Citation Nr: 23044873 Decision Date: 08/11/23 Archive Date: 08/11/23 DOCKET NO. 15-44 837 DATE: August 11, 2023 REMANDED Entitlement to service connection fora liver disability, to include cirrhosis, is remanded. Entitlement to service connection for high blood pressure is remanded. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for stool and anus problems, to include as secondary to the service-connected chronic low back pain, is remanded. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected allergic rhinitis nasal congestion and/or service-connected chronic low back pain, is remanded. Entitlement to a left leg/hip disorder, to include a neurological disorder and/or chronic pain syndrome, and to include as secondary to service-connected chronic low back pain and/or service-connected chronic adjustment disorder with depressed mood, is remanded. Entitlement to service connection for chest pain, to include chronic pain syndrome, and to include as secondary to service-connected chronic low back pain and/or service-connected allergic rhinitis nasal congestion and/or service-connected chronic adjustment disorder with depressed mood, is remanded. Entitlement to service connection for a cervical spine disorder, to include as secondary to service-connected chronic low back pain and/or service-connected tension headaches, is remanded. Entitlement to increased disability ratings for residuals of a gunshot wound to the left arm, rated as 10 percent disabling prior to July 21, 2021, and as 20 percent disabling since July 21, 2021, is remanded. Entitlement to increased disability ratings for degenerative arthritis of the lumbar spine with spinal stenosis and degenerative disc disease, rated as 40 percent disabling prior to August 7, 2015, and as 50 percent disabling since August 7, 2015, is remanded. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU) from April 17, 2011, to June 3, 2012, to include on an extraschedular basis, is remanded. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1989 to September 1997. These issues are on appeal from Rating Decisions dated in May 2012, November 2012, June 2013, August 2013, September 2014, March 2015, March 2016, and October 2016. These matters were previously before the Board in September 2019, at which time they were remanded for additional development. The Board recognizes that its previous remand addressed the issue of entitlement to service connection for a left knee disorder. However, in a June 2021 Rating Decision, the RO granted entitlement to service connection for left knee strain. As this is considered a full grant of the benefit sought on appeal with respect to this issue, it is no longer before the Board. REASONS FOR REMAND 1. Entitlement to service connection for a liver disability, to include cirrhosis The Veteran seeks entitlement to service connection for a liver disability, to include cirrhosis. In its previous decisions, the RO noted that although the Veteran's VA treatment records revealed abnormal liver function test results (mildly high aspartate transaminase and bilirubin), there was no diagnosis of cirrhosis of the liver. As such, the Veteran was not afforded a VA examination. However, VA treatment records dated as recently as May 2023 continue to document abnormal results of liver function studies as well as hepatitis. Moreover, these records also document alcohol dependence. The Board emphasizes that the Veteran is currently service connected for chronic adjustment disorder with depressed mood, which has been rated as 70 percent disabling effective June 4, 2012. Furthermore, the Board notes that an April 2013 VA Mental Disorders examination diagnosed the Veteran as having both adjustment disorder, chronic, with depressed mood, as well as alcohol abuse, and indicated that it was not possible to differentiate which symptoms were attributable to each diagnosis because the Veteran was self-medicating against pain and depression through the use of alcohol. On remand, the Veteran should be provided with a VA examination to ascertain all diagnoses of the liver during the appeal period, to include hepatitis, and to determine the likelihood that these diagnoses were caused or aggravated by his service-connected chronic adjustment disorder with depressed mood, to include the use of alcohol to self-medicate against depression. 2. Entitlement to service connection for high blood pressure The Veteran also seeks entitlement to service connection for high blood pressure. In its previous decisions, the RO noted that the evidence did not show a confirmed diagnosis of high blood pressure. As such, the Veteran was not afforded a VA examination. However, private treatment records dated in 2019 from Mays & Schnapp Pain Clinic in Memphis, Tennessee, documented a history of hypertension. Moreover, VA treatment records dated in April 2023 documented a history of hypertension without medications, and show elevated blood pressure readings in December 2022, February 2023, and April 2023. The Board emphasizes that the U.S. Court of Appeals for Veterans Claims (Court) determined that VA must examine blood pressure readings from before veterans start taking daily blood pressure medication, even if those readings predate the claim for benefits. Wilson v. McDonough, 35 Vet. App. 75, 78-80 (2021). As such, on remand, the Veteran should be afforded a VA examination to ascertain whether the Veteran's elevated blood pressure readings warrant a hypertension diagnosis and to determine the likely onset and etiology of any confirmed diagnosis of hypertension. 3. Entitlement to service connection for PTSD The Veteran also seeks entitlement to service connection for PTSD. The Board notes that the Veteran has already been service connected for chronic adjustment disorder with depressed mood. In its September 2019 Remand, the Board noted that, in a June 2016 statement, the Veteran reported a 1989 PTSD evaluation, although he did not identify the provider and the records had not been associated with the claims file. As such, the Board found that a remand was required to allow VA to obtain authorization and request these records. Pursuant to the Board's Remand, in September 2021, VA sent the Veteran correspondence requesting that he complete a VA Form 21-4142, General Release for Medical Provider Information to VA, for the physician who performed his 1989 PTSD evaluation. However, in October 2021, the Veteran simply returned the form directing VA to "see records," and failed to provide the private medical provider/facility name or address to VA. The Board notes that the Veteran was most recently provided with a VA PTSD examination in December 2015, approximately eight years ago, at which time he was diagnosed as having adjustment disorder with depressed mood. At that time, the VA examiner indicated that the Veteran did not meet the full criteria for PTSD due to not endorsing the avoidance criteria during the interview. However, since then, treatment records which diagnose the Veteran as having PTSD have been associated with the claims file. For instance, private treatment records dated in November 2019 from Mays & Schnapp Pain Clinic in Memphis, Tennessee, indicated that the Veteran suffered from mood disorder, possibly bipolar, anxiety disorder, and some degree of PTSD. As such, on remand, the Veteran should be provided with a VA examination to ascertain the likelihood that he has a diagnosis of PTSD that is separate and distinct from this service-connected chronic adjustment disorder with depressed mood, and, if so, the likelihood that the PTSD diagnosis is related to service or developed secondary to a service-connected disability. Additionally, as the Veteran's PTSD claim is being remanded to provide him with a current examination, the Veteran should also be afforded another opportunity to properly complete a VA Form 21-4142, General Release for Medical Provider Information to VA, to authorize VA to obtain records from the private physician who performed his 1989 PTSD evaluation. 4. Entitlement to service connection for stool and anus problems, to include as secondary to service-connected chronic low back pain The Veteran also seeks entitlement to service connection for stool and anus problems. In its September 2019 Remand, the Board directed that the Veteran be afforded an examination to determine the nature of any current stool/anus problems. Pursuant to the Board's September 2019 Remand, the Veteran was afforded a VA Rectum and Anus Conditions examination as well as a VA Intestinal Conditions examination in January 2021. However, although the examiner acknowledged a November 2019 VA treatment note in which the Veteran reported abdominal pain, chronic diarrhea with occasional constipation, and prior rectal bleeding (and for which a gastrointestinal consult was requested), the examiner indicated that the Veteran had never been diagnosed with an intestinal condition, to include chronic diarrhea. The examiner then opined that, "No diagnosis of the claimed 'anus condition,' less likely than not from service/ Nor proximately due to the service-connected chronic low back pain (to include the medications taken for the treatment of the low back pain), or neither aggravated beyond its natural progression by the service-connected chronic low back pain (to include the medications taken for the treatment of the low back pain)." Significantly, the Board notes that the January 2021 VA Intestinal Conditions examination did not consult any laboratory testing, imaging studies or diagnostic procedures, or any other significant diagnostic test findings and/or results. Additionally, a review of the Veteran's VA treatment records appears to indicate that he was prescribed docusate as a stool softener from 2016 until at least 2021, which was not mentioned in the January 2021 VA Intestinal Conditions examination report. Indeed, in correspondence to his VA primary care provider in October 2019, the Veteran requested prescription of "a stool softener or docusate and some fiber powder" due to "bowel and stomach issues." See McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that a service connection claim may be granted if a diagnosis of a chronic disability was made during the pendency of the appeal, even if the most recent medical evidence suggests that the disability resolved). As such, the Board finds the January 2021 VA Intestinal Conditions examination to be inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 311-312 (2007) (once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one). On remand, the Veteran should be provided with a new examination to ascertain whether he had a disability manifested by chronic diarrhea and rectal bleeding at any time during the period on appeal, regardless of whether it has since resolved. 5. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected allergic rhinitis nasal congestion and/or service-connected chronic low back pain The Veteran also seeks entitlement to service connection for obstructive sleep apnea. The Board's September 2019 Remand directed that the RO obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's currently diagnosed obstructive sleep apnea was at least as likely as not (1) proximately due to service-connected chronic low back pain and/or service-connected allergic rhinitis nasal congestion, or (2) aggravated beyond its natural progression by service-connected chronic low back pain and/or service-connected allergic rhinitis nasal congestion. Pursuant to the Board's September 2019 Remand directives, an addendum opinion was obtained in April 2021 in which the clinician indicated that, "OSA less likely than not from SC allergic rhinitis. No evidence of any aggravation beyond natural progression from SC allergic rhinitis or nasal congestion. Sleep apnea is a sleep disorder in which breathing repeatedly stops and starts that occurs when throat muscles relax. With obesity, During sleep, when throat and tongue muscles are more relaxed, this soft tissue can cause the airway to become blocked. Although they can be co-existing comorbidities, there is no anatomical / pathophysiological / neuronal or hormonal correlation to causation." Thereafter, in a May 2021 addendum opinion, the same clinician added that, "SA diagnosed 2020 neither caused nor aggravated beyond natural progression by low back condition. Sleep apnea is a sleep disorder in which breathing repeatedly stops and starts that occurs when throat muscles relax. With obesity, During sleep, when throat and tongue muscles are more relaxed, this soft tissue can cause the airway to become blocked." While neither the April 2021 nor May 2021 VA addendum opinions linked the Veteran's diagnosed obstructive sleep apnea to his service-connected chronic low back pain and/or allergic rhinitis nasal congestion, both opinions suggested that obesity was a factor in the Veteran developing sleep apnea. Indeed, a December 2020 VA Pulmonary Diagnostic Study Report diagnosed the Veteran as having both "Moderate Obstructive Sleep Apnea" and "Obese - weight loss thru diet and exercise." The Board emphasizes that obesity may be an "intermediate step" in a secondary-service-connection analysis when the service-connected disability causes or aggravates obesity. Walsh v. Wilkie, 32 Vet. App. 300, 307 (2020). There must be some evidence in the record which draws an association or suggests a relationship between the veteran's obesity, or weight gain resulting in obesity, and a service-connected condition. Garner v. Tran, 33 Vet. App. 241, 249 (2021). The considerations that could give rise to a reasonably raised theory of secondary service connection with obesity as an intermediate step may include, but are not limited to, (1) mobility limitations or reduced physical activity as a result of a service-connected physical disability (in particular, orthopedic conditions or chronically painful conditions); (2) reduced physical activity or inability to follow a course of exercise or diet as a result of service-connected mental disability; (3) side effects of medication (e.g., weight gain), where the medication is prescribed for a service-connected disability; (4) treatise evidence suggesting a connection between all or some combination of obesity, service-connected disability, and the claimed condition; (5) lay statements by a veteran attributing weight gain or obesity to the service-connected disability; and (6) statements by treating physicians or medical examiners attributing weight gain or obesity to the service-connected disability. Id. Here, the Veteran has been service-connected for chronic adjustment disorder with depressed mood as well as several orthopedic and neurologic disabilities. The Board also emphasizes that the Veteran's VA treatment records have indicated that the Veteran was obese and that sleep apnea was a known risk of obesity. Significantly, his October 2012 VA Mental Disorders examination indicated that he lacked the energy to get out of the house and that his psychiatric symptomatology resulted in depressed mood, chronic sleep impairment, and disturbances of motivation and mood. Similarly, his December 2015 VA PTSD examination indicated that his psychiatric symptomatology resulted in depressed mood, chronic sleep impairment, and disturbances of motivation and mood. His January 2021 VA Knee and Lower Leg examination indicated that the Veteran regularly wore a brace due to back pain and occasionally used a cane for balance, and that his service-connected left knee strain prevented him from sitting, standing, and walking for long periods of time, and prevented him from jogging, jumping, hiking, climbing, running, sprinting, bending, squatting, hopping, dancing, kneeling, and crawling. Similarly, his December 2020 VA Back (Thoracolumbar Spine) examination indicated that the Veteran's degenerative arthritis of the spine prevented him from sitting, standing, and walking for long periods of time on any surface, and prevented him from jogging, jumping, hiking, climbing, running, sprinting, bending, squatting, hopping, dancing, kneeling, and crawling. As such, opinions are necessary to address whether the Veteran's service-connected disabilities (to include any medications used to treat his service-connected disabilities) either (1) caused the Veteran to become obese or (2) aggravated the Veteran's obesity; whether the obesity or aggravation of obesity was a substantial factor in causing the current sleep apnea; and whether the Veteran's sleep apnea would not have occurred but for the obesity caused or aggravated by the service-connected disabilities. 6. Entitlement to a left leg/hip disorder, to include a neurological disorder and/or chronic pain syndrome, and to include as secondary to service-connected chronic low back pain and/or service-connected chronic adjustment disorder with depressed mood The Veteran also seeks entitlement to service connection for a left leg/hip disorder. The Board notes that he has already been granted entitlement to service connection for left knee strain as well as left lower extremity neuropathy of the sciatic nerve. In its September 2019 Remand, the Board directed that the Veteran be afforded a VA neurological examination by an appropriate clinician to determine the nature of any neurological disorder of the left leg and hip, to include chronic pain syndrome and neuropathy. Pursuant to the Board's September 2019 Remand directives, the Veteran was afforded a VA Hip and Thigh Conditions examination in January 2021, at which time the examiner acknowledged that the Veteran experienced falls in 2014 and 2017 after his "left leg gave out," although there was "no left leg / left hip diagnosis per se." As such, the examiner concluded that the Veteran did not have any current diagnosis associated with a left leg/hip disorder. However, although the examiner noted abnormal range of motion in the left hip, she indicated that any abnormal range of motion in the left hip was related to back pain and normal/appropriate for the Veteran. Additionally, the January 2021 VA Peripheral Nerves Conditions examination found that the Veteran did not have a peripheral nerve condition or peripheral neuropathy of the left lower extremity; significantly, however, no electromyography (EMG) studies or other significant diagnostic testing had been performed to ascertain whether a peripheral nerve deficit was present. Crucially, these January 2021 findings contradict the findings of the December 2020 Back (Thoracolumbar Spine) Conditions examination conducted approximately one month earlier, which found that there was mild involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve). As such, the Board finds that the January 2021 Hip and Thigh Conditions examination and Peripheral Nerves Conditions examination to be inadequate. See Barr, supra. On remand, the Veteran should be afforded a new examination to ascertain the likely nature and etiology of any symptomatology associated with the left leg and hip. The examiner should specifically discuss whether the abnormal ranges of motion for the left hip documented in the January 2021 Hip and Thigh Conditions examination constituted a distinct and separate disability, and, if so, whether that disability was caused or aggravated by the Veteran's service-connected degenerative arthritis of the lumbar spine with spinal stenosis and degenerative disc disease. Furthermore, appropriate diagnostic testing, such as EMG studies, should be undertaken to ascertain whether the Veteran has any additional neurological disabilities in the left lower extremity. 7. Entitlement to service connection for chest pain, to include chronic pain syndrome, and to include as secondary to service-connected chronic low back pain and/or service-connected allergic rhinitis nasal congestion and/or service-connected chronic adjustment disorder with depressed mood The Veteran also seeks entitlement to service connection for chest pain. In its September 2019 Remand, the Board directed that the Veteran be provided with an examination to determine the nature of his claimed chest pain (to include chronic pain syndrome); if the Veteran had a current diagnosis related to the chest, then the examiner was asked to opine whether it was at least as likely as not related to an in-service injury, event, or disease, and whether it is at least as likely as not (1) proximately due to the service-connected chronic low back pain and/or the service-connected chronic adjustment disorder with depressed mood and/or the service-connected allergic rhinitis nasal congestion, or (2) aggravated beyond its natural progression by the service-connected chronic low back pain and/or the service-connected chronic adjustment disorder with depressed mood and/or the service-connected allergic rhinitis nasal congestion. Pursuant to the Board's September 2019 Remand, the Veteran was afforded a VA Muscle Injuries Disability examination in January 2021, at which time the examiner acknowledged that the Veteran experienced "intermittent chest pain in middle part of chest." However, the examiner simply indicated that, "For the claimant's claimed condition of chest pain there is no diagnosis because the condition has resolved." In an attached opinion, the VA examiner explained that "No current diagnosis of chest pain / less likely than not from service. Intermittent chest pain documented once by pharmacist 2019 with no evidence of recurrence / progression / chronicity / residuals / sequelae. No evaluations by a medical provider." However, in a February 2021 VA treatment note, the Veteran reported an inability to take deep breaths accompanied by chest tightness. The Veteran indicated that he had several emergency room visits for this in past, although the resulting cardiac workups were always negative. Additionally, VA chest radiology reports from November 2018 indicated a history of chest pain, suggesting that the Veteran's chest pain predated the 2019 pharmacist documentation. These additional VA treatment records documenting chest symptomatology render the January 2021 VA examiner opinion inadequate, as the factual bases underlying the opinion are not accurate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (indicating that an opinion based upon an inaccurate factual premise has no probative value). As such, the Veteran should be afforded another VA examination to determine the likely nature and etiology of his chest symptomatology that considers his February 2021 VA treatment for chest tightness as well as notations of a history of chest pain in 2018. 8. Entitlement to service connection for a cervical spine disorder, to include as secondary to service-connected chronic low back pain and/or service-connected tension headaches The Veteran also seeks entitlement to service connection for a cervical spine disorder. In its September 2019 Remand, the Board directed the RO to obtain and addendum opinion regarding whether the Veteran's currently diagnosed cervical strain, C5/C6 disc bulge, osteoarthrosis, and stenosis of the cervical spine were at least as likely as not (1) proximately due to service-connected chronic low back pain and/or service-connected tension headaches, or (2) aggravated beyond its natural progression by service-connected chronic low back pain and/or service-connected tension headaches. Pursuant to the Board's September 2019 Remand directives, a VA opinion was obtained in April 2021 in which the clinician simply stated, "Cervical stenosis less likely than not from SC chr back pain and SC tension headaches. No evidence of aggravation beyond natural progression with SC back condition and tension headaches. there is no anatomical / pathophysiological / neuronal or hormonal correlation to causation or aggravation." However, the Board notes that the Veteran has also been service connected for left knee strain. Significantly, the report of the January 2021 VA Hip and Thigh Conditions examination indicated that the Veteran used regular bracing (on his back and left knee) for ambulation, and occasionally used a cane for balance. Additionally, an April 2021 VA opinion noted that, "With back pain, when he does not use his cane for support, his leg gives away and has had falls." Similarly, VA treatment records have suggested abnormal gait and body mechanics related to the Veteran's service-connected orthopedic disabilities. For instance, an October 2020 VA Physical Therapy Note indicated that the Veteran's gait was "ambulatory with a cane recently since he had knee injection; has been using cane for 7 years and rollator for community ambulation." Additionally, VA treatment records noted that, "Patient has mild antalgic gait. Hinged brace in place," as recently as March 2021. As such, upon Remand, an addendum opinion should be obtained from a qualified orthopedic physician as to the likelihood that the Veteran's diagnosed cervical strain, C5/C6 disc bulge, osteoarthrosis, and stenosis of the cervical spine was either caused or aggravated by any of his service-connected orthopedic disabilities, to include any abnormal posture, gait, ambulation, or other body mechanic resulting from those service-connected disabilities or from use of assistive devices used to accommodate those disabilities. Finally, the Board notes that VA treatment records from February 2023 indicate an MRI transcript from The Imaging Center was scanned into the Veteran's chart; however, a copy of that MRI transcript is not in the claims file. On remand, the RO should associate with the record a copy of the MRI transcript, as well as any other records stored in VistA imaging. 9. Entitlement to increased disability ratings for residuals of a gunshot wound to the left arm The Veteran also seeks entitlement to increased disability ratings for his service-connected residuals of a gunshot wound to the left arm. In its September 2019 Remand, the Board directed that the Veteran be provided with a VA joints examination to assess the current severity of his residuals of a gunshot wound to the left arm. Following this development, the RO was instructed to readjudicate the issues on appeal; if the benefits sought were not granted to the Veteran's satisfaction, then the RO was instructed to send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. Pursuant to the Board's September 2019 Remand directives, the Veteran was provided with VA Muscle Injuries Disability examinations in January 2021 and July 2021, as well as a VA Scars/Disfigurement Disability examination in July 2021. Based on the results of those examinations, in a June 2023 Rating Decision, the RO increased the rating for the Veteran's residuals of left arm gunshot wound from 10 percent disabling to 20 percent disabling effective July 21, 2021. The Rating Decision then stated that, "This decision is an award of all benefits sought on appeal, and therefore, the appeal is considered satisfied in full on this issue." Significantly, the RO then failed to readjudicate the issue of entitlement to higher disability ratings for residuals of a gunshot wound to the left arm in the June 2023 Supplemental Statement of the Case. The Board emphasizes that the June 2023 Rating Decision did not constitute an award of all benefits sought on appeal with respect to the residuals of a left arm gunshot wound on appeal. Accordingly, a remand is necessary for the RO to issue a Supplemental Statement of the Case on this issue. See Stegall v. West, 11 Vet. App. 268 (1998) (where remand orders of the Board are not complied with, the Board errs in failing to ensure compliance). 10. Entitlement to increased disability ratings for degenerative arthritis of the lumbar spine with spinal stenosis and degenerative disc disease, and entitlement to a TDIU from April 17, 2011, to June 3, 2012, to include on an extraschedular basis Finally, the Veteran seeks entitlement to increased disability ratings for degenerative arthritis of the lumbar spine with spinal stenosis and degenerative disc disease, and entitlement to a TDIU from April 17, 2011, to June 3, 2012, to include on an extraschedular basis. Because the development requested above with respect to the remanded claims (which necessarily involves medical testing relevant to the Veteran's lumbar spine symptomatology) could significantly impact decisions on the issues of entitlement to increased disability ratings for lumbar spine pathology and entitlement to a TDIU, the issues are inextricably intertwined. A remand of the claims of entitlement to increased disability ratings for lumbar spine pathology and entitlement to a TDIU are therefore also required. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records dated from May 2023 to the present. In addition, associate with the claims file any records currently stored in VistA Imaging, including the MRI transcript noted in the February 2023 VA treatment record. The Board reminds the AOJ that the Board does not have access to VistA Imaging, so any documentation contained in it must be printed from VistA and uploaded/added to the Veteran's VBMS or Virtual VA file. All attempts to obtain these records must be documented in the claims file. The Veteran and his attorney must be notified of any inability to obtain the requested documents. 2. Ask the Veteran to complete VA Forms 21-4142/21-4142a for the physician who performed his 1989 PTSD evaluation. Make two requests for the authorized records from the provider, unless it is clear after the first request that a second request would be futile. The communication should further advise the Veteran that failure to return the form could result in a denial of his claim as the matter will be considered without the benefit of this information. 3. Provide the Veteran with a VA examination to ascertain the likely nature and etiology of all disabilities of the liver, to include his diagnosed hepatitis. All pertinent evidence of record should be made available to and reviewed by the examiner. Based on a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any diagnosed disability of the liver, to include the Veteran's diagnosed hepatitis, was caused or aggravated by any of the Veteran's service-connected disabilities, to include chronic adjustment disorder with depressed mood (and the use of alcohol to self-medicate against depression). The examiner is reminded that aggravation under 38 C.F.R. § 3.310(b) does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for any incremental increase in disability, meaning any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence. All opinions expressed by the examiner must be accompanied by a complete rationale. If any of the above requested opinions cannot be made without resort to speculation, then the examiner must state this and specifically explain why an opinion cannot be provided without resort to speculation. In providing this opinion, the examiner is asked to discuss the April 2013 VA Mental Disorders examination which diagnosed the Veteran as having both adjustment disorder, chronic, with depressed mood, as well as alcohol abuse, and indicated that it was not possible to differentiate which symptoms were attributable to each diagnosis because the Veteran was self-medicating against pain and depression through the use of alcohol. 4. Schedule the Veteran for a VA examination to determine the likely etiology of any diagnosed hypertension. The examiner should review the file and provide a complete rationale for all opinions expressed. The examiner should provide an opinion as to the following: a. Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any diagnosed hypertension is related to the Veteran's active service. b. Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any diagnosed hypertension was caused by the Veteran's service-connected disabilities, to include any medication prescribed to treat those disabilities. c. Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any diagnosed hypertension has been aggravated by the Veteran's service-connected disabilities, to include any medication prescribed to treat those disabilities. The examiner is reminded that aggravation under 38 C.F.R. § 3.310(b) does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for any incremental increase in disability, meaning any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence. All opinions expressed by the examiner must be accompanied by a complete rationale. If any of the above requested opinions cannot be made without resort to speculation, then the examiner must state this and specifically explain why an opinion cannot be provided without resort to speculation. In providing this opinion, the examiner is asked to discuss the private treatment records dated in 2019 from Mays & Schnapp Pain Clinic in Memphis, Tennessee, which document a history of hypertension, as well as the VA treatment records dated in April 2023 which document a history of hypertension without medications, and show elevated blood pressure readings in December 2022, February 2023, and April 2023. 5. Schedule the Veteran for a psychiatric examination to determine the nature of his psychiatric symptomatology. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. The examiner is asked to identify all of the Veteran's psychiatric disorders diagnosed during the period on appeal, to include chronic adjustment disorder with depressed mood, alcohol abuse, and PTSD. If PTSD is not diagnosed, then it should be adequately explained why this diagnosis is not appropriate. In providing these opinions, the examiner is asked to discuss the private treatment records dated in November 2019 from Mays & Schnapp Pain Clinic in Memphis, Tennessee, indicating that the Veteran suffered from mood disorder, possibly bipolar, anxiety disorder, and some degree of PTSD. If the examiner finds that the Veteran meets the diagnostic criteria for PTSD, then the examiner should then determine whether any of the Veteran's symptoms associated with his PTSD overlap with the symptoms associated with his service-connected chronic adjustment disorder with depressed mood, or whether the PTSD diagnosis instead constitutes a separate and distinct disability. If the examiner finds that the Veteran's PTSD constitutes a separate and distinct disability, then the examiner should opine as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that this disability was caused by service or incurred during service, to include any verified stressor. If the examiner finds that the Veteran's PTSD constitutes a separate and distinct disability, then the examiner should also opine as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that this disability was either (1) caused or (2) aggravated by any service-connected disability, to include chronic adjustment disorder with depressed mood. With respect to the questions concerning aggravation, the examiner is advised that aggravation under 38 C.F.R. § 3.310(b) does not require "permanent worsening" of the nonservice-connected disability. If aggravation is found, then the examiner should attempt to identify the baseline level of severity of disability prior to such aggravation. All opinions expressed by the examiner must be accompanied by a complete rationale. If any of the above requested opinions cannot be made without resort to speculation, then the examiner must state this and specifically explain why an opinion cannot be provided without resort to speculation. 6. Provide the Veteran with an examination to determine the nature and severity of all gastrointestinal disabilities diagnosed during or within close proximity to the rating period on appeal. All pertinent evidence of record should be made available to and reviewed by the examiner. The examiner should: a. Identify all gastrointestinal disabilities manifesting during the period on appeal, to include chronic diarrhea and rectal bleeding. If the examiner finds that the Veteran's documented chronic diarrhea and rectal bleeding do not constitute "gastrointestinal disabilities," then the bases of those determinations should be fully explained. b. Opine as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that each identified gastrointestinal disability, to include chronic diarrhea and rectal bleeding, had their onsets in or were otherwise caused by his period of active service. c. Opine as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that each identified gastrointestinal disability, to include chronic diarrhea and rectal bleeding, were proximately due to a service-connected disability (to include any medications prescribed to treat a service-connected disability). d. Opine as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that each identified gastrointestinal disability, to include chronic diarrhea and rectal bleeding, were proximately aggravated by a service-connected disability (to include any medications prescribed to treat a service-connected disability). The examiner is reminded that aggravation under 38 C.F.R. § 3.310(b) does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for any incremental increase in disability, meaning any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence. Any opinion expressed by the VA examiner should be accompanied by a complete rationale. In providing the above opinions, the examiner is asked to specifically reference the November 2019 VA treatment note in which the Veteran reported abdominal pain, chronic diarrhea with occasional constipation, and prior rectal bleeding; the report of the October 2020 VA colonoscopy; and the prescription of docusate as a stool softener from 2016 until at least 2021. If the VA examiner is unable to offer an opinion without resorting to speculation, then a thorough explanation as to why an opinion cannot be rendered should be provided. If the examiner rejects the Veteran's November 2019 lay statements regarding chronic diarrhea and rectal bleeding, then he or she must provide a reason for doing so. If the examiner finds that the Veteran suffered from chronic diarrhea and/or rectal bleeding during the period on appeal but that these conditions have since resolved, then etiological opinions must still be provided. 7. Provide the Veteran with an examination to determine the likely etiology of his diagnosed obstructive sleep apnea. All pertinent evidence of record should be made available to and reviewed by the examiner. The VA examiner should furnish an opinion with respect to the following questions: (a.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's diagnosed sleep apnea was caused by a service-connected disability (chronic adjustment disorder with depressed mood, tension headaches, degenerative arthritis of the lumbar spine with spinal stenosis and degenerative disc disease, frequent urinations, residuals of left arm gunshot wound, left knee strain, allergic rhinitis, left lower extremity radiculopathy, right lower extremity radiculopathy, left arm scars, and erectile dysfunction), to include any medication prescribed to treat these disabilities. (b.) If not, whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's diagnosed sleep apnea was aggravated (worsened) by a service-connected disability, to include any medication prescribed to treat these disabilities. (c.) Whether the Veteran's service-connected disabilities (chronic adjustment disorder with depressed mood, tension headaches, degenerative arthritis of the lumbar spine with spinal stenosis and degenerative disc disease, frequent urinations, residuals of left arm gunshot wound, left knee strain, allergic rhinitis, left lower extremity radiculopathy, right lower extremity radiculopathy, left arm scars, and erectile dysfunction), to include any medication prescribed to treat these disabilities, (1) caused the Veteran to become obese or (2) aggravated the Veteran's obesity. Both causation and aggravation must be addressed. (d.) If so, then the examiner is asked to opine as to whether the obesity or aggravation of obesity was a substantial factor in causing the Veteran's current obstructive sleep apnea. (e.) The examiner is also asked to opine as to whether the Veteran's obstructive sleep apnea would not have occurred but for the obesity caused or aggravated by the service-connected disability (or medication prescribed to treat the service-connected disability). The examiner is reminded that aggravation under 38 C.F.R. § 3.310(b) does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for any incremental increase in disability, meaning any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence. The examiner should provide a complete rationale for all opinions provided. In providing these opinions, the examiner is asked to specifically discuss the VA treatment records indicating the Veteran was obese and listing sleep apnea as a known risk of obesity. The examiner is also asked to address the previous VA examination reports indicating that the Veteran's service-connected psychiatric symptomatology manifested as depression and disturbance of motivation and mood, and that his service-connected back and left knee disabilities prevented him from sitting, standing, and walking for long periods of time, and prevented him from jogging, jumping, hiking, climbing, running, sprinting, bending, squatting, hopping, dancing, kneeling, and crawling. If an opinion cannot be provided without resorting to mere speculation, then the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 8. Provide the Veteran with an examination(s) to determine the nature and severity of all disabilities of the left lower extremity diagnosed during or within close proximity to the rating period on appeal. Such an examination should include diagnostic testing, such as electromyographic (EMG) and/or nerve conduction studies, to ascertain the involvement of any nerves in the left lower extremity. All pertinent evidence of record should be made available to and reviewed by the examiner. All peripheral nerve disabilities of the left lower extremity (to include any paralysis of the left sciatic nerve, left external popliteal (common peroneal) nerve, left anterior crural (femoral) nerve, left external cutaneous nerve of the thigh, and/or left illio-inguinal nerve) should be clearly identified. Additionally, the examiner should opine as to whether the abnormal ranges of motion documented for the left hip in the January 2021 VA Hip and Thigh Conditions examination report constitute a disability that is separate and distinct from the Veteran's service-connected degenerative arthritis of the lumbar spine with spinal stenosis and degenerative disc disease. If the examiner finds that the Veteran's abnormal left hip motion constitutes a separate and distinct disability, then the examiner should also opine as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that this disability was either (1) caused or (2) aggravated by any service-connected disability, to include degenerative arthritis of the lumbar spine with spinal stenosis and degenerative disc disease and/or left knee strain (to include any abnormal gait resulting from these disabilities). The examiner is reminded that aggravation under 38 C.F.R. § 3.310(b) does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for any incremental increase in disability, meaning any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence. Any opinion expressed by the VA examiner should be accompanied by a complete rationale. In providing the above opinion, the examiner is asked to specifically reference the December 2020 Back (Thoracolumbar Spine) Conditions examination which found that there was mild involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve), as well as the January 2021 VA Hip and Thigh Conditions examination which acknowledged that the Veteran experienced falls in 2014 and 2017 after his "left leg gave out" and found abnormal range of motion in the left hip. If the VA examiner is unable to offer an opinion without resorting to speculation, then a thorough explanation as to why an opinion cannot be rendered should be provided. 9. Provide the Veteran with an examination to determine the nature of his claimed chest pain/tightness, to include chronic pain syndrome. All pertinent evidence of record should be made available to and reviewed by the examiner. The examiner is asked to opine as to: a. whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any diagnosed disability manifested by chest pain/tightness is related to an in-service injury, event, or disease. b. whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any diagnosed disability manifested by chest pain/tightness is proximately due to the Veteran's service-connected chronic low back pain and/or the service-connected chronic adjustment disorder with depressed mood and/or the service-connected allergic rhinitis nasal congestion, or (2) aggravated beyond its natural progression by the Veteran's service-connected chronic low back pain and/or the service-connected chronic adjustment disorder with depressed mood and/or the service-connected allergic rhinitis nasal congestion. The examiner is reminded that aggravation under 38 C.F.R. § 3.310(b) does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for any incremental increase in disability, meaning any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence. The examiner should provide a complete rationale for all opinions provided. In providing these opinions, the examiner is asked to specifically discuss the November 2018 VA chest radiology report which indicated a history of chest pain; the 2019 and 2020 VA notations of "intermittent chest pain in middle part of chest," as well as the February 2021 VA treatment note in which the Veteran reported an inability to take deep breaths accompanied by chest tightness. If the examiner finds that these documented symptoms do not constitute a chest disability for purposes of VA benefits, then that determination must be fully explained. If an opinion cannot be provided without resorting to mere speculation, then the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 10. Obtain an addendum opinion from an orthopedic physician regarding the likely etiology of the Veteran's diagnosed cervical strain, C5/C6 disc bulge, osteoarthrosis, and stenosis of the cervical spine. The clinician should review a copy of the claims file, including this Remand. The decision as to whether the Veteran should report for an additional physical examination is left to the discretion of the clinician asked to provide the requested opinion(s). Based on a review of the claims file and the results of the Veteran's examination (if held), the clinician is asked to opine as to whether the Veteran's cervical strain, C5/C6 disc bulge, osteoarthrosis, and stenosis of the cervical spine is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) caused or aggravated by any of his service-connected orthopedic disabilities, to include any abnormal posture, gait, ambulation, or other body mechanic resulting from those service-connected disabilities (or from use of assistive devices used to accommodate those disabilities). In doing so, the clinician is reminded that the Veteran is service connected for the following orthopedic disabilities: degenerative arthritis of the lumbar spine with spinal stenosis and degenerative disc disease and left knee strain. The clinician's analysis must address the evidence of record suggesting altered body mechanics due to service-connected disabilities, such as: the report of the January 2021 VA Hip and Thigh Conditions examination indicating that the Veteran used regular bracing (on his back and left knee) for ambulation, and occasionally used a cane for balance; the April 2021 VA opinion noting that, "With back pain, when he does not use his cane for support, his leg gives away and has had falls"; the October 2020 VA Physical Therapy Note indicating that the Veteran's gait was "ambulatory with a cane recently since he had knee injection, and that he has been using a cane for 7 years and rollator for community ambulation"; as well as the VA treatment records noting that, "Patient has mild antalgic gait. Hinged brace in place," as recently as March 2021. "Aggravation" means any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease, and not due to the natural progress of the nonservice-connected disease. If aggravation is found, then the examiner should attempt to quantify the extent of additional disability resulting from the aggravation. A fully-explained rationale for the requested opinions should be provided. If the clinician cannot provide an opinion without resorting to speculation, then he/she should explain why an opinion cannot be provided. If the clinician rejects the Veteran's reports, then he/she must provide an explanation for such rejection. The Veteran is generally competent to report symptoms observed and treatment received. 11. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issues on appeal should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, then the Veteran and his representative should be issued a Supplemental Statement of the Case. An appropriate period of time should be allowed for response. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Anthony M. Flamini 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.