Citation Nr: A23000819 Decision Date: 01/17/23 Archive Date: 01/17/23 DOCKET NO. 220401-232682 DATE: January 17, 2023 ORDER Entitlement to service connection for sleep apnea, to include as secondary to service-connected coronary artery disease (CAD) status post coronary artery bypass graft (CABG), congestive heart failure (CHF), and atrial fibrillation (a "heart disability"), gastroesophageal reflux disease (GERD), deviated septum, and/or posttraumatic stress disorder (PTSD), is granted. Entitlement to service connection for a stroke, to include as secondary to service-connected heart disability and/or PTSD, is granted. Entitlement to service connection for left lower extremity (LLE) nerve disorder, to include as secondary to service-connected discogenic disease at L5-S1, is denied. Entitlement to service connection for hypertension, to include as due to in-service exposure to herbicide agents, is granted. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for right lower extremity (RLE) radiculopathy is denied. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for seborrheic dermatitis is denied. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for deviated septum is denied. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for GERD is denied. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for a heart disability is denied. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for surgical scar, status post CABG, is denied. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of a 100 percent initial evaluation for a heart disability is denied. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of a 100 percent evaluation for PTSD is denied. Entitlement to an effective date as of February 18, 2020 for the award of the grant of special monthly compensation (SMC) at the housebound rate under 38 U.S.C. § 1114(s) is granted. Entitlement to an effective date earlier than September 18, 2020 for the award of basic eligibility to Dependents' Educational Assistance (DEA) under 38 U.S.C. Chapter 35 is denied. REMANDED Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a sinus disorder, to include sinusitis, and to include as due to in-service exposure to herbicide agents, is remanded. FINDINGS OF FACT 1. Resolving all reasonable doubt in favor of the Veteran, the positive and negative evidence is in approximate balance that his currently diagnosed obstructive sleep apnea was caused by his service-connected heart disability, GERD, deviated septum, and/or PTSD. 2. Resolving all reasonable doubt in favor of the Veteran, the positive and negative evidence is in approximate balance that his currently diagnosed status post right basal ganglia stroke with left hemiparesis. 3. The most persuasive evidence demonstrates that the Veteran does not have a current diagnosis for a LLE nerve disorder separate from his service-connected status post right basal ganglia stroke with left hemiparesis. 4. Resolving all reasonable doubt in favor of the Veteran, the positive and negative evidence is in approximate balance that his currently diagnosed hypertension was caused by his in-service exposure to herbicide agents. 5. On September 18, 2020, VA received the Veteran's VA Form 21-0966 (Intent to File); there was no communication prior to September 18, 2020 and within one year of the formal claim that could be construed as an intent to file a claim. 6. In January 2021, the Veteran filed a VA Form 21-526EZ seeking service connection for ischemic heart disease/heart attack, paralysis of lower extremities, skin condition of the scalp, GERD/acid reflux, and sinusitis; and an increased evaluation for PTSD. 7. The evidence demonstrates that September 18, 2020 is the earliest date entitlement arose for the Veteran's 100 percent evaluation for a heart disability. 8. The evidence demonstrates that September 18, 2020 is the earliest date entitlement arose for the Veteran's 100 percent evaluation for PTSD. 9. Resolving all reasonable doubt in favor of the Veteran, the evidence demonstrates that as of February 18, 2020, but no earlier, it is factually ascertainable that he is permanently housebound based on his service-connected disabilities. 10. The evidence demonstrates that September 18, 2020 is the earliest date that the Veteran met the criteria for basic eligibility to DEA benefits. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for sleep apnea, to include as secondary to service-connected heart disability, GERD, deviated septum, and/or PTSD, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to service connection for a stroke, to include as secondary to service-connected heart disability and/or PTSD, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for entitlement to service connection for LLE nerve disorder, to include as secondary to service-connected discogenic disease at L5-S1, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for entitlement to service connection for hypertension, to include as due to in-service exposure to herbicide agents, have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for RLE radiculopathy have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400, 3.2400. 6. The criteria for entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for seborrheic dermatitis have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400, 3.2400. 7. The criteria for entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for deviated septum have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400, 3.2400. 8. The criteria for entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for GERD have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400, 3.2400. 9. The criteria for entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for a heart disability have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400, 3.2400. 10. The criteria for entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for surgical scar, status post CABG, have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400, 3.2400. 11. The criteria for entitlement to an effective date earlier than September 18, 2020 for the award of the grant of a 100 percent initial evaluation for a heart disability have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400, 3.2400. 12. The criteria for entitlement to an effective date earlier than September 18, 2020 for the award of the grant of a 100 percent evaluation for PTSD have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400, 3.2400. 13. The criteria for entitlement to an effective date as of February 18, 2020 for the award of the grant of SMC at the housebound rate under 38 U.S.C. § 1114(s) have been met. 38 U.S.C. §§ 1114(s), 5110, 5107; 38 C.F.R. §§ 3.102, 3.155, 3.350, 3.400. 14. The criteria for entitlement to an effective date earlier than September 18, 2020 for the award of basic eligibility to DEA under 38 U.S.C. Chapter 35 have not been met. 38 U.S.C. §§ 1155, 3501, 3510, 5107, 5113; 38 C.F.R. §§ 3.102, 3.340, 3.341, 3.400, 3.807(a), 4.3. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from August 1956 to October 1959 and from June 1962 to November 1976. Among other awards, the Veteran is in receipt of the Bronze Star Medal, Combat Infantryman Badge, Purple Heart, and Silver Star. The rating decisions on appeal were issued in April 2021 and July 2021 and constitute initial decisions; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies. The appellant initially requested the hearing option in the April 2022 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) (NOD). In August 2022, the appellant withdrew the hearing request; therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the appellant or his representative within 90 days following receipt of the withdrawal. 38 C.F.R. § 20.302(b). Although the issue certified to the Board was for entitlement to service connection for sinusitis, in light of Clemons v. Shinseki, 23 Vet. App. 1 (2009), the issue has been recharacterized as entitlement to service connection for a sinus disorder to comport with the record. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic diseases, such as hypertension and other organic diseases of the nervous system, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. That presumption is rebuttable by probative evidence to the contrary. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection when the requirements for application of the presumption are not met. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Other organic diseases of the nervous system include peripheral nerves conditions, such as peripheral neuropathy. Continuity of symptomatology may establish service connection if a claimant can demonstrate (1) that a condition was "noted" during service; (2) there is post-service evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). In addition, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). On August 10, 2022, the President signed into law the Sergeant First Class Health Robinson Honoring our Promise to Address Comprehensive Toxins Act of 2022 (PACT Act), Pub. L. No. 117-168, 136 Stat. 1759 (2022), which, in pertinent part, amended the provisions under 38 U.S.C. § 1116 to expand the presumption of exposure to certain herbicide agents to veterans who served in certain locations. A veteran who performed covered service shall be presumed to have been exposed during such service to an herbicide agent and may be presumed to have been exposed during service to any other chemical compound in an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 U.S.C. § 1116(c). The term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, specifically: 2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram. 38 U.S.C. § 1116(a)(3); 38 C.F.R. § 3.307(a)(6)(i). For purposes of application of this legal presumption, covered service means active military, naval, air, or space service performed (1) in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975; (2) in Thailand at any U.S. or Royal Thai base during the period beginning on January 9, 1962, and ending on June 30, 1976, without regard to where on the base the veteran was located or what military job specialty the veteran performed; (3) in Laos during the period beginning on December 1, 1965, and ending on September 30, 1969; (4) in Cambodia at Mimot or Krek, Kampong Cham Province during the period beginning on April 16, 1969, and ending on April 30, 1969; or (5) on Guam or American Samoa, or in the territorial waters thereof, during the period beginning on January 9, 1962, and ending on July 31, 1980, or served on Johnston Atoll or on a ship that called at Johnston Atoll during the period beginning on January 1, 1972, and ending on September 30, 1977. Veterans Agent Orange Exposure Equity Act of 2022, Pub. L. No. 117-168, Title IV, § 403(b), (d), 136 Stat. 1775, 1780-1782 (August 10, 2022); 38 U.S.C. § 1116(d). Furthermore, the PACT Act expanded the specific diseases associated with exposure to herbicide agents entitled to presumptive service. Fair Care for Vietnam Veterans Act of 2022, Pub. L. 117-168, Title IV, § 404(b), (c), 136 Stat. 1775, 1780-1782 (August 10, 2022). Those diseases that are listed at 38 U.S.C. § 1116(a)(2) and 38 C.F.R. § 3.309(e), including early-onset peripheral neuropathy and hypertension, shall be presumptively service-connected if there are circumstances establishing herbicide agent exposure during covered service, even though there is no record of such disease during such service. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.307(a); see also Veterans Agent Orange Exposure Equity Act of 2022. Hypertension is among the diseases associated with exposure to herbicide agents which have been added under the PACT Act. See 38 U.S.C. § 1116(a)(2)(M). Generally, 38 C.F.R. § 3.307(a) applies where an enumerated disease becomes manifest to a degree of 10 percent or more at any time after service. 38 C.F.R. § 3.307(a)(6)(ii). For early-onset peripheral neuropathy, the regulation applies where it became manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active service. 38 C.F.R. § 3.307(a)(6)(ii). Notwithstanding the provisions relating to presumptive service connection, a veteran may establish service connection for a disability with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In determining whether service connection is warranted, the Board shall consider the benefit-of-the-doubt doctrine. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claimant is entitled to the benefit-of-the-doubt when the competing evidence is in "approximate balance" or "nearly equal." That is, exact equipoise is not required to trigger the favorable benefit-of-the-doubt rule. Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021) (en banc). 1. Entitlement to service connection for sleep apnea, to include as secondary to service-connected heart disability, GERD, deviated septum, and/or PTSD The Veteran asserts that his sleep apnea was caused by a service-connected disability. The question before the Board is whether the Veteran's sleep apnea is etiologically related to his active duty service or was caused or aggravated by a service-connected disability. Based on a careful review of all subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for sleep apnea is warranted. The evidence shows that the Veteran has a current diagnosis for obstructive sleep apnea. See February 2021 VA treatment record. The Veteran's service treatment records (STRs) do not document any complaints, treatment, or diagnosis for any findings related to any sleep problems. At a November 1976 separation examination, there was no pertinent symptomatology noted. Post-service VA treatment records document the Veteran's reports of sleep problems. A February 2008 VA treatment record reflects that the Veteran complained of having poor sleep with early awakening after sleeping for two hours, difficulty returning to sleep, and feeling not well rested and sleepy the next day. At a March 2008 VA Sleep Medicine Consult, the VA physician documented the Veteran's witnessed sleep apnea and daytime somnolence. Subsequent VA treatment records from 2011 to 2021 show that the Veteran had moderate obstructive sleep apnea and was using a continuous positive airway pressure machine. No etiology for the Veteran's sleep apnea was discussed. In August 2022, the Veteran submitted an April 2022 opinion from Dr. M.S., a board certified physician in internal medicine. After conducting a review of the Veteran's relevant medical records and research of medical literature, Dr. M.S. noted that the Veteran had been definitively diagnosed with obstructive sleep apnea and additionally suffered from CAD, GERD, a deviated septum, and PTSD. Dr. M.S. opined that it was much more likely than that the Veteran's obstructive sleep apnea was a direct result of each one of his above noted service-connected disabilities. In making that conclusion, Dr. M.S. explained that more recent medical literature had found a previously unknown associated causal connection between CAD and obstructive sleep apnea. The presence of CAD promotes a state of proinflammatory and prothrombotic factors which promotes changes within the central nervous system. Such changes has the effect of interrupting normal neuronal pathways, which has a causal relationship to obstructive sleep apnea. Further, Dr. M.S. found that there is a mutual relationship between sleep and GERD. Noting that the precise mechanism by which GERD is associated with sleep apnea is unknown, Dr. M.S. stated that it has been shown that sleep disturbances may not only induce GERD but that there is a directly proportional relationship between sleep apnea and GERD, i.e., the more severe the GERD, the more severe the sleep apnea. Regarding the relationship between the Veteran's service-connected deviated septum and his obstructive sleep apnea, Dr. M.S. discussed how obstructive sleep apnea is a disorder of the upper respiratory system, which consists of the nose, nasal cavity, mouth, throat, and larynx. After describing the respiratory process that occurs during respiration and various dysfunctions, including sleep apnea, Dr. M.S. noted that with an almost complete nasal airway obstruction, the body will compensate by switching from nasal to mouth breathing. This results in a significant disadvantage as mouth breathing results in a minimum two and one-half times increase in higher total resistance, which is due primarily to the tongue and an increase in the oscillation of the soft palate, and is one of the well-established causes of sleep apnea. Finally, Dr. M.S. stated that the medical literature had documented a correlation between obstructive sleep apnea and PTSD. Sleep fragmentation, which is prevalent in PTSD, increases the propensity for upper airway collapse in patients with sleep apnea. In commenting on the VA examiners who disputed the causal connection between PTSD and sleep apnea, Dr. M.S. discussed how medical literature showed that prolonged sleep deprivation, sleep fragmentation, and hyperarousal are associated with military service or definitive contributing factors to obstructive sleep apnea, and which are also the etiology of PTSD. Further, the chronic stress associated with PTSD has been shown to increase the likelihood of developing obstructive sleep apnea and, bidirectionally, sleep disturbances of obstructive sleep apnea increase the likelihood of PTSD. Overall, Dr. M.S. determined that the medical literature substantiated that each one of the Veteran's service-connected disabilities was a direct cause of his sleep apnea. Taking into consideration the totality of the evidence, the Board finds that the April 2022 opinion from Dr. M.S. provides the most persuasive evidence regarding the etiology of the Veteran's obstructive sleep apnea as it was based on Dr. M.S.'s training, experience and review of the Veteran's medical records and medical literature research. Given that the record does not include any evidence to the contrary, the Board finds that the positive and negative evidence is in approximate balance that the Veteran's obstructive sleep apnea was caused by his service-connected CAD, GERD, deviated septum, and/or PTSD. Accordingly, resolving all reasonable doubt in favor of the Veteran, his service connection claim for sleep apnea must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for a stroke, to include as secondary to service-connected heart disability and/or PTSD The Veteran asserts that his stroke was caused by his service-connected heart disability and/or PTSD. The question before the Board is whether the Veteran's stroke was etiologically related to his active duty service or was caused or aggravated by a service-connected disability. Based on a careful review of all the subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for a stroke is warranted. The Veteran's STRs do not document any complaints, treatment, or diagnosis for any findings related to a stroke. At a November 1976 separation examination, no abnormal findings pertinent to a stroke was noted. The record shows that the Veteran was diagnosed with status post right basal ganglia stroke with left hemiparesis in October 2016. See January 2017 VA treatment record. Since the Veteran's stroke, he has had left-sided weakness on the left upper extremity and left lower extremity. See February 2021 VA treatment record. A December 2016 VA treatment record noted that the Veteran, who had paroxysmal atrial fibrillation, had a stroke, which was "thought to possibly be cardioembolic." In August 2022, the Veteran submitted an April 2022 opinion from Dr. M.S., a board certified physician in internal medicine. After conducting a review of the Veteran's relevant medical records and research of medical literature, Dr. M.S. opined that it was more likely than not that the Veteran's stroke was the direct result of his service-connected CAD and PTSD. Noting that the Veteran had sustained a cerebrovascular accident in 2016, specifically a lacunar infarct of the right side, Dr. M.S. explained that medical research shows that arteriosclerotic heart disease or CAD, which is the hardening of the arteries can and in fact does lead to heart attack or stroke. Indeed, Dr. M.S. discussed how without proper blood flow arriving and departing from the brain due to CAD/arteriosclerotic heart disease, several life threatening complications can result. Dr. M.S. noted that CAD or arteriosclerotic heart disease is one of the main risk factors for stroke. Additionally, Dr. M.S. described how PTSD is associated with the development of stroke risk factors, given the particular behavioral manifestations of PTSD that increase the risk of stroke, including poor medication compliance, poor sleep patterns, and poor nutrition. Dr. M.S. also stated that chronic stress modifies the brain morphology and function. Overall, Dr. M.S. concluded that the Veteran's specific medical history and medical literature supported finding that it was more likely than not that the Veteran's cerebrovascular accident was caused by his service-connected CAD and PTSD. Taking into consideration the totality of the evidence, the Board finds that the April 2022 opinion from Dr. M.S. provides the most persuasive evidence regarding the etiology of the Veteran's stroke as it was based on Dr. M.S.'s training, experience and review of the Veteran's medical records and medical literature research. Given that the record does not include any evidence to the contrary, the Board finds that the positive and negative evidence is in approximate balance that the Veteran's stroke was caused by his service-connected CAD and/or PTSD. Accordingly, resolving all reasonable doubt in favor of the Veteran, his service connection claim for a stroke must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for LLE nerve disorder, to include as secondary to service-connected discogenic disease at L5-S1 The Veteran asserts that his LLE nerve disorder was caused by his service-connected discogenic disease at L5-S1. The question before the Board is whether the Veteran has a current diagnosis for a LLE nerve disorder. Based on a careful review of all subjective and clinical evidence, the Board finds that the most persuasive evidence weighs against finding service connection for LLE nerve disorder is not warranted. The Veteran's STRs do not document any findings related to any complaints, treatment, or diagnosis for any LLE nerve problems. At a November 1976 separation, the Veteran had normal neurologic clinical evaluation results. On his associated report of medical history, nerve damage was only reported in his left hand and chest. Further, the Veteran also reported having recurring incapacitating back pains, but no other associated symptoms were identified. At an August 1977 VA examination, the Veteran reported having experienced acute low back pain with radiation down the LLE to the knee level while building an office unit in 1970 during service. He said that from 1974 to the present, the Veteran had low back pain which radiated down to the medial aspect of his left forefoot. He also describing feeling numbness and tingling paresthesias in his left foot. Following an objective evaluation of the Veteran's back, the August 1977 examiner found sciatic tenderness noted on the left. The Veteran was diagnosed with low back syndrome with radiculitis, left probably L5-S1. At a January 2017 VA clinic visit, the VA treating physician noted that the Veteran had completed his inpatient rehabilitation in December 2016 following his status post right basal ganglia stroke with left hemiparesis. The VA treating physician noted that the Veteran has had some spasms in the LLE, which were mild, but not affecting him. The Veteran was diagnosed with status post right basal ganglia stroke, left hemiparesis, and neuropathic pain. At a May 2021 VA peripheral nerves examination, the Veteran reported having left upper extremity and left lower extremity paralysis since a stroke occurred in October 2016. He had minimal movement of his left leg due to weakness. He reported having intermittent burning pain of his left leg and left foot with numbness and tingling. He was unable to walk or stand for short periods without the assistance of a hemi-walker. He was transported by wheelchair most of the time. Upon objective evaluation, the Veteran was diagnosed with left hemiplegia/hemiparesis following a cerebral infarction affecting left non-dominant side. The May 2021 VA examiner opined that the Veteran's left lower hemiplegia/hemiparesis was less likely than not proximately due to or the result of his service-connected discogenic disease L5-S1. The May 2021 VA examiner found that the conditions of paralysis of LLE and discogenic disease at L5-S1 are not medically related. The paralysis of LLE was a separate entity entirely from the discogenic disease at L5-S1 and unrelated to it. A thorough review of medical literature failed to demonstrate a causal relationship. In May 2021, the Veteran also underwent a VA spine examination. The Veteran reported having low back pain with lower extremity radiculopathy in both legs. The May 2021 VA examiner performed an objective evaluation. Muscle strength testing results showed no muscle movement on the left, which was found to be due to the Veteran's left hemiplegia secondary to stroke. Reflex examination results showed hyperactive without clonus results at the left knee and ankle, which was found to be due to the Veteran's neurologic condition of left hemiplegia secondary to stroke. The May 2021 VA examiner concluded that due to the Veteran's left hemiplegia from stroke in 2016, the VA examiner was unable to determine if left lower extremity was completely related to low back condition or due to left hemiplegia. No underlying disability, other than the Veteran's service-connected status post right basal stroke with left hemiparesis, has been clinically diagnosed during the appeal period or proximate thereto. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). While the Veteran is certainly competent to report his history of LLE neurological symptoms, he has not demonstrated that he has the requisite specialized knowledge or training to attribute his LLE nerve symptoms to a separate disability from his now service-connected left hemiparesis due to stroke. Layno v. Brown, 6 Vet. App. 465, 470 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran has not presented any competent and credible evidence of a current diagnosis for a LLE nerve disorder separate from his service-connected left hemiparesis due to a stroke. The available evidence does not support that the Veteran has any persistent symptomatology that would suggest that he has underlying chronic disability, other than that for which he is already service-connected. Accordingly, the Veteran's assertions that he may have an additional LLE nerve disorder has little probative value. In summary, the evidence is neither evenly balanced or approximately so with regard to whether the Veteran's claim for service connection for LLE nerve disorder is warranted. Rather, the evidence persuasively weighs against service connection for LLE nerve disorder. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application as to this claim. Lynch v. McDonough, 21 F.4th (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Accordingly, the service connection claim for LLE nerve disorder is denied. 4. Entitlement to service connection for hypertension, to include as due to in-service exposure to herbicide agents The Veteran asserts that his hypertension was caused by exposure to herbicide agents. The question before the Board is whether the Veteran's hypertension is etiologically related to his active duty service. Based on a careful review of all the subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for hypertension is warranted. At the outset, the Board notes that in the July 2021 rating decision, the AOJ found that the Veteran was exposed to herbicides during military service based on his confirmed service in the Republic of Vietnam. The AOJ also found that a May 2021 Disability Benefit Questionnaire confirmed the Veteran's current diagnosis for hypertension. The Board is bound by these favorable findings. 38 C.F.R. § 3.104(c). The Board recognizes that the May 2021 VA examiner opined that the Veteran's hypertension was less likely than not related to his active duty service. On that basis, the May 2021 VA examiner relied solely on the finding that there was no evidence of hypertension during service. However, the May 2021 VA examiner did not specifically address the Veteran's presumed in-service exposure to herbicide agents. Now, the Board must address whether the Veteran's currently diagnosed hypertension was directly caused by his exposure to herbicide agents during his active duty service. The Board notes that the National Academies of Sciences, Engineering, and Medicine, on November 15, 2018, moved hypertension to the category of "sufficient" evidence of an association from its previous classification in the "limited or suggestive" category, indicating that there is enough epidemiologic evidence to conclude that there is a positive association between hypertension and exposure to herbicide agents, including Agent Orange. See National Academy of Science (NAS) November 2018 update report titled, Veterans and Agent Orange Update 11 (2018). The Board finds that the study provided by the NAS, which is made up of experts in the given field of science, is probative evidence that is relevant here. Based on this recent scientific evidence, the Board finds that the persuasive evidence supports a finding that the Veteran's hypertension is etiologically related to his exposure to an herbicide agent while serving in Vietnam. Accordingly, resolving all reasonable doubt in favor of the Veteran, the Board concludes that the positive and negative evidence is in approximate balance that the Veteran's currently diagnosed hypertension was directly caused by his in-service exposure to herbicide agents. Therefore, the Veteran's service connection claim for hypertension must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Effective Date 5. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for RLE radiculopathy 6. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for seborrheic dermatitis 7. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for deviated septum 8. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for GERD 9. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for a heart disability 10. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of service connection for surgical scar, status post CABG The Veteran generally asserts that he warrants an effective date earlier than September 18, 2020 for the awards of service connection for RLE radiculopathy, seborrheic dermatitis, deviated septum, GERD, a heart disability, and surgical scar, status post CABG. Generally, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity based on an initial claim or supplemental claim will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Under 38 C.F.R. § 3.2400(a), the modernized review system, also known as the Appeals Modernization Act (AMA), is applicable to all claims or requests for reopening finally decided claims for which VA issues notice of a decision on or after the effective date of the AMA. The AMA became effective on February 19, 2019. 38 C.F.R. § 19.2(a). In this case, the Veteran filed a VA Form 21-0966 (Intent to File) on September 18, 2020. On January 20, 2021, the Veteran filed a VA Form 21-526EZ seeking service connection for ischemic heart disease/heart attack, paralysis of lower extremities, skin condition of the scalp, GERD/acid reflux, and sinusitis. Generally, if a formal application for benefits is received within a year of an intent to file, the date of claim for effective date purposes is the date the intent to file was received. 38 C.F.R. § 3.155(d)(1)(ii). Furthermore, once VA receives a complete claim, VA will adjudicate as part of the claim entitlement to any ancillary benefits that arise as a result of the adjudication decision. The claimant may, but need not, assert entitlement to ancillary benefits at the time the complete claim is filed. VA will also consider all lay and medical evidence of record in order to adjudicate entitlement to benefits for the claimed condition as well as entitlement to any additional benefits for complications of the claimed conditions. 38 C.F.R. § 3.155(d)(2). Here, in an April 2021 rating decision, the AOJ granted service connection for CAD. Subsequently, in a July 2021 rating decision, the AOJ granted service connection for surgical scar, status post CABG, GERD, deviated septum, seborrheic dermatitis of the scalp, and RLE radiculopathy. The AOJ assigned effective dates as of September 18, 2020, the date of VA's receipt of the Veteran's intent to file. The Board notes that the claims for surgical scar, status post CABG, and deviated septum were not specifically claimed by the Veteran. However, the issue was inferred and service connection was awarded in the July 2021 rating decision for the surgical scar, status post CABG, based on the findings of a May 2021 VA examination, which found that the Veteran had an anterior chest scar from his CABG. Similarly, as part of the Veteran's claim for sinusitis, he was afforded a VA examination in May 2021, during which he was diagnosed with deviated septum. Based on the overall evidence, the AOJ granted service connection for deviated septum in the July 2021 rating decision. Again both issues were assigned effective dates as of the date of the intent to file on September 18, 2020. A review of the record shows that there was no communication prior to September 18, 2020 and within one year of the formal claim filed on January 20, 2021 that could be construed as an intent to file a claim. The Board is sympathetic to the Veteran's assertions that he warrants an effective date earlier than September 18, 2020 for his awards of service connection for RLE radiculopathy, seborrheic dermatitis, deviated septum, GERD, a heart disability, and surgical scar, status post CABG. However, as the Veteran filed his intent to file on September 18, 2020, the Board finds that there is no legal basis upon which to assign an effective date earlier than September 18, 2020 for service connection RLE radiculopathy, seborrheic dermatitis, deviated septum, GERD, a heart disability, and surgical scar, status post CABG. In summary, the evidence is neither evenly balanced or approximately so with regard to whether the Veteran's claims for an effective date earlier than September 18, 2020 for the awards of the grant of service connection for RLE radiculopathy, seborrheic dermatitis, deviated septum, GERD, a heart disability, and surgical scar, status post CABG, are warranted. Rather, the evidence persuasively weighs against an effective date earlier than September 18, 2002 for the awards of the grant of service connection for RLE radiculopathy, seborrheic dermatitis, deviated septum, GERD, a heart disability, and surgical scar, status post CABG. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application as to these claims. Lynch v. McDonough, 21 F.4th (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Accordingly, the earlier effective date claims for the awards of service connection for RLE radiculopathy, seborrheic dermatitis, deviated septum, GERD, a heart disability, and surgical scar, status post CABG, are denied. 11. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of a 100 percent initial evaluation for a heart disability The Veteran generally asserts that he warrants an effective date earlier than September 18, 2020 for the award of a 100 percent evaluation for a heart disability. Generally, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity based on an initial claim or supplemental claim will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. In this case, the AOJ granted a 100 percent initial evaluation for a heart disability in a July 2021 rating decision. The AOJ assigned an effective date as of September 18, 2020, the date VA received the Veteran's intent to file. As noted above, the effective date of the evaluation will be the date of the claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. However, the effective date for the initial rating cannot be earlier than the award of service connection. As it has already been established that September 18, 2020 is the earliest date for the award of the grant of service connection for a heart disability, the Board may not assign the initial 100 percent evaluation for a heart disability prior to September 18, 2020. In summary, the evidence is neither evenly balanced or approximately so with regard to whether the Veteran's claim for an effective date earlier than September 18, 2020 for the award of the grant of a 100 percent initial evaluation for a heart disability is warranted. Rather, the evidence persuasively weighs against an effective date earlier than September 18, 2020 for the award of the grant of a 100 percent initial evaluation for a heart disability. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application as to this claim. Lynch v. McDonough, 21 F.4th (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Accordingly, the earlier effective date claim for the award of a 100 percent initial evaluation for a heart disability denied. 12. Entitlement to an effective date earlier than September 18, 2020 for the award of the grant of a 100 percent evaluation for PTSD The Veteran asserts that he warrants an effective date earlier than September 18, 2020 for the grant of a 100 percent evaluation for PTSD. Basically, the Veteran, through his attorney, asserts that the Veteran's initial 100 percent evaluation for his service-connected mental health disability, which was reduced in 1982, should be reinstated. Alternatively, the Veteran asserts that he definitely had symptoms that qualify him for a 100 percent evaluation up to one year prior to the filing of the intent to file. The method of determining the effective date of an increased evaluation is set forth in 38 U.S.C. § 5110(a) and (b)(2), and 38 C.F.R. § 3.400(o). The general rule with respect to the effective date of an award of increased compensation is that the effective date of such award "shall not be earlier than the date of receipt of application thereof." 38 U.S.C. § 5110(a). This statutory provision is implemented by regulation which provides that the effective date for an award of increased compensation will be the date of receipt of claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o)(1). An exception to the rule applies, however, under circumstances where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation. In that regard, VA regulations provide that the earliest date as of which it factually ascertainable based on all evidence of record that an increase in disability had occurred if a complete claim or intent to file a claim is received within one year from such date, otherwise, date of receipt of claim. When medical records indicate an increase in a disability, receipt of such medical records may be used to establish effective date(s) for retroactive benefits based on facts found of an increase in a disability only if a complete claim or intent to file a claim for an increase is received within one year of the date of the report of examination, hospitalization, or medical treatment. 38 C.F.R. § 3.400(o)(2). As background, the Veteran was awarded service connection for paranoid schizophrenia in a November 1977 rating decision. The AOJ assigned a 100 percent evaluation effective August 25, 1977. In a June 1982 rating decision, the AOJ reduced the Veteran's evaluation for schizophrenia to zero percent, effective March 12, 1982, when he did not report for an examination and the AOJ found no present evidence of any disabilities associated with schizophrenia. Based on the findings of a June 1982 examination, the AOJ awarded the Veteran a 70 percent evaluation for schizophrenia, effective June 7, 1982. The Veteran appealed that decision seeking a 100 percent evaluation, but his claim was denied in a March 1983 statement of the case. He did not file a Substantive Appeal, and the decision denying him a higher 100 percent evaluation for schizophrenia became final. Prior to September 18, 2020, the record does not show that the Veteran sought to file for an increased evaluation for his service-connected mental health disorder. The record shows that the Veteran filed a VA Form 21-0966 (Intent to File) on September 18, 2020. Within one year of that intent to file, on January 20, 2021, the Veteran filed a VA Form 21-526EZ seeking a higher evaluation for his service-connected mental health disorder. In an April 2021 rating decision, the AOJ granted a 100 percent evaluation for the Veteran's mental health disorder, now characterized as PTSD, effective September 18, 2020, the date the intent to file was received by VA. The Board considered whether it was factually ascertainable that the Veteran's PTSD increased in disability within the one-year period preceding the intent to file. However, the available evidence, either lay or medical, within that one-year period prior to September 18, 2020 does not demonstrate any such increase. Indeed, there is no evidence of mental health treatment during that period, and the Veteran did not provide any lay statements regarding his symptomatology during such period. Thus, the earliest date entitlement arose for the Veteran's 100 percent evaluation for PTSD is September 18, 2020. The Board is sympathetic to the Veteran's assertions that his mental health symptomatology qualifying him for a 100 percent evaluation existed prior to September 18, 2020. However, the available evidence does not support such a finding, and there is simply no legal authority for the Board to assign an effective date earlier than the date already assigned by the AOJ for the award of a 100 percent evaluation for PTSD under these circumstances. The pertinent legal authority governing effective dates is clear and specific, and the Board is bound by that authority. In summary, the evidence is neither evenly balanced or approximately so with regard to whether the Veteran's claim for an effective date earlier than September 18, 2020 for the award of the grant of a 100 percent evaluation for PTSD is warranted. Rather, the evidence persuasively weighs against an earlier effective date for the award of the grant of a 100 percent evaluation for PTSD. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application as to this claim. Lynch v. McDonough, 21 F.4th (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Accordingly, the earlier effective date claim for the award of the grant of a 100 percent evaluation for PTSD is denied. 13. Entitlement to an effective date as of February 18, 2020 for the award of the grant of SMC at the housebound rate under 38 U.S.C. § 1114(s) The Veteran is seeking an effective date earlier than September 18, 2020 for the award of the grant of SMC at the housebound rate under 38 U.S.C. § 1114(s). With respect to the effective dates of awards of SMC, the Board notes that claims for SMC are by definition a type of increased (i.e., "special") compensation. SMC is available when, as the result of a service-connected disability, a veteran suffers additional hardships above and beyond those contemplated by the rating schedule. Breniser v. Shinseki, 25 Vet. App. 64, 68 (2011); see also 38 U.S.C. § 1114(k)-(s). A veteran is presumed to be seeking the maximum benefit allowed by law or regulation; therefore, an appeal for a higher rating may include the inferred issue of entitlement to SMC even where the veteran has not expressly placed entitlement to SMC at issue. Akles v. Derwinski, 1 Vet. App. 118 (1991). Thus, claims for an earlier effective date for SMC are treated analogously to claims for an earlier effective date for increased ratings. SMC at the housebound rate is payable where the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). A veteran will be considered housebound where the evidence shows that, as a direct result of his service-connected disability or disabilities, he is substantially confined to his dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his lifetime. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). In this case, the Veteran was awarded SMC at the housebound rate in a July 2021 rating decision based on the finding that the Veteran met the statutory schedular criteria. The AOJ assigned an effective date as of September 18, 2020, the date VA received the Veteran's intent to file. The Board considered whether it was factually ascertainable within the one-year period preceding the date of the intent to file that the Veteran warranted SMC at the housebound rate. In that regard, the Board notes that a February 18, 2020 VA Social Work Note stated that the Veteran's care needs were based on his diagnoses for cerebral infarction, open heart surgery and chronic osteoarthritis. The Veteran's wife reported that the Veteran was paralyzed on his left side and needed total assistance with dressing. He had received a hospital bed, but struggled with bed mobility. He used a power wheelchair for mobility. Following a review of the Veteran's care needs, the Veteran was found to be homebound. Without the assistance of a home health aide, the Veteran would be in need of nursing home care. The Veteran was found to have significant cognitive impairment, was dependent in three or more activities of daily living, including bathing, dressing and transferring, was clinically depressed, and was dependent in three or more independent activities of daily living, including transferring, meal preparation, light housekeeping, mobility (ability to leave home), and laundry. Based on these findings, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence supports that as of February 18, 2020, the Veteran met the criteria for being housebound on a factual basis. Thus, the Veteran's claim for an effective date as of February 18, 2020, but no earlier, for the award of the grant of SMC at the housebound rate under 38 U.S.C. § 1114(s) is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 14. Entitlement to an effective date earlier than September 18, 2020 for the award of basic eligibility to DEA under 38 U.S.C. Chapter 35 The Veteran is seeking an effective date earlier than September 18, 2020 for the award of basic eligibility to DEA under 38 U.S.C. Chapter 35. Except as provided in subsections (b) and (c), effective dates relating to awards under Chapter 35 shall, to the extent feasible, correspond to effective dates relating to awards of disability compensation. 38 U.S.C. § 5113. Subsection (b) provides that when determining the effective date of an award under Chapter 35 for an individual described in paragraph (b)(2) of 38 U.S.C. § 5113, based on an original claim, VA may consider the individual's application as having been filed on the eligibility date of the individual if that eligibility date is more than one year before the date of the initial rating decision. For these purposes, "eligibility date" means the date on which the individual became an eligible person as defined by 38 U.S.C. § 5113 (a)(1), and "initial rating decision" means a decision by VA that establishes the veteran's total disability as permanent in nature. 38 U.S.C. § 5113(b)(3). In the case of a veteran who is alive, the conditions for basic eligibility for DEA include: (1) the Veteran's discharge from service under conditions other than dishonorable; and (2) the Veteran has a permanent total service-connected disability. 38 C.F.R. § 3.807(a). Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Total disability may or may not be permanent. 38 C.F.R. § 3.340(a). A permanent total disability will be taken to exist when such impairment is reasonably certain to continue throughout the life of the disabled person. 38 C.F.R. § 3.340(b). Permanent total disability ratings may not be granted as a result of any incapacity from acute infectious disease, accident, or injury, unless there is present one of the recognized combinations or permanent loss of use of extremities or sight, or the person is in the strict sense permanently helpless or bedridden, or when it is reasonably certain that a subsidence of the acute or temporary symptoms will be followed by irreducible totality of disability by way of residuals. The age of the disabled person may be considered in determining permanence. Id. The term "total disability permanent in nature" for the purpose of DEA benefits means any disability rated total for the purposes of disability compensation which is based upon an impairment reasonably certain to continue throughout the life of the disabled person. 38 U.S.C. § 3501(a)(8). In an April 2021 rating decision, the AOJ awarded the Veteran basic eligibility to DEA benefits, effective September 18, 2020, based upon the determination that he had a permanent and total service-connected disability by virtue of his 100 percent evaluation for PTSD. Since the effective date for DEA benefits is directly related to a finding that the Veteran has a total disability that was permanent in nature, an effective date prior to September 18, 2020 is not warranted, as neither of the effective dates for the 100 percent evaluations for PTSD and a heart disability have changed. In summary, the evidence is neither evenly balanced or approximately so with regard to whether the Veteran's claim for an effective date earlier than September 18, 2020 for the award of basic eligibility to DEA under 38 U.S.C. Chapter 35 is warranted. Rather, the evidence persuasively weighs against an effective date earlier than September 18, 2020 for the award of basic eligibility to DEA under 38 U.S.C. Chapter 35. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application as to this claim. Lynch v. McDonough, 21 F.4th (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Accordingly, the earlier effective date claim for the award of basic eligibility to DEA under 38 U.S.C. Chapter 35 is denied. REASONS FOR REMAND 1. Entitlement to service connection for a left shoulder disability is remanded. The issue of entitlement to service connection for a left shoulder disability is remanded to correct a duty to assist error that occurred prior to the July 2021 rating decision on appeal. The Veteran asserts that he injured both shoulders during his Vietnam service, when he was pulling and carrying another soldier to safety. His STRs show that he was diagnosed with bilateral shoulder strain in March 1975. At a May 2021 VA examination, the VA examiner diagnosed the Veteran with left shoulder subluxation; however, the VA examiner did not provide an etiological opinion specifically addressing that diagnosis. Rather, the VA examiner found that the Veteran's left shoulder hemiparesis (complete loss of function) was due to his status post right basal ganglia infarct that occurred in 2016 and was unrelated to his bilateral shoulder strain. Because the May 2021 VA examiner did not address the Veteran's left shoulder subluxation diagnosis, the Board finds that the May 2021 VA opinion is inadequate for adjudicative purposes. Accordingly, a remand is required to obtain a supplemental opinion and to correct the pre-decisional duty to assist error. The Board emphasizes that it is not determining whether or not the Veteran's statements that his current left shoulder disability was related to his in-service left shoulder injury are credible at this time, as the additional development set forth in the directives below could impact that determination. Although the Board is requesting a medical opinion regarding his lay contentions, this is for thoroughness and not based on a finding these contentions are credible. 2. Entitlement to service connection for a sinus disorder, to include sinusitis, and to include as due to in-service exposure to herbicide agents, is remanded. The issue of entitlement to service connection for a sinus disorder is remanded to correct a duty to assist error that occurred prior to the July 2021 rating decision on appeal. In a May 2021 VA opinion, the VA examiner diagnosed the Veteran with allergic rhinitis, found that there was no objective evidence to support a chronic diagnosis for sinusitis, and stated that the Veteran's STRs did not include a diagnosis for sinusitis during and after service. However, a review of the record shows that at the time of the Veteran's separation from service, on his November 1976 report of medical history, the examiner noted as follows, "ENT nasal congestion sinusitis." No further information was provided on his November 1976 separation examination report, and this notation was the only reference to sinusitis found in the Veteran's STRs. Furthermore, post-service VA treatment records starting in 2008 document the Veteran's complaints for chronic sinus congestion. He also indicated that he has had trouble breathing through his nose since he underwent a nasal procedure in the 1960's. Because the May 2021 VA examiner did not address the Veteran's complete medical history, the Board finds that the May 2021 VA opinion is inadequate for adjudicative purposes. Accordingly, a remand is required to obtain a clarifying opinion regarding the Veteran's reported symptoms and current diagnosis and to correct a pre-decisional duty to assist error. The Board emphasizes that it is not determining whether or not the Veteran's statements that he has experienced nasal congestion and trouble breathing through his nose since service are credible at this time, as the additional development set forth in the directives below could impact that determination. Although the Board is requesting a medical opinion regarding these lay contentions, this is for thoroughness and not based on a finding those contentions are credible. The matters are REMANDED for the following actions: 1. Obtain an addendum opinion from an appropriately qualified clinician (M.D.) to determine whether the Veteran's current left shoulder disability had its onset during active duty or was otherwise etiologically related to service, to include his reported in-service left shoulder injury while pulling and carrying another soldier to safety. In providing the above opinion, the examiner must specifically address the May 2021 VA examiner's diagnosis for left shoulder subluxation. The examiner must also address the Veteran's in-service diagnosis for left shoulder strain in March 1975. Finally, the examiner must consider that the Veteran has received multiple combat medals for his military service. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 2. Obtain an addendum opinion from an appropriately qualified clinician (M.D.) to clarify whether the Veteran has a current sinus disorder and whether such disorder had its onset during active duty service or was otherwise etiologically related to service, to include his exposure to herbicide agents. In providing the above opinion, the examiner must address the following: (a.) Assertions that the Veteran had nasal congestion during service and that those symptoms continued following service. (b.) The November 1976 notation on the Veteran's report of medical history that he had nasal congestion symptoms and a diagnosis for sinusitis. (c.) VA treatment records documenting the Veteran's complaints of chronic nasal congestion and trouble breathing through his nose. (d.) The Veteran is presumed to have been exposed to herbicide agents during service. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Journet Shaw, 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.