Citation Nr: 23041537
Decision Date: 07/28/23 Archive Date: 07/28/23

DOCKET NO. 18-34 422A
DATE: July 28, 2023

ORDER

Service connection for periodontal disease, to include gingivitis, for compensation purposes is denied.

Service connection for hypercholesterolemia (high cholesterol) is denied.

REMANDED

Service connection for a pulmonary disorder, to include fibrosing mediastinitis (FM), asthma, pulmonary hypertension, chronic obstructive pulmonary disease (COPD), and pulmonary nodules, is remanded.

Service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD) and depression is remanded.

Service connection for hypothyroidism is remanded.

Service connection for an immune disorder, to include Hashimoto's thyroiditis, claimed as secondary to FM, is remanded.

Service connection for obstructive sleep apnea (OSA), claimed as secondary to FM or obesity, is remanded.

Service connection for diabetes mellitus, type 2, claimed as secondary to FM, obesity, or an immune disorder, is remanded.

Service connection for a skin disorder, to include tinea versicolor and facial lesions, claimed as secondary to FM, is remanded.

Service connection for a heart condition, claimed as secondary to FM, is remanded.

Service connection for a right shoulder disability, to include arthritis, is remanded.

Service connection for a left shoulder disability, to include arthritis, is remanded.

Service connection for a right elbow disability, to include arthritis is remanded.

Service connection for a left elbow disability, to include arthritis is remanded.

Service connection for a right hand/fingers disability, to include arthritis, is remanded.

Service connection for a left hand/fingers disability, to include arthritis is remanded.

Service connection for a right hip disability, to include arthritis is remanded.

Service connection for a left hip disability, to include arthritis, is remanded.

Service connection for a right knee disability, to include arthritis is remanded.

Service connection for a left knee disability, to include arthritis is remanded.

Service connection for a left foot disability is remanded.

Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded.

FINDINGS OF FACT

1. The Veteran's periodontal disease, to include gingivitis, is not a disability for VA compensation purposes.

2. The Veteran's hypercholesterolemia (high cholesterol) is not a disability for VA compensation purposes.

CONCLUSIONS OF LAW

1. The criteria for service connection for periodontal disease, to include gingivitis, for compensation purposes are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.381, 4.150.

2. The criteria for entitlement to service connection for hypercholesterolemia are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from January 1988 to January 1995.

This case comes to the Board of Veterans' Appeals (Board) on appeal from a decision of the Agency of Original Jurisdiction (AOJ) dated in September 2015.

The Veteran testified before the undersigned Veterans Law Judge at an October 2022 hearing; a transcript of the hearing is of record.

The Board has recharacterized the Veteran's claims of service connection for a pulmonary disorder and a psychiatric disorder as reflected on the title page to include consideration of all disabilities reasonably raised by the record. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that the scope of a disability claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record).

Service Connection

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 elements required to establish service connection are: (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). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d).

1. Service connection for periodontal disease (to include gingivitis) is denied.

The Veteran contends that she has gingivitis that was treated in service. See her March 2015 claim, September 2016 notice of disagreement, October 2022 Board hearing transcript at pages 27 to 28.

Gingivitis is defined as inflammation of the gingivae (gums); when it is associated with bony changes, the condition is referred to as periodontitis. See Dorland's Illustrated Medical Dictionary 775 (32nd ed. 2012). Periodontal disease is defined as any of a group of pathological conditions that affect the surrounding and supporting tissues of the teeth, generally classified as inflammatory (gingivitis and periodontitis), dystrophic (periodontal trauma and periodontosis), and anomalies. Id., at page 541.

Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not compensable disabilities. 38 C.F.R. § 3.381 (b).

The Veteran has a current diagnosis of periodontal disease. See August 2018 VA dental and oral conditions examination. The examiner opined that the Veteran did not have a diagnosis of gingivitis that was at least as likely as not incurred in or caused by the conditions during service. The rationale was that a review of the Veteran's service treatment records showed that she received routine dental treatment including restorations, cleanings, and extraction of 3rd molars, and had slight periodontitis for which she received routine maintenance recalls.

The Veteran's service dental records reflect treatment for slight (incipient) periodontitis.

Periodontal disease is not a disability for VA compensation purposes. See 38 C.F.R. §§ 3.381(b), 4.150. Thus, entitlement to service connection for periodontal disease (to include gingivitis) for compensation purposes must be denied.

As the competing evidence is not in approximate balance, or nearly equal, the benefit-of-the-doubt rule is inapplicable, and the claim of service connection for periodontal disease, to include gingivitis, for compensation purposes must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

2. Service connection for hypercholesterolemia (high cholesterol) is denied.

The Veteran contends that she has hypercholesterolemia (high cholesterol) that is related to service. See her March 2015 claim.

Upon review of the record, the Board finds that service connection for hypercholesterolemia (high cholesterol) is not warranted. Although the evidence of record shows that the Veteran has high cholesterol, hypercholesterolemia is a laboratory finding and is not considered a disabling condition for VA purposes. See 38 U.S.C. §§ 1110, 1131; see also Allen v. Brown, 7 Vet. App. 439, 448 (1995) (noting that based on the definition found in 38 C.F.R. § 4.1, the term disability "should be construed to refer to impairment of earning capacity due to disease, injury, or defect, rather than to the disease, injury, or defect itself"); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). As high cholesterol does not represent a disability, service connection must be denied.

REASONS FOR REMAND

1. Service connection for a pulmonary disorder, to include fibrosing mediastinitis (FM), asthma, COPD, pulmonary hypertension, and pulmonary nodules, is remanded.

The Veteran initially claimed service connection for interstitial pulmonary fibrosis, pleurisy, asthma, chest pain, and shortness of breath. See her March 2015 claim and September 2016 notice of disagreement. She now contends that she had undiagnosed histoplasmosis prior to entry into service, that was aggravated during service and ultimately resulted in fibrosing mediastinitis (FM). See her statements dated in October 2017, July 2019, and June 2022, and October 2022 Board hearing transcript, at page 19.

In her July 2019 statement, the Veteran said she originally filed a claim of service connection for interstitial pulmonary fibrosis because it was the closest match to FM. At the Board hearing, she testified that she had never been diagnosed with interstitial fibrosis, but had been diagnosed with FM, asthma, and pulmonary hypertension, and asserted that the latter two conditions were related to FM. See Board hearing transcript, at page 21.

As noted above, the Board has recharacterized this claim in light of the Veteran's contentions and the evidence of record. See Clemons, supra (a claim is not necessarily limited in scope to a single or particular diagnosis and should be construed based on the reasonable expectations of the non-expert, self-represented claimant and the evidence developed in processing that claim); Murphy v. Wilkie, 983 F.3d 1313, 1320 (Fed. Cir. 2020) (explaining that, to comply with the Clemons lenient-claim-scope rule, "VA must look to all possible diseases or injuries for which the veteran could have reasonably expected to have included in the filing").

The Board notes that prior to active duty, on medical examination performed for U.S. Air Force ROTC commissioning purposes in November 1986, the examiner noted that the Veteran's pulmonary function tests (PFTs) were within normal limits. See DPRIS Response, pages 102-103, received on August 25, 2018.

Service treatment records reflect occasional treatment for upper respiratory infections.

Post-service medical records show that the Veteran has been diagnosed with fibrosing mediastinitis, asthma, pulmonary hypertension, pulmonary nodules, and COPD. See private medical records from Baptist Memorial Hospital dated from October 2006 to February 2007, private medical records received from the Social Security Administration (SSA), including a report of a June 2010 medical examination by E.W., MD, and VA pulmonary treatment notes dated in August 2012, October 2017, September 2018, and December 2018. A July 2019 VA pulmonary note reflects a diagnostic assessment of dyspnea that is likely multifactorial, pulmonary hypertension, tobacco abuse, COPD, and OSA.

The Board cannot make a fully-informed decision on the issue of service connection for a pulmonary disorder because no VA examiner has opined whether any current pulmonary disorder is related to service. This claim is remanded for a VA examination and medical opinion.

2. Service connection for an acquired psychiatric disorder, to include PTSD and depression, is remanded.

The Veteran contends that she has PTSD due to in-service stressors, including military sexual trauma (MST) and sexual harassment, and has depression secondary to PTSD and/or her other medical conditions.

Private medical records reflect that over the years, the Veteran has been diagnosed with various psychiatric disorders, including obsessive-compulsive disorder (OCD), questionable schizophrenia, anxiety, major depressive disorder, and a provisional diagnosis of undifferentiated somatoform disorder. See SSA records including a January 2003 private medical record from Urgent Care, and reports of psychological examinations performed for the SSA in June 2010 and August 2011.

Subsequent VA medical records reflect diagnoses of pathological gambling, depression, anxiety, major depressive disorder, and PTSD. See VA mental health notes dated in March 2014, December 2020, April 2021, and May 2022.

In a July 2018 statement in support of claim for service connection for PTSD secondary to personal assault (VA Form 21-0781a), the Veteran reported an in-service incident in August 1989, while she was on temporary duty, in which she went to dinner with her supervisor who tried to give her lots of alcohol, and then tried to kiss her when they were walking back to her hotel. At the hotel he tried to enter her hotel room despite her refusal, and tried to force the door open. She said she struggled to shut the door and managed to lock the door while he was trying to get in. She said she reported the incident to women in her office, who told a female captain who spoke to her about the incident and said she had to document it.

In a July 2019 statement, she said that during service, her superior tried to kiss her and then tried to force himself into her room. She stated that he later retaliated when she did not give in to his demands. She submitted buddy statements from her sister and a coworker, I.L.C., in support of her statement.

An April 2021 VA mental health note reflects that the Veteran reported MST during service, and said she tried to report the incident when she was in service, but did not remember the SARC's full name and had not been able to track her down. The psychiatrist diagnosed major depressive disorder and chronic PTSD secondary to MST.

In a June 2022 statement and during the October 2022 Board hearing, the Veteran reported that the above in-service stressor involving her supervisor also included MST, and occurred in the summer of 1988. She also reported two additional incidents: one in April 1988, when someone followed her from the gym and tried to get into her room, and kept telephoning her afterward, and another in 1993 when she was working at a golf course cleaning bathrooms, and an acquaintance tried to kiss her and sexually assault her, but she convinced him to leave. A remand is required to allow VA to attempt to corroborate the Veteran's reported stressors.

Remand is also required for a VA examination and medical opinion as to whether any current psychiatric disorder is related to service.

3. Service connection for hypothyroidism is remanded.

4. Service connection for an immune disorder, to include Hashimoto's thyroiditis, claimed as secondary to FM, is remanded.

5. Service connection for obstructive sleep apnea (OSA), claimed as secondary to FM or obesity, is remanded.

6. Service connection for diabetes mellitus, type 2, claimed as secondary to FM, obesity, or an immune disorder, is remanded.

The Veteran contends that she incurred hypothyroidism in service, which resulted in weight gain during service, and that she recalled being told that she was snoring by her former husband in 1990, and by her parents in 1991, and that this was around the time she gained weight. See her June 2022 statement, Board hearing transcript, at page 24. She contends that she has an immune disorder secondary to FM. See her March 2015 claim. She contends that she has sleep apnea due to FM or weight gain. See her March 2015 claim, and July 2022 statement. She contends that she has diabetes mellitus, type 2, that is secondary to FM, weight gain due to MST, or an immune disorder. See Board hearing transcript, at pages 4-6, 23.

Service treatment records reflect that in January 1990, the Veteran reported that she had previously been prescribed Levothyroxine. In July 1991, she was diagnosed with obesity (at a weight of 144). In June 1992, she requested a thyroid check, and said she was gaining weight even with dieting and tired easily. She weighed 165. She was referred for thyroid function tests and blood tests, which were noted to be normal later that month. In October 1993, she was referred by her squadron for weight management, at which time her weight was 162.

VA medical records and private medical records received from the SSA reflect diagnoses of hypothyroidism, diabetes mellitus, type 2, obesity, and obstructive sleep apnea (OSA). See November 2011 medical examination by W.G., MD, July 2012 VA outpatient treatment record, and March 2014 sleep study. A September 2006 private medical record from Urgent Care dated in September 2006 reflects that the Veteran had a prior medical history of thyroid disease.

SSA records include a June 2010 medical examination by E.W., MD, which indicates that the Veteran originally had Hashimoto's thyroiditis and was now on thyroid supplementation. The pertinent diagnostic assessments were obesity and thyroid problems. The Board notes that Hashimoto's thyroiditis is an autoimmune disorder.

Obesity can be an intermediate step between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310. Walsh v. Wilkie, 32 Vet. App. 300, 306-07 (2020). In other words, service connection may be established on a secondary basis for a disability which would not have occurred but for obesity that was caused or aggravated by a service-connected disability. Id.

Remand is necessary for an opinion addressing whether the claimed conditions are related to service or a service-connected disability, or whether obesity, as an intermediate step for secondary service connection, was caused or aggravated by a service-connected disability.

7. Service connection for a skin disorder, to include tinea versicolor and facial lesions, claimed as secondary to FM, is remanded.

The Veteran contends that she has skin disorders, to include tinea versicolor and facial lesions, that were incurred in service as a result of histoplasmosis and/or sun exposure, or that is secondary to FM. See Board hearing transcript at pages 26-27.

Service treatment records reflect treatment for tinea versicolor in August 1990 and April 1992, and for facial lentigines in January 1994. On separation medical examination in October 1994, the Veteran's skin was listed as normal, and in an October 1994 report of medical history, the examiner noted that the Veteran had a history of a skin rash since 1988 of the upper body and neck, diagnosed as tinea versicolor, but had no current disability.

VA medical records reflect treatment for actinic keratoses, seborrheic keratoses, and sebaceous hyperplasia. See, e.g., VA dermatology notes dated in March 2019 and February 2022.

The Board cannot make a fully-informed decision on the issue of service connection for a skin disorder because no VA examiner has opined whether any current skin disorder is related to service. This claim is remanded for a VA examination and medical opinion.

8. Service connection for a heart condition, claimed as secondary to FM, is remanded.

The Veteran contends that she has a heart condition, including a heart murmur, that was incurred in service or is secondary to FM. See Board hearing transcript, at page 25.

The Board notes that on medical examination performed for U.S. Air Force ROTC commissioning purposes in November 1986 (prior to active service), the examiner noted a benign Grade II/VI systolic decrescendo heart murmur with LSB. See DPRIS Response, pages 102-103, received on August 25, 2018. A systolic heart murmur was also noted on periodic medical examination in July 1993 and on separation medical examination in October 1994. A July 1993 echocardiogram was normal.

The Board cannot make a fully-informed decision on the issue of service connection for a heart condition because no VA examiner has opined whether any current heart condition is related to service. This claim is remanded for a VA examination and medical opinion.

9. Service connection for a right shoulder disability, to include arthritis, is remanded.

10. Service connection for a left shoulder disability, to include arthritis, is remanded.

11. Service connection for a right elbow disability, to include arthritis, is remanded.

12. Service connection for a left elbow disability, to include arthritis, is remanded.

13. Service connection for a right hand/fingers disability, to include arthritis, is remanded.

14. Service connection for a left hand/fingers disability, to include arthritis, is remanded.

15. Service connection for a right hip disability, to include arthritis, is remanded.

16. Service connection for a left hip disability, to include arthritis is remanded.

17. Service connection for a right knee disability, to include arthritis, is remanded.

18. Service connection for a left knee disability, to include arthritis, is remanded.

The Veteran contends that she has disabilities of the bilateral shoulders, bilateral elbows, bilateral hands and fingers, bilateral hips, and bilateral knees, including arthritis and joint pain, that are related to service. See her March 2015 claim, September 2015 report of general information, and October 2022 Board hearing transcript. She testified that she was treated for joint pain and arthritis in service, and had continuing symptoms of joint pain after service. See her June 2022 statement, and Board hearing transcript, at page 24. She also contends that she has an immune disorder that caused arthritis. Id., at page 23.

Medical records received from the SSA include a report of a November 2011 medical examination reflecting a diagnostic assessment of arthritic complaints, predominantly of the knees, and probable degenerative joint disease and osteoarthritis.

The Board cannot make a fully-informed decision on the issues of service connection for disabilities of the right shoulder, left shoulder, right elbow, left elbow, right hand/fingers, left hand/fingers, right hip, left hip, right knee, or left knee because no VA examiner has opined whether these disabilities are related to service.

19. Service connection for a left foot disability, claimed as secondary to PTSD, is remanded.

The Veteran initially claimed service connection for a toe condition. At the Board hearing, she clarified that she was seeking service connection for disabilities of the left foot, including the second toe, a "little ball" on the bottom of her foot, and plantar fasciitis. She contends that these left foot conditions are due to running in military boots during service, and that she had left foot problems ever since service. See Board hearing transcript, at pages 29-30. Alternatively, she contends that her left foot/toe condition is secondary to PTSD and personal trauma. See her March 2015 claim.

Service treatment records reflect that in July 1991, the Veteran was treated for complaints of striking her right forefoot and the medial border of the left great toe three days ago when she fell off a chair at home. X-ray studies of the right foot and left great toe were negative for fractures. She was diagnosed with contusions of the right foot and left great toe. She was treated for a small puncture wound of the left foot in July 1992, after reportedly stepping on a rusty nail.

VA medical records reflect treatment for complaints of foot pain.

The Board cannot make a fully-informed decision on the issue of service connection for a left foot disability because no VA examiner has opined whether this disability is related to service.

20. Entitlement to a TDIU is remanded.

Finally, because a decision on the above remanded issues could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. A remand of the claim for a TDIU is required.

The Veteran has previously submitted Veteran's Applications for Increased Compensation Based on Unemployability (VA Form 21-8940) in March 2015 and July 2018, in which she reported that her highest level of education was four years of college, and that she last worked in October 2009.

The Veteran should be asked to complete a new VA Form 21-8940, since she has reported subsequent employment in 2021 and 2022. See Board hearing transcript, at page 30-32. The Board observes that she has also reported that she has a master's degree in management and procurement. See SSA records including reports of psychological examinations by B.T., Psy.D. in June 2010, J.M., Ph.D. in August 2011, and W.G., MD in November 2011, and an April 2021 VA mental health note.

The matters are REMANDED for the following action:

1. Obtain updated VA medical records.

2. Attempt to corroborate the Veteran's claimed in-service stressors based on personal assault, including MST and sexual harassment. The Veteran stated that she reported one of the incidents, involving her supervisor, soon after it occurred. See Board hearing transcript, pages 7-8, and VA mental health note dated April 30, 2021. If more details are needed, contact the Veteran to request the information.

3. Send the Veteran a VA Form 21-8940, and ask her to fill the form out completely.

4. Schedule the Veteran for a VA examination for her claimed pulmonary disorders. The examiner must review the claims file, including her service treatment records, which include a November 1986 medical examination performed for U.S. Air Force ROTC commissioning purposes reflecting that pulmonary function tests (PFTs) were within normal limits. See DPRIS Response, pages 102-103, received on August 25, 2018.

The examiner is asked to provide a response to the following:

Is it at least as likely as not (approximately 50 percent probability) that any current pulmonary disorder, to include fibrosing mediastinitis (FM), asthma, pulmonary hypertension, COPD, and pulmonary nodules, is related to service, including documented upper respiratory infections, or claimed undiagnosed histoplasmosis?

In providing the requested opinion, consider the Veteran's description of her in-service symptoms as well as her post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms in service and thereafter represented the onset of her current disability, this should be noted. Stated another way, do the Veteran's reports about her symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible?

A complete rationale should be provided for all opinions, citing to specific evidence of record and medical principles, as necessary. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training).

If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional with the knowledge and training needed to render such an opinion.

5. After the Veteran's reported stressors have been developed, schedule the Veteran for a psychiatric examination to determine the nature and etiology of any posttraumatic stress disorder (PTSD). If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. The claims file, including service records and records from the SSA, must be reviewed.

The examiner must opine whether the evidence of record, including the Veteran's lay statements (including her July 2018 (VA Form 21-0781a) and hearing testimony, statements made by C.J. (her sister) and I.L.C. in July 2019, statements made by R.S.S., L.P., and R.C. in December 2022, and the Veteran's service records, corroborate the claim that a personal assault occurred in service (38 C.F.R. § 3.304(f)(5)). If the examiner finds that evidence indicates that a personal assault occurred during the Veteran's active service, the examiner must opine whether any PTSD is at least as likely as not related to the in-service personal assault.

If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not (approximately 50 percent probability) related to an in-service injury, event, or disease, to include claimed MST and sexual harassment.

The examiner should also provide an opinion as to whether any of the Veteran's other currently diagnosed medical conditions may be attributed in any way (either causally or by aggravation) to a history of MST.

A complete rationale for the examiner's opinions should be provided, citing to specific evidence of record, as necessary. Citation to relevant peer reviewed medical literature reviewed in rendering the opinion would be of considerable assistance to the Board. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided.

6. Schedule the Veteran for a VA examination for her claimed hypothyroidism, immune disorder (to include Hashimoto's thyroiditis), OSA, diabetes mellitus, type 2, and a skin disorder (to include tinea versicolor and facial lesions). The examiner must review the claims file.

The examiner is asked to provide a response to the following:

(a) For diagnosed hypothyroidism and claimed immune disorder (to include Hashimoto's thyroiditis) (see June 2010 medical examination by E.W., MD, in the SSA records) please opine as to whether it is at least as likely as not (approximately 50 percent probability) that such disorder:

(i) had its onset in service or is otherwise related to service. In addressing this question, please review the January 1990 service treatment record reflecting the Veteran's report of a prior prescription for Levothyroxine, and the June 1992 service treatment records reflecting that thyroid function tests were conducted.

(ii) was caused by a pulmonary disorder (only if a pulmonary disorder is service-connected);

(iii) got worse due to a pulmonary disorder (only if a pulmonary disorder is service-connected);

(iv) (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service.

(b) For diagnosed OSA and diabetes mellitus, type 2, please opine as to whether it is at least as likely as not (approximately 50 percent probability) that such disorder:

(i) had its onset in service or is otherwise related to service. In addressing this question, please assume as true the Veteran's reports that she snored after gaining weight in service, and provide a discussion of whether a nexus between sleep apnea and/or diabetes mellitus, type 2, and service is "medically plausible" based on the same. Otherwise, the opinion will be rendered inadequate.

(ii) was caused by a pulmonary disorder (only if a pulmonary disorder is service-connected);

(iii) got worse due to a pulmonary disorder (only if a pulmonary disorder is service-connected);

(iv) with regard to diabetes mellitus: (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service.

(v) (Only if service connection is granted for any disability) Do any of the Veteran's service-connected disabilities result in obesity, and is this obesity an "intermediate step" between the disorder and the currently diagnosed OSA and/or diabetes mellitus?

(c) For the claimed skin disorder (to include tinea versicolor and facial lesions), please opine as to whether it is at least as likely as not (approximately 50 percent probability) that any current skin disorder:

(i) had its onset in service or is otherwise related to service. In addressing this question, please consider service treatment records reflecting treatment for tinea versicolor and facial lentigines.

(ii) was caused by a pulmonary disorder (only if a pulmonary disorder is service-connected);

(iii) got worse due to a pulmonary disorder (only if a pulmonary disorder is service-connected);

7. Schedule the Veteran for a VA examination for her claimed heart condition. The examiner must review the claims file. The examiner is asked to provide a response to the following:

(a) Is the Veteran's systolic heart murmur, which existed prior to service (see November 1986 medical examination performed for U.S. Air Force ROTC commissioning purposes, found in DPRIS Response, pages 102-103, received on August 25, 2018), a congenital or developmental defect or a congenital or hereditary disease?

For VA purposes, a "defect" is defined as a structural or inherent abnormality or condition that is more or less stationary in nature and is generally incapable of improvement or deterioration.

In contrast, a "disease" is capable of improvement or deterioration. The physician must offer the opinion in the terms as listed above.

(b) If the systolic heart murmur is a congenital or developmental defect, was it subject to, or aggravated by, a superimposed disease or injury, that resulted in additional disability? Please identify the additional disability.

(c) If the preexisting systolic heart murmur is a congenital or hereditary disease, did it at least as likely as not (approximately 50 percent probability) increase in severity during service? See service treatment records, including a July 1993 echocardiogram.

(d) If so, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease?

(e) With regard to any other current heart condition, please opine as to whether it is at least as likely as not (approximately 50 percent probability) that such disorder:

(i) had its onset in service or is otherwise related to service.

(ii) was caused by a pulmonary disorder (only if a pulmonary disorder is service-connected);

(iii) got worse due to a pulmonary disorder (only if a pulmonary disorder is service-connected);

(iv) (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service.

8. Schedule the Veteran for a VA examination for her claimed arthritis of the bilateral shoulders, bilateral elbows, bilateral hands and fingers, bilateral hips, and bilateral knees, and a left foot disability. The examiner must review the claims file.

The examiner is asked to provide a response to the following:

(a) Please opine as to whether it is at least as likely as not (approximately 50 percent probability) that any current disability of the bilateral shoulders, bilateral elbows, bilateral hands and fingers, bilateral hips, bilateral knees, and/or a left foot disability:

(i) had its onset in service or is otherwise related to service. In addressing this question as to the left foot, please consider service treatment records reflecting treatment in July 1991 for a left foot contusion and in July 1992 for a left foot puncture. With regard to all of the claims, please assume as true the Veteran's reports that she had pain in these joints during and after service, and provide a discussion of whether a nexus between these disabilities and service is "medically plausible" based on the same. Otherwise, the opinion will be rendered inadequate.

(ii) was caused by a pulmonary disorder or PTSD (only if these disabilities are service-connected);

(iii) got worse due to a pulmonary disorder or PTSD (only if these disabilities are service-connected);

(iv) with regard to arthritis, if diagnosed: (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service.

S.C. Krembs

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board C.L. Wasser, 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.