medical opinion regarding whether the Veteran's left wrist disability had an onset in service or is otherwise related to service or secondary to his service-connected left upper extremity radial nerve disability. See McLendon v. Nicholson, 20 Vet. App. 79, 85-86 (2006). 12. Entitlement to service connection for right hand disability is remanded. The Veteran seeks service connection for right hand and right upper extremity nerve disability, asserting that such disabilities began during service or are related to injuries in service. As noted above, service connection for right upper extremity neuropathy disability, including right median nerve palsy with complete atrophy of thenar eminence, has been granted above. However, the December 2018 VA contract examiner also diagnosed the Veteran with degenerative arthritis in his right hand and there is no adequate medical opinion regarding whether such disability is related to service. The December 2018 examiner opined that the Veteran's right hand disability is less likely than not due to his service-connected right arm scar but provided no rationale. The examiner did not opine as to whether the Veteran's right hand arthritis is related to service, including the in-service injury resulting in the scar. The Veteran has claimed right hand problems since service. In addition, an October 2017 private back examiner noted that the Veteran has right hand/thumb atrophy due to his back disability but provided no rationale. Accordingly, remand is warranted to obtain VA medical opinion. 13. Entitlement to service connection for sleep apnea is remanded. The Veteran seeks service connection for sleep apnea, asserting that his condition began in service or is secondary to his respiratory disabilities. The Veteran has been diagnosed with sleep apnea and submitted reports from his friend and brother that his snoring began in service. A May 2022 private examiner opined that the Veteran's sleep apnea more likely than not developed during service and is connected to service including burn pit exposure and sleep-wake cycles from serving as a combat engineer. The examiner included general information about sleep apnea and burn pits but did not provide a rationale for the opinion that the Veteran's sleep apnea had an onset during service or is related to his in-service activities. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The Veteran has also submitted materials suggesting that allergies increase the likelihood for sleep apnea and contribute to apneic episodes. Accordingly, remand is appropriate to obtain VA medical opinion regarding whether the Veteran's sleep apnea had an onset in service, is related to service, or is secondary to a service-connected disability. See McLendon v. Nicholson, 20 Vet. App. 79, 85-86 (2006). The matters are REMANDED for the following action: 1. Send the Veteran a statement of the case that addresses the issues of service connection for heart condition, right ventricle deviation, right ventricle hypertrophy, foot spurs, weak ankles, and hip pain, and the effective date for TDIU. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue[s] should be returned to the Board for further appellate consideration. 2. Obtain the non-VA treatment records scanned into the Veteran's VA medical file which are not in the claims file, including the February 2015, March 2015, August 2019, September 2019, October 2019, November 2019, February 2020, January 2021, February 2021, December 2021, and May 2022 treatment records. 3. After outstanding records are obtained to the extent possible, ask the appropriate examiner (for erectile dysfunction) to review the Veteran's file. The necessity of an in-person examination is left to the discretion of the examiner. The examiner should opine regarding whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's erectile dysfunction was caused by or aggravated by his service-connected back disability, to include any medications for such disability, or his service-connected respiratory disability. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected condition. The examiner should consider all medical and lay evidence of record. The examiner should specifically address the Veteran's assertion that his erectile dysfunction is related to medications for his service-connected back disability and the online materials submitted by the Veteran in December 2017 listing drugs that can cause erectile dysfunction, including medication prescribed for his back. If the Veteran's reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject his contentions). The examiner is asked to explain the reasons behind any opinions expressed. 4. After outstanding records are obtained to the extent possible, ask the appropriate examiner (for shoulder disability) to review the Veteran's file. The necessity of an in-person examination is left to the discretion of the examiner. - The examiner should identify all right and left shoulder disabilities the Veteran has experienced at any time during the claims period, even if resolved. The examiner is advised that for VA purposes a "disability" includes pain causing functional impairment of earning capacity. - With regard to diagnosis/disability, the examiner should opine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's symptoms represent an objective indication of chronic disability resulting from an undiagnosed illness or a diagnosed, but medically unexplained chronic multi-symptom illness (MUCMI) related to the Veteran's Gulf War service. - For any disability identified (to include "pain" causing functional impairment of earning capacity) that is not determined to be an undiagnosed illness or MUCMI, the examiner should opine regarding whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disability had an onset in service or is otherwise related to service, to include Gulf War exposures. - For any arthritis disability, the examiner should also opine regarding whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the arthritis manifested to a compensable degree within one year of separation from service (i.e., May 1993). - The examiner should also opine regarding whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's shoulder disability was caused by or aggravated by his service-connected left upper extremity radial nerve disability. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected condition. The examiner should consider all medical and lay evidence of record. The examiner should specifically address the Veteran's reports of continuous pain since service, his service treatment records showing right and left shoulder complaints, including a notation of left shoulder pain relating to a left collar bone fracture, and the December 2017 private opinion that the Veteran's bilateral shoulder disability is more likely than not connected to his service. If the Veteran's reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject his contentions). The examiner is asked to explain the reasons behind any opinions expressed. 5. After outstanding records are obtained to the extent possible, ask the appropriate examiner (for wrist disability) to review the Veteran's file. The necessity of an in-person examination is left to the discretion of the examiner. - The examiner should identify all left wrist disabilities the Veteran has experienced at any time during the claims period, even if resolved, including arthritis. The examiner is advised that for VA purposes a "disability" includes pain causing functional impairment of earning capacity. - With regard to diagnosis/disability, the examiner should opine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's symptoms represent an objective indication of chronic disability resulting from an undiagnosed illness or a diagnosed, but medically unexplained chronic multi-symptom illness (MUCMI) related to the Veteran's Gulf War service. - For any disability identified (to include "pain" causing functional impairment of earning capacity) that is not determined to be an undiagnosed illness or MUCMI, the examiner should opine regarding whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disability had an onset in service or is otherwise related to service, to include Gulf War exposures. - For any arthritis disability, the examiner should also opine regarding whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the arthritis manifested to a compensable degree within one year of separation from service (i.e., May 1993). - The examiner should also opine regarding whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's wrist disability was caused by or aggravated by his service-connected left upper extremity radial nerve disability. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected condition. The examiner should consider all medical and lay evidence of record. The examiner should specifically address the Veteran's service treatment records showing left wrist pain and limited motion, left arm pain, and a scar on his left forearm. If the Veteran's reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject his contentions). The examiner is asked to explain the reasons behind any opinions expressed. 6. After outstanding records are obtained to the extent possible, ask the appropriate examiner (for right hand disability) to review the Veteran's file. The necessity of an in-person examination is left to the discretion of the examiner. - The examiner should identify all right hand disability (aside from the already service-connected right median nerve palsy with complete atrophy of thenar eminence) the Veteran has experienced at any time during the claims period, even if resolved, including arthritis. The examiner is advised that for VA purposes a "disability" includes pain causing functional impairment of earning capacity. - With regard to diagnosis/disability, the examiner should opine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's symptoms represent an objective indication of chronic disability resulting from an undiagnosed illness or a diagnosed, but medically unexplained chronic multi-symptom illness (MUCMI) related to the Veteran's Gulf War service. - For any disability identified (to include "pain" causing functional impairment of earning capacity) that is not determined to be an undiagnosed illness or MUCMI, the examiner should opine regarding whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disability had an onset in service or is otherwise related to service, to include Gulf War exposures. - For any arthritis disability, the examiner should also opine regarding whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the arthritis manifested to a compensable degree within one year of separation from service (i.e., May 1993). - The examiner should opine regarding whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that such disability was caused by or aggravated by his service-connected back disability. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected condition. The examiner should consider all medical and lay evidence of record. The examiner should specifically address the Veteran's assertion that his right hand disability is related to the incident in service when he injured his right arm in the antecubital fossa region while jumping off of an armored personnel carrier during service in Germany and his report that he slowly lost his grip since that time. The examiner should also address the October 2017 examiner's notation that the Veteran has right hand/thumb atrophy due to his back disability. If the Veteran's reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject his contentions). The examiner is asked to explain the reasons behind any opinions expressed. 7. After outstanding records are obtained to the extent possible, ask the appropriate examiner (for sleep apnea) to review the Veteran's file. The necessity of an in-person examination is left to the discretion of the examiner. - The examiner should identify all sleep disability the Veteran has experienced at any time during the claims period, even if resolved, to include sleep apnea. - The examiner should opine regarding whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's disability: (a) had an onset in service; (b) is otherwise related to service, to include his Gulf War exposures and consideration of how his MOS affected his sleep schedule; or (c) is caused by or aggravated by his service-connected respiratory disability. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected condition. - The examiner should opine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's symptoms represent an objective indication of chronic disability resulting from an undiagnosed illness or a diagnosed, but medically unexplained chronic multi-symptom illness (MUCMI) related to the Veteran's Gulf War service. The examiner should consider all medical and lay evidence of record. The examiner should specifically address the reports that the Veteran's snoring began in service, the May 2022 private opinion that the Veteran's sleep apnea more likely than not developed during service and is connected to service including burn pit exposure and sleep-wake cycles from serving as a combat engineer, and the materials submitted by the Veteran in June 2022 suggesting that allergies increase the likelihood for sleep apnea and contribute to apneic episodes. If the Veteran's reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject his contentions). The examiner is asked to explain the reasons behind any opinions expressed. 8. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Purcell, 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.