Citation Nr: A23020468 Decision Date: 08/16/23 Archive Date: 08/16/23 DOCKET NO. 201215-125965 DATE: August 16, 2023 ORDER Service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for bruxism, claimed as teeth grinding, is granted. Service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for tinnitus is granted. A total disability rating based on individual unemployability (TDIU) is denied. REMANDED Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for bilateral hearing loss is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for substance use disorder is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for anal pain is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for a bladder disorder, to include incontinence and dysfunction, is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for damage to penis and scrotum is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for hypertension is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for migraine headaches is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for a digestive disorder, to include weight loss, is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for vomiting is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for blurred vision is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for dizziness is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for fainting is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for a left wrist disorder is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for a right wrist disorder is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for left foot and toe disorder is remanded. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for right foot and toe disorder is remanded. FINDINGS OF FACT 1. Resolving all doubt in the Veteran's favor, his currently diagnosed bruxism is related to his service-connected PTSD, to include medications taken for such disability. 2. Resolving all doubt in the Veteran's favor, his currently diagnosed tinnitus is related to his military service. 3. The Veteran has no ratable service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for bruxism have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 101 (24), 1131, 5107; 38 C.F.R. §§ 3.1, 3.6, 3.102, 3.303. 3. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 3.102, 3.340, 3.341, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from June 1985 to August 1987. He received a discharge under other than honorable conditions. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in February 2020 (tinnitus), September 2020 (substance use disorder), and October 2020 (remaining issues) by a Department of Veterans Affairs (VA) Regional Office (RO) under the modernized appeals system. In December 2020, the Veteran filed several timely Decision Review Request: Board Appeals (Notice of Disagreement) (VA Form 10182) and requested hearings before a Veterans Law Judge, which were held on March 31, 2023. Based on the Veteran's election, the Board may only consider the evidence of record at the time of the issuance of the respective February 11, 2020 (tinnitus), September 8, 2020 (substance use disorder), and October 2, 2020 (remaining issues) rating decisions, and any evidence submitted by the Veteran at the hearing or within 90 days thereafter, i.e., by June 29, 2023. 38 C.F.R. § 20.302 (a). However, under the AMA, the Board is not permitted to remand for anything other than a pre-decisional duty to assist error. Any evidence submitted after the rating decisions on appeal cannot be used as the basis of a pre-decisional duty to assist error as it was submitted after the rating decision. Simply put, this evidence is post-decisional, not pre-decisional. In this instance, the Veteran underwent several VA examinations in May and June 2023, and submitted several disability benefit questionnaires (DBQ) completed by his private physician in the 90 days following his Match 2023 hearing. This evidence was submitted after the rating decisions on appeal and thus cannot be used as the basis of a pre-decisional duty to assist error. Thus, the Board cannot remand for a new VA examination or addendum opinions based on such evidence. By way of background, the Board notes the October 2020 rating decision denied, as relevant, the Veteran's claims for migraines, vomiting, dizziness, left foot and toe disorder, right foot and toe disorder, a digestive disorder, a bladder disorder, anal pain, bruxism, left wrist disorder, right wrist disorder, bilateral hearing loss, damage to penis and scrotum, and entitlement to a TDIU as no new and material evidence had been received. However, under the AMA, the Board is bound by favorable findings made by the AOJ. In this regard, a February 2020 rating decision previously determined new and relevant evidence had been received and reconsidered the Veteran's claims for service connection for migraines, vomiting (also claimed as chest pains), dizziness, left foot and toe disorder, right foot and toe disorder, a digestive disorder, a bladder disorder, anal pain, bruxism, left wrist disorder, right wrist disorder, bilateral hearing loss, and damage to penis and scrotum, but again denied such claims. Additionally, a June 2020 rating decision determined new and relevant evidence had been received and reconsidered the Veteran's claim for entitlement to a TDIU, but again denied such claim. Thus, the February 2020 and June 2020 rating decisions implicitly made the favorable finding of receiving new and relevant evidence as they readjudicated the Veteran's claims on the merits. As the Veteran filed his various notice of disagreement forms (VA Form 10182) within one year of the February 2020 and June 2020 rating decisions, the Board will only address such claims on the merits. Threshold Matter The healthcare and related benefits authorized by Chapter 17 of Title 38 of the United States Code shall be provided to certain former service persons with administrative discharges under other than honorable conditions for any disability incurred or aggravated during active military, naval, or air service in line of duty. 38 C.F.R. § 3.360 (a). With certain exceptions, such benefits shall be furnished for any disability incurred or aggravated during a period of service terminated by a discharge under other than honorable conditions. Specifically, they may not be furnished for any disability incurred or aggravated during a period of service terminated by a bad conduct discharge or when one of the bars listed in § 3.12(c) apply. 38 C.F.R. § 3.360 (b). In making determinations of health-care eligibility, the same criteria will be used as is now applicable to determinations of service incurrence and in line of duty when there is no character of discharge bar. 38 C.F.R. § 3.360 (c). As noted above, the Veteran was discharged from active duty service on August 4, 1987 under other than honorable conditions, therefore the health-care and related benefits are authorized under Chapter 17, 38 U.S.C. according to the service connection criteria that would otherwise apply. Service Connection Claims 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). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 U.S.C. § 1110; 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310 (b). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as organic diseases of the nervous system, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. In an October 4, 1995 opinion, VA's Under Secretary for Health determined that it was appropriate to consider high frequency sensorineural hearing loss an organic disease of the nervous system and therefore a presumptive disability. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Pertinent to a claim for service connection, such a determination requires a finding of a current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § § 4.1; see also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability"). However, VA requires a diagnosis that conforms to the Diagnostic and Statistical Manual of Mental Disorders (DSM) to compensate for a psychiatric disability, therefore constraining the application of Saunders in the context of claims for service connection for psychiatric disabilities. Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the United States Court of Appeals for Veterans Claims (Court) held that the requirement of the existence of a current disability is satisfied when a claimant has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a claimant filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for bruxism, claimed as teeth grinding. The Veteran contends his currently diagnosed bruxism, or teeth grinding, is due to anxiety as a result of several in-service assaults, to include military sexual trauma (MST) that occurred during basic training. In this regard, the Veteran was assaulted by several men in the shower who inserted a broom handle or plunger into his rectum, causing him to fall, and hit his head. Additionally, the Veteran claims he was attacked a second time while on watch, hitting his head on a valve, and a third time when he was in the brig. He asserts all three occasions resulted in a loss of consciousness. Although service treatment records (STRs) do not contain references to these events, the Veteran is currently service-connected for treatment purposes only for posttraumatic stress disorder with major depressive disorder (PTSD) as a result of his MST, and his STRs and military personnel record reference his being confined for 72 hours in the brig. In December 2019, the Veteran underwent VA examination for his claimed bruxism. At the time, the Veteran stated he grinds his teeth more when he has intrusive thoughts. The examiner, a nurse practitioner, noted the Veteran had a diagnosis of sleep-related bruxism per history, but such could not be confirmed, and opined that such was less likely than not due to the Veteran's PTSD as the condition could not be confirmed, and there was no causal link between the Veteran's subjective complaint of bruxism and his mental health condition. In August 2020, the Veteran submitted a letter from his private dentist, Dr. A.C., in which Dr. A.C. stated the Veteran "shared with me his PTSD report. He has significant general wear on the teeth consistent with chronic bruxism...". While Dr. A.C. does not provide an etiological opinion, his statement suggests he found a link between the Veteran's PTSD and his teeth grinding. In June 2023, the Veteran also submitted a disabilities benefit questionnaire (DBQ) completed by the Veteran's private physician, Dr. J.S., which noted a diagnosis of chronic teeth grinding. In June 2023, the Veteran underwent VA examination for his currently diagnosed bruxism. After a review of the record and physical examination, the examiner, a dentist, opined that the Veteran's bruxism was at least as likely as not related to his PTSD and/or the medication he is prescribed for such condition. In this regard, the examiner noted that the Veteran's medical records reflect he was taking medications known to medically induce bruxism, specifically Lisinopril, Amlodipine Besylate, Topiramate, and Quetiapine Fumarate. The examiner also noted that drug induced bruxism is often caused by anti-depressants. In this regard, the Board notes that the Veteran is prescribed Lisinopril and Amlodipine Besylate for hypertension and Topiramate for migraines, but the Veteran is not currently service-connected for such disorders. (See June 2023 VA hypertension and migraine examinations.) However, the Veteran is also prescribed Quetiapine Fumarate for mood stabilization and depression. See March and April 2023 VA treatment records. Based on the foregoing, the Board finds the evidence is at least in equipoise as to whether the Veteran's bruxism is proximately due to his use of medications to treat his service-connected PTSD. Therefore, the Board resolves all doubt in his favor and finds that service connection for bruxism is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 2. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for tinnitus. The Veteran contends he has tinnitus due to working with machinery in the engine room, and that he first noticed a ringing in his ears while still in the service that has continued through the present time. Further, he testified at his March 2023 Board hearing that he did not have acoustic trauma following his military discharge as he worked in an office environment. As an initial matter, the Board finds that the Veteran has a current diagnosis of tinnitus as such disorder can be identified through lay observations alone and he has offered competent and credible descriptions of experiencing tinnitus throughout the appeal period. Charles v. Principi, 16 Vet. App. 370, 374 (2002) (holding that lay evidence is competent to establish such disorders as tinnitus, which are characterized by unique and readily identifiable features that are capable of lay "observation".) Moreover, such diagnosis was confirmed at the June 2023 VA examination. Additionally, while the Veteran's STRs are negative for any complaints, treatment, or diagnosis referable to tinnitus, his reported in-service noise exposure is consistent with his military occupational specialty (MOS) as a Seaman's Apprentice and his military personnel record reflects his work in an engine room. Thus, the remaining inquiry is whether the Veteran's tinnitus is related to his military service, to include his acknowledged in-service noise exposure. At his October 2019 and June 2023 VA examinations, the examiners determined the Veteran did have a diagnosis of tinnitus but opined that such was less likely than not caused by his military service. As rationale, both cited the lack of complaints of tinnitus in the Veteran's STRs and stated that there was no nexus of auditory damage on active duty to relate to the current report of tinnitus to his conceded in-service noise exposure. In this regard, when a claim involves a diagnosis based on purely subjective complaints, the Board is within its province to weigh the Veteran's testimony and determine whether it supports a finding of service incurrence and continued symptoms since service. Barr v. Nicholson, 21 Vet. App. 303, 305 (2007); Charles, supra. Therefore, the Board resolves all doubt in favor of the Veteran and finds that his current tinnitus had its onset in service. Thus, service connection for such disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to a TDIU. The Veteran claims he is entitled to a TDIU on the basis that he is unable to secure and maintain employment as a result of his PTSD. Total disability ratings for compensation may be assigned where the schedular rating is less than total, when, in the judgment of the rating agency, the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38C.F.R. §§3.340, 3.341, 4.16(a). However, if there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16 (a). Here, the Veteran fails to satisfy the schedular criteria for a TDIU as he has no ratable service-connected disability, let alone one considered 60 percent disabling. In an April 1997 Administrative Decision, VA reviewed the circumstances of the Veteran's discharge from service and found the Veteran discharged under other than honorable conditions per 38 C.F.R. § 3.12. A discharge from service under a condition specified in 38 C.F.R. § 3.12 is a bar to the payment of benefits unless it is found that the person was insane at the time of committing the offense causing such discharge. 38 C.F.R. § 3.12 (b). As VA indicated in its Administrative Decision, insanity was not an issue in the Veteran's case, and this bar did not preclude the Veteran's entitlement to health care under Chapter 17 of 38 U.S.C. Since then, pursuant to Chapter 17, VA awarded the Veteran service connection for PTSD, and by virtue of this decision, tinnitus and bruxism, for treatment purposes only. He is not now service connected and rated for any disability for compensation purposes. The criteria for entitlement to a TDIU are therefore not met. REASONS FOR REMAND 4. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for bilateral hearing loss. The Veteran contends he has bilateral hearing loss due to working with machinery in the engine room, and that he first noticed hearing loss while still in the service which has continued through the present time. Further, he testified at his March 2023 Board hearing that he did not have acoustic trauma following his military discharge as he worked in an office environment. In the alternative, the Veteran contends his bilateral hearing loss is due to his PTSD. See also September 2020 VA Form 20-0995. In this regard, while the Veteran's STRs are negative for any complaints, treatment, or diagnosis of right ear hearing loss, there was a threshold shift of 10 decibels and 15 decibels for the 2000 Hz. and 4000 Hz. frequencies, respectively, in the left ear from his December 1984 entrance examination to his May 1986 separation examination. In October 2019, the Veteran underwent a VA examination. At such time, the examiner found that the Veteran had conductive hearing loss in his right ear, which the examiner opined was not consistent with acoustic trauma. However, the examiner did not provide a secondary service connection opinion, that the Veteran's bilateral hearing loss was due to or aggravated by his service-connected PTSD. Thus, a remand is necessary to cure a pre-decisional duty to assist error by obtaining an addendum opinion addressing secondary service connection. 5. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for substance use disorder. At his March 2023 Board hearing, the Veteran testified he used alcohol and cannabis to self-medicate for his service-connected PTSD. In this regard, VA treatment records reflect diagnoses of cannabis dependence and alcohol dependence, and a "reported history of alcohol and cannabis use disorders in the context of PTSD/MDD." See August 2020 records. Therefore, as the Veteran has a current diagnosis of substance abuse disorder and VA treatment records suggest such may be related to PTSD, a remand is necessary to cure a pre-decisional duty to assist error by obtaining an addendum opinion addressing direct service connection. 6. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for anal pain. At his March 2023 Board hearing, the Veteran testified that he has had anal pain since his MST, and that when he has intrusive thoughts about the event, he clenches his rectum, which has led to problems with defecating. See also July 2018 statement. In this regard, VA treatment records reflect a diagnosis of fecal incontinence with incomplete defecation and difficulty with bowel movements. See December 2019 and March 2020 records. In January 2020, the Veteran underwent VA examination for his claimed anal pain. At the time, the examiner opined that it was less likely than not that his anal pain was proximately due to or the result of the Veteran's service-connected PTSD as there were no records to review to support damage [or] anal pain. However, the examiner did not offer a direct service connection opinion, to address whether the Veteran's anal pain was due to his assault. Private treatment records reflect a diagnosis of "anal or rectal pain," and a Colorectal Anal Distress Inventory score of 100/100. Further, they document the Veteran's reports of anal pain since he was assaulted in the Navy. See Eskenazi Health Center records. Thus, a remand is necessary to cure a pre-decisional duty to assist error by obtaining an addendum opinion addressing direct service connection. 7. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for a bladder disorder, to include incontinence and dysfunction. 8. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for damage to penis and scrotum. Specific to his claim for a bladder disorder, the Veteran testified that since his MST, he has experienced bed wetting, wet dreams, and painful urination, and at times, cannot empty his bladder. Additionally, he testified to experiencing penile and scrotal pain since the assault when his scrotum was grabbed and pulled very hard. See also September 2020 statement. In January 2020, the Veteran underwent VA urinary tract and male reproductive examinations. However, the January 2020 examiner opined that it was less likely than not that any bladder or penile disorders were proximately due to or the result of the Veteran's service-connected PTSD, as she was unable to confirm any such diagnoses. However, private treatment records dated October 2019 note the Veteran reported chronic anal, genital, and scrotal pain since his MST, as well as a diagnosis of dysuria and that such "[m]ay be related to anxiety as much as to [a] physical problem. However, given his past anal trauma, need to consider that damage to bladder or prostate may have occurred." August 2020 records reflect a diagnosis of nighttime incontinence and bladder urgency up to 20 times a day. See Eskenazi Health Center records. Thus, as the record includes a current diagnosis of bladder disorders and suggests that such may be related to either the psychological and/or physical effects of his in-service MST and notes the Veteran's reports of genital and scrotal pain, remand is necessary to cure a pre-decisional duty to assist error by obtaining an addendum opinion that addresses such matters. ? 9. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for hypertension. The Veteran contends his high blood pressure is due to anxiety and reliving the trauma of his in-service MST. In the alternative, he contends his high blood pressure is due to pain levels from his mouth, back, wrists, feet, and pelvic pain. See March 2023 Board testimony. However, as the Veteran did not raise the theory of entitlement to service connection based on pain levels from his mouth, back, wrists, feet, and pelvic pain until the March 2023 Board hearing, i.e., subsequent to the rating decision on appeal, such cannot serve as a pre-decisional duty-to-assist error in the AOJ's failure to obtain a VA examination and/or opinion. Thus, pursuant to the AMA, the Board may not remand for an examination and/or opinion addressing such theory of entitlement. In this regard, the Veteran's STRs are negative for any complaint, treatment, or diagnosis referable to hypertension, and the Veteran's claim was denied for lack of a current diagnosis. However, private treatment records included in the claims file at the time of the October 2020 rating decision do reflect a diagnosis of hypertension. See October 2019 Eskenazi Health Center records. Therefore, in light of the Veteran's diagnosis of hypertension, the Board finds a remand is necessary to correct a duty to assist error and afford the Veteran a VA examination to determine the nature and etiology of his claimed hypertension. 10. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for migraines. The Veteran contends he has experienced migraines since basic training as a result of head trauma resulting in loss of consciousness and/or his PTSD. See December 2019 VA examination, September 2020 statement, and March 2023 testimony. In this regard, the Veteran's STRs contain an October 1986 complaint of headache. The Veteran underwent VA examination in December 2019, and at that time, migraines, including migraine variants, were diagnosed. However, the examiner opined that the Veteran's migraines were less likely than not related to his PTSD, as his mental health conditions were recently diagnosed, and that the onset of the condition (as well as headache characteristics) does not reasonably correlate with a medical relationship regarding the Veteran's mental health conditions, especially since migraines are common in the general population and often have a genetic predisposition. However, the examiner did not address whether the Veteran's migraines were related to his in-service head trauma or explain whether this particular Veteran has a genetic predisposition to migraines. Further, in regard to the unfavorable secondary service connection opinion, while the Veteran's PTSD was not diagnosed until 2019, the Veteran's mental health disorder stems from events that occurred from 1985 to 1987. Thus, such opinion is insufficient to decide the claim. Therefore, in light of the Veteran's diagnosis of migraines, and the fact that no adequate opinion has been obtained, the Board finds a remand is necessary in order to correct a pre-decisional duty to assist error by obtaining an addendum opinion that addresses such matters. 11. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for a digestive disorder, to include weight loss. 12. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for vomiting. The Veteran contends he has digestive issues, to include weight loss, and vomiting as a result of anxiety and intrusive thoughts of his MST, which can make him feel nauseated. His contends his vomiting began while still in the Navy. He further reported losing about 8 to 15 pounds. He also stated that his prostrating migraines have affected his diet, and his hypertension produces vomiting. See September 2020 statement and March 2023 testimony. The Veteran's STRs are negative for any complaint, treatment, or diagnosis referable to either digestive issues or vomiting; however, VA treatment records reflect the Veteran's reports of difficulty having bowel movements, weight loss, nausea, vomiting, and the Veteran is prescribed medication for constipation. See March 2020, April 2020, and May 2020 records. Additionally, private treatment records dated December 2019 reflect the Veteran had undergone weight loss, losing 50 pounds in one year. See Eskenazi records. However, the Veteran has not been afforded a VA examination or opinion to determine the nature and etiology of his claimed digestive disorder or vomiting. As the evidence now suggests the Veteran may have digestive disorders, to include constipation and diarrhea, that may be related to his acknowledged in-service assault, and VA treatment records contain complaints of vomiting, the Board finds a remand is necessary to correct a duty to assist error and afford the Veteran a VA examination to determine the nature and etiology of his claimed digestive disorder and vomiting. Additionally, the claims for service connection for digestive disorder or vomiting are inextricably intertwined with the remanded claims for service connection for migraines and hypertension, and thus, must also be remanded. See Parker, supra; Harris, supra. 13. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for blurred vision. 14. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for dizziness. 15. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for fainting. The Veteran contends his blurred vision, dizziness, and fainting are due to his PTSD, and/or to head trauma sustained during his in-service assaults, resulting in loss of consciousness. In the alternative, he contends such disorders are due to his migraines and/or his blurred vision and dizziness are due to his hypertension. While the Veteran's STRs contain a July 1987 note that he was unable to see due to serum blockage, such are otherwise negative for any complaint, treatment, or diagnosis referable to blurred vision, dizziness, or fainting. However, March 2020 VA treatment records reflect the Veteran's reports of dizziness, fainting, and blurred vision, although he thought that might be due to his prescribed medications. In addition, his December 2019 VA headache examination also notes changes in vision. However, the Veteran has not been afforded a VA examination or opinion to determine the nature and etiology of his claimed blurred vision, dizziness, or fainting disorders. As the post-service treatment records contain diagnoses of such disorders, the Board finds a remand is necessary to correct a duty to assist error and afford the Veteran a VA examination to determine the nature and etiology of his claimed blurred vision, dizziness, or fainting. Additionally, the claims for service connection for blurred vision, dizziness, and fainting are inextricably intertwined with the remanded claims for service connection for migraines and hypertension, thus, must also be remanded. See Parker, supra; Harris, supra. 16. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for a left wrist disorder. 17. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for a right wrist disorder. The Veteran contends his bilateral wrist disorders are due to working in the engine room. Specifically, he testified that the hydraulic valves were very tight, and using the wrenches and tools to turn the valves, over 50 times each watch, was painful. Additionally, as a seaman, handling heavy ropes, wet with seawater, placed stress on his wrists. See also September 2020 statement. The Veteran's STRs are negative for any complaint, treatment, or diagnosis referable to either wrist; however, VA treatment records do reflect complaints of wrist pain and private treatment records dated January 2020 reflect bilateral chronic wrist pain. See Eskenazi Health records. However, despite being diagnosed with bilateral wrist pain, an adequate etiological opinion has not been obtained. Therefore, in light of the Veteran's documented bilateral wrist pain, the Board finds a remand is necessary in order to correct a pre-decisional duty to assist error and afford the Veteran a VA examination to determine the nature and etiology of his claimed bilateral wrist disorder. 18. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for left foot and toe disorder. 19. Entitlement to service connection for treatment purposes only under Chapter 17 of Title 38, U.S.C. for right foot and toe disorder. The Veteran contends his bilateral foot and toe disorders are due to his duties in the Navy. Specifically, he testified that he stood for many hours a day on metal grate or solid steel diamond plate flooring while working in the engine room, and while loading and unloading goods on and off the ship. See also September 2020 statement. The Veteran's STRs are negative for any complaint, treatment, or diagnosis referable to either feet or toe pain; however, VA treatment records dated April 2020 do reflect complaints of foot pain, and private treatment records reflect a "painful deformity of the great toe region," and a diagnosis of bilateral hallux rigidus and degenerative joint disease (DJD) of the first metatarsophalangeal joints bilaterally. See September 2012 Westfield Foot and Ankle records and January 2020 Eskenazi Health records. However, despite being diagnosed with several foot and/or toe disorders, an adequate etiological opinion has not been obtained. Therefore, in light of the Veteran's diagnoses of bilateral hallux rigidus and DJD of the first metatarsophalangeal joints, the Board finds a remand is necessary in order to correct a pre-decisional duty to assist error and afford the Veteran a VA examination to determine the nature and etiology of his claimed bilateral foot and toe disorders. ? The matters are REMANDED for the following action: 1. The Board observes the Veteran is currently homeless. Therefore, verify the Veteran's current mailing address and advise all components of VA of the correct address. Specific procedures to notify homeless veterans are set forth in 38 C.F.R. § 1.710. Upon remand, those procedures should be followed (unless it is established that the Veteran is not homeless). (A) If necessary, enlist the help of the Veteran's representative. Of note, the Veteran's representative, The American Legion, recently represented the Veteran at his March 2023 Board hearing. (B) If the examination scheduling request is cancelled or attempts to contact the Veteran are unsuccessful, a report of contact or report of general information explaining the failed attempt(s) to schedule an examination or contact the Veteran, or his authorized representative, should be placed in the Veteran's electronic file. 2. Forward the record, to include a copy of this remand, to an appropriate medical professional to obtain an addendum opinion addressing the etiology of the Veteran's bilateral hearing loss. The need for an additional examination of the Veteran is left to the discretion of the medical professional selected to write the addendum opinion. Following a review of the record, the examiner should offer an opinion as to whether it at least as likely as not that his bilateral hearing loss is caused or aggravated by his PTSD. For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. A rationale for any opinion offered should be provided. 3. Forward the record, to include a copy of this remand, to an appropriate medical professional to obtain an addendum opinion addressing the etiology of the Veteran's substance abuse disorder. The need for an additional examination of the Veteran is left to the discretion of the medical professional selected to write the addendum opinion. Following a review of the record, the examiner should offer an opinion as to whether it is at least as likely as not that such is caused or aggravated by his PTSD. For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. In reaching an opinion, the examiner is to consider the August 2020 VA treatment record that states the Veteran had a "reported history of alcohol and cannabis use disorders in the context of PTSD/MDD." A rationale for any opinion offered should be provided. 4. Forward the record, to include a copy of this remand, to an appropriate medical professional to obtain an addendum opinion addressing the etiology of the Veteran's anal pain. The need for an additional examination of the Veteran is left to the discretion of the medical professional selected to write the addendum opinion. Following a review of the record, the examiner should address the following inquiries: (A) Is it at least as likely as not that the Veteran's anal pain is a result of his acknowledged in-service MST? In reaching an opinion, the examiner is to consider the Veteran's reports that he has experienced anal pain since the MST. (B) Is it at least as likely as not that his anal pain is caused or aggravated by his PTSD? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. In reaching an opinion, the examiner is to consider the Veteran's report that when he has intrusive thoughts about the event, he clenches his rectum, which has led to problems with defecating. A rationale for any opinion offered should be provided. 5. Forward the record, to include a copy of this remand, to an appropriate medical professional to obtain an addendum opinion addressing the etiology of the Veteran's bladder disorder and claimed damage to his penis and scrotum. The need for an additional examination of the Veteran is left to the discretion of the medical professional selected to write the addendum opinion. Following a review of the record, the examiner should address the following inquiries: (A) Is it at least as likely as not that the Veteran's bladder disorder and damage to his penis and scrotum a result of his acknowledged in-service MST? In reaching an opinion, the examiner is to consider the Veteran's reports that he has experienced bed wetting, wet dreams, painful urination, genital and scrotal pain since the MST and the October 2019 private treatment record that states "given his past anal trauma, [we] need to consider that damage to bladder or prostate may have occurred." (B) Is it at least as likely as not that his bladder disorder and damage to his penis and scrotum is caused or aggravated by his PTSD? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. In reaching an opinion, the examiner is to consider the October 2019 private treatment record that states his dysuria "[m]ay be related to anxiety as much as to [a] physical problem." A rationale for any opinion offered should be provided. 6. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his hypertension. The record, including a copy of this Remand, must be made available for review in connection with the examination, and all indicated tests and studies should be undertaken. Following a review of the record, the examiner should address the following inquiries: (A) Is it at least as likely as not that the Veteran's hypertension is a result of his acknowledged in-service MST? In reaching an opinion, the examiner is to consider the Veteran's contention that his blood pressure rises due to anxiety and reliving the trauma of his in-service MST. (B) Is it at least as likely as not that his hypertension is caused or aggravated by his PTSD? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. A rationale for any opinion offered should be provided. 7. Forward the record, to include a copy of this remand, to an appropriate medical professional to obtain an addendum opinion addressing the etiology of the Veteran's migraines. The need for an additional examination of the Veteran is left to the discretion of the medical professional selected to write the addendum opinion. Following a review of the record, the examiner should address the following inquiries: (A) Is it at least as likely as not that the Veteran's migraines are is a result of his military service, to include his acknowledged MST and/or resulting head trauma? In reaching an opinion, the examiner is to consider the Veteran's reports of losing consciousness during his MST, and that his headaches began in-service as noted by the October 1986 STR. (B) Is it at least as likely as not that his migraines are caused or aggravated by his PTSD? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. A rationale for any opinion offered should be provided. 8. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his claimed digestive disorder, to include weight loss and vomiting. The record, including a copy of this Remand, must be made available for review in connection with the examination, and all indicated tests and studies should be undertaken. Thereafter, the examiner should address the following inquiries: (A) Is it at least as likely as not that the Veteran's claimed digestive disorder, to include weight loss and vomiting is a result of his acknowledged in-service MST? In reaching an opinion, the examiner is to consider the Veteran's contention that anxiety and reliving the trauma of his in-service MST can make him feel nauseated and that he began vomiting while still in the Navy. Further, the examiner is to consider the December 2019 private treatment record that notes a 50-pound weight loss in one year. (B) Is it at least as likely as not that a digestive disorder, to include weight loss and vomiting, is caused or aggravated by his PTSD? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. A rationale for any opinion offered should be provided. 9. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his blurred vision. The record, including a copy of this Remand, must be made available for review in connection with the examination, and all indicated tests and studies should be undertaken. Following a review of the record, the examiner should offer an opinion as to whether it is at least as likely as not that the Veteran's blurred vision, are a result of his acknowledged in-service MST and/or resulting head trauma. A rationale for any opinion offered should be provided. 10. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his dizziness and fainting. The record, including a copy of this Remand, must be made available for review in connection with the examination, and all indicated tests and studies should be undertaken. Following a review of the record, the examiner should offer an opinion as to whether it is at least as likely as not that the Veteran's dizziness and/or fainting is a result of his acknowledged in-service MST and/or resulting head trauma? A rationale for any opinion offered should be provided. 11. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his claimed bilateral wrist pain. The record, including a copy of this Remand, must be made available for review in connection with the examination, and all indicated tests and studies should be undertaken. Following a review of the record, the examiner should offer an opinion as to whether it is at least as likely as not that his bilateral wrist disorder is related to his military service, to include his duties working in the engine room and handling heavy ropes. A rationale for any opinion offered should be provided. 12. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his bilateral foot and toe disorder, currently diagnosed as bilateral hallux rigidus and DJD of the first metatarsophalangeal joints. The record, including a copy of this Remand, must be made available for review in connection with the examination, and all indicated tests and studies should be undertaken. Following a review of the record, the examiner should offer an opinion as to whether it is at least as likely as not that his bilateral foot and toe disorder is related to his military service, to include standing for many hours a day on metal grate or solid steel diamond plate flooring while working in the engine room, and while loading and unloading goods on and off the shipping. A rationale for any opinion offered should be provided. Wendy Daknis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.M. Kelly, 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.