Citation Nr: 1123279 Decision Date: 06/17/11 Archive Date: 06/28/11 DOCKET NO. 06-11 573 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for a right shoulder disability (claimed as degenerative joint disease (DJD) and arthritis), to include as secondary to service-connected disabilities. 2. Entitlement to service connection for a sleep disorder, to include chronic insomnia, sleep apnea, and restless leg syndrome, claimed as secondary to service-connected disabilities. 3. Entitlement to service connection for a bilateral knee disorder (claimed as DJD and arthritis), to include as secondary to service-connected disabilities. 4. Entitlement to a compensable rating for residuals of a duodenal ulcer with a history of gastritis, duodenitis, and hiatal hernia. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Bosely, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1966 to October 1986. This case originally came before the Board of Veterans' Appeals (Board) on appeal from a November 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which denied the benefits sought on appeal. In September 2007, the Veteran testified before the undersigned Veterans Law Judge at a travel board hearing held at the RO. A transcript of the hearing has been associated with the claims file. In April 2009, the Board remanded the issues on appeal to the RO for additional evidentiary development. The case has now been returned to the Board for further appellate action. The issues of service connection for (1) a bilateral knee disorder, and (2) a sleep disorder, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In January 2010, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that he wished to withdraw his appeal on the issue of service connection for a right shoulder disorder. 2. Throughout the period of appellate review, the Veteran's service-connected residuals of a duodenal ulcer with a history of gastritis, duodenitis, and hiatal hernia, is shown to be productive of a disability picture that more nearly approximates hiatal hernia with recurrent epigastric distress with pyrosis and infrequent dysphagia and regurgitation, but not duodenal ulcer more nearly approximating a moderate condition with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations; gastritis with multiple small eroded or ulcerated areas and symptoms; or persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran have been met as to the claim of service connection for a right shoulder disorder. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2010). 2. The criteria for the assignment of a 10 percent evaluation, but not more, for the service-connected residuals of a duodenal ulcer with a history of gastritis, duodenitis, and hiatal hernia, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.114 including Diagnostic Codes 7305, 7307, 7346 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Withdrawal The Board previously remanded the claim of service connection for a right shoulder disorder in April 2009. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2010). Withdrawal may be made by an appellant or by his or her authorized representative. 38 C.F.R. § 20.204. The Veteran submitted correspondence in January 2010 withdrawing his appeal on the claim of service connection for a right shoulder disorder. Hence, there remain no allegations of errors of fact or law for appellate consideration on that issue. Accordingly, the Board does not have jurisdiction to review the appeal as to that issue, and it is dismissed. II. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim. Accordingly, notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent a letter in July 2004 that fully addressed all notice elements and was issued prior to the initial RO decision in this matter. The letter provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. Moreover, an April 2006 letter informed the Veteran of what type of information and evidence was needed to establish a disability rating and effective date. Although a document fully meeting the VCAA's notice requirements was not provided to the Veteran before the rating decision on appeal, the claim was fully developed and then readjudicated most recently in an October 2010 Supplemental Statement of the Case (SSOC), which was issued after all required notice was provided. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, the Veteran's statements in support of the claim are of record, including testimony provided at a Board before the undersigned. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. Also, the Veteran was afforded VA examinations, most recently in January 2010 to evaluate the severity of his service-connected residuals of a duodenal ulcer with a history of gastritis, duodenitis, and hiatal hernia. The Board finds that the VA examinations are adequate because, as shown below, they were based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because they describe the service-connected disability picture in detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Furthermore, the Veteran has not asserted, and the evidence does not show, that his symptoms have materially increased in severity since that evaluation. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect.); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Board accordingly finds no reason to remand for further examination. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The Board also finds that there was substantial compliance with the April 2009 Board remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to substantial compliance with a remand order. See Stegall v. West, 11 Vet. App. 268 (1998); see D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to the internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). Specifically in this case, the Board, in pertinent part, directed the AMC/RO arrange for the Veteran to undergo a VA examination to determine the current severity of his service-connected residuals of a duodenal ulcer. As indicated, the Veteran underwent an adequate VA examination in January 2010. Accordingly, the Board finds that there was substantial compliance with the April 2009 remand directives. Accordingly, no further remand is necessary. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries, 22 Vet. App. at 104-05. III. Analysis The Veteran contends that a compensable evaluation is warranted for his service-connected gastrointestinal disability. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which assigns ratings based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. 41. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). A claimant, however, may experience multiple distinct degrees of disability, resulting in different levels of compensation, from the time the increased rating claim is filed to the time a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is therefore undertaken with consideration that different (staged) ratings may be warranted for different time periods during the period of appellate review beginning within one year of his June 2004 claim. Disability ratings of the digestive system as assigned under 38 C.F.R. § 4.114, diagnostic codes 7200 through 7354. Pertinent in this appeal are Diagnostic Codes 7305, concerning ulcer, duodenal; 7307, concerning gastritis, hypertrophic; and 7346, concerning hernia hiatal. According to the rating schedule, ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Under Diagnostic Code 7305, concerning ulcer, duodenal, a 10 percent evaluation is warranted for mild condition with recurring symptoms once or twice yearly. A 20 percent rating is warranted for a moderate condition with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations. A 40 percent rating is warranted for the moderately severe condition with less than severe but with impairment of health manifested by anemia and weight loss, or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. The highest rating, 60 percent rating is warranted for a severe condition with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7305 (2010). Under Diagnostic Code 7307, concerning gastritis, hypertrophic, a 10 percent evaluation is assigned for chronic hypertrophic gastritis, with small nodular lesions and symptoms. A 30 percent evaluation is warranted for multiple small eroded or ulcerated areas and symptoms. The highest evaluation, 60 percent, is assigned for severe hemorrhages, or large ulcerated or eroded areas. See 38 C.F.R. § 4.114, Diagnostic Code 7307. Under Diagnostic Code 7346, concerning hernia hiatal, a rating of 10 percent is assigned with two or more of the symptoms for the 30 percent evaluation with less severity. A rating of 30 percent is assigned with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The highest rating, 60 percent, is assigned for a hiatal hernia with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. Terms such as "severe," "considerable," and "of lesser severity" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Also, the Board notes that the joining of schedular criteria in the rating schedule by the conjunctive "and" in a diagnostic code does not always require all criteria to be met, except in the case of diagnostic codes that use successive rating criteria, where assignment of a higher rating requires that elements from the lower rating are met. Tatum v. Shinseki, 23 Vet. App. 152 (2009). In the present case, the Board finds, after carefully reviewing the pertinent medical and lay evidence, that the service-connected disability picture more nearly resembles the criteria for the assignment of a 10 percent rating under Diagnostic Code 7346, concerning hiatal hernia, in light of evidence showing persistent epigastric distress with pyrosis. The Board finds, on the other hand, that a rating higher than 10 percent is not warranted. First, under Diagnostic Code 7305, the evidence does not demonstrate duodenal ulcer more nearly approximating a moderate condition with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations. Second, under Diagnostic Code 7307, the evidence does not demonstrate gastritis more nearly approximating multiple small eroded or ulcerated areas and symptoms. Finally, under Diagnostic Code 7346, the evidence does not demonstrate persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 38 C.F.R. § 4.114 In particular, the first pertinent evidence consists of a July 2003 private primary care treatment note showing that the Veteran was generally well-nourished, but had symptoms of gastrointestinal reflux disease (GERD) on medication. Private cardiology treatment notes from August 2003 show that the Veteran was treated for complaints of chest pain. It was noted that the Veteran denied GERD symptoms, but endorsed indigestion symptoms. Treatment notes from September 2003 through March 2004 then show that he had no gastrointestinal symptoms such as nausea or vomiting. A July 2004 VA primary care treatment note shows complaints that the Veteran was still losing weight despite having a healthy appetite. A non-VA treatment note from July 2004 shows that the Veteran denied nausea; loss of appetite; abnormal weight loss; vomiting; dysphagia; reflex; and abdominal pain. The assessment was esophageal reflux and weight loss on examination, and the Veteran was sent for further consultations to determine cause of his weight loss. Shortly thereafter, in August 2004, the Veteran underwent a VA examination. The VA examiner noted that the Veteran had a history of peptic ulcer disease (PUD), GERD, and hiatal hernia, for which he was taking medication. His symptoms were controlled by the medication and avoiding spicy foods, and this had not changed for years. The Veteran would also sit upright after eating, and he did not eat prior to going to bed. He had no nausea, vomiting, diarrhea, constipation, or hematemesis. No changes in stool compatible with melena. There was no tenderness. The VA examiner's assessment was history of duodenal ulcer, gastritis, and hiatal hernia with symptoms controlled on current medication, with no significant change. Also pertinent during this time period, private treatment records from December 2004 through March 2005 show that the Veteran denied nausea, vomiting, constipation, diarrhea, but he related symptoms of GERD with reflux. The Board notes, at this point, that there is occasional evidence of inconsistent complaints. For example, a private primary care treatment record from March 2005 shows that the Veteran denied nausea and vomiting, loss of appetite, abnormal weight loss; dysphagia, reflux, and abdominal pain. (It was noted that he was well appearing and well developed.) The next day, by comparison, the Veteran reported during a private neurological consultation that he had weight loss, some difficulty swallowing with indigestion, and history of hematemesis. However, physical examination again showed him as "healthy." Also, a VA examiner in an unrelated VA examination in May 2007, regarding the spine, concluded that there was malingering, so "no subjective reports by [the Veteran] should be used for rating purposes." These inconsistencies and indications of exaggeration tend to reduce the probative weight of his statements. See Dalton v. Nicholson, 21 Vet. App. 23, 36 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (in weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness). The remaining evidence during the period of appellate review includes an August 2005 treatment note showing that his weight was down to 156.3, which was noted to be a 20 pound weight loss in three months, and he complained of loss of appetite, reflux, loss of weight, tiredness. However, the pertinent assessment was esophageal reflux, on medication, stable. A May 2005 VA primary care follow-up note also shows complaints of needing to sleep in a recliner due to shoulder and reflux symptoms, despite medication, and, at times, he needed over-the-counter antacids, and he would watch what he ate as he could not eat anything greasy or spicy. It was also noted that his symptoms were "80% controlled" with his current regime. A September 2005 private follow-up note for treatment of tiredness and weight loss reflects that laboratory reports were within normal limits, except for mild anemia; the assessment was tiredness due to boredom; loss of weight due to anorexia and not eating [unreadable]; and GERD controlled on medication. In a May 2006 testimonial statement, the Veteran wrote that he took medication one time per day, but still had regurgitation with arm and shoulder pain and often diarrhea. The medical records demonstrate that he then continued to undergo regular follow-up treatment. In October 2006, it was noted that had gained 6 pounds in the last month. Also in October 2006, the Veteran again had complaints of unintentional weight loss, abdominal pain, and heartburn/indigestion, but he had no nausea or vomiting. Then, at a private pain management consultation in February 2007, the Veteran related his history of ulcer, but reported that he was stable on medication. It was noted that there were "No GI issues." A private March 2008 primary care treatment note shows weight at 185 with normal appetite; no heartburn, nausea or vomiting; and not tiring easily. By April 2008, he denied all gastrointestinal symptoms. In fact, in July 2008, a private treatment record shows that the Veteran was intentionally trying to lose weight. He had heartburn, but a normal appetite with no nausea or vomiting, and with no difficulty chewing or dysphagia. Treatment notes throughout July and September 2008 show similar symptomatology. Also pertinent, the Veteran testified at his September 2007 Board hearing that his diet was restricted so that he could not eat anything too spicy. His symptoms were under control if he stayed away from those foods and took medication. If his symptoms "act[ed] up" he would avoid all spicy food and use over-the-counter antacids. He explained that "act[ing] up" meant burning, regurgitation, and diarrhea, which would happen every 3 weeks or so, and then took approximately 3 days to get back under control. Also, he sometimes, but not always, had cramping/abdominal pain. The Veteran further testified that his pain had been so bad at times that he would lie in bed in the fetal position. He would have this often if he went too long without taking precautions. He reported that he was not anemic; his weight during the prior year ranged from 155 to 185; and his physical activity depended on "how stable" he felt. He would walk and do different types of exercises recommended to him. The most recent pertinent evidence of record consists of the results of a January 2010 VA examination. The VA examiner reviewed prior diagnostic testing results, including a June 2009 esophagogastroduodenoscopy (EGD), which showed post-operative diagnosis of gastritis, moderate, and hiatal hernia. The VA examiner characterized the Veteran's course of symptoms as intermittent with remissions. The Veteran was on medication, bland diet, limited milk, no alcohol. He also had flares of mid-abdomen stomach pain with regurgitation, and history of bloating after eating; and weekly nausea lasting one-half hour. The VA examiner's assessment was status post ulcer disease without current activity, duodenal ulcer with no effects on activities of daily living (ADLs). The VA examiner found that there was no current evidence on EGD of duodenal ulcer or residuals. The Veteran had moderate gastritis unrelated to his previous PUD due to treatment in 2001. Also, the VA examiner explained, the hiatal hernia that was shown during service was shown on the recent EGD, and this produced subjective symptoms of weekly reflux with bloating and nausea lasting 1/2 hour without considerable impairment of health. The Board finds, in summary, that the more credible and probative evidence shows a disability picture more nearly approximating recurrent epigastric distress with pyrosis and infrequent diagnosis of dysphagia and regurgitation. Thus, a 10 percent rating is assignable under Diagnostic Code 7346. However, the evidence makes clear that the Veteran's symptoms are not productive of considerable impairment of health. To the contrary, as shown, he was described as well-developed, healthy, or well-appearing. He had treatment, including in September 2005, for complaints of tiredness and weight loss, but these were found to be due to boredom and anorexia, which are not conditions of his service-connected disability. Therefore, such symptoms are not attributable to the service-connected disability. See Mittleider v. West, 11 Vet. App.181, 182 (1988) (per curiam). His GERD symptoms, at that time, were noted to be controlled on medication. The January 2010 VA examiner concluded that the Veteran's symptoms were "moderate," but the examiner specifically clarified that there was no current evidence on EGD of duodenal ulcer or residuals. The Board points out that the remaining evidence is consistent with the VA examiner's assessment. Furthermore, the Veteran explained at his Board hearing that flare-ups occurred only when he did not adhere to his treatment regime, and the flare-ups were brought under control after three days. Thus, the evidence is inconsistent with a higher rating under the potentially applicable alternative diagnostic codes, 7305 and 7307. 38 C.F.R. § 4.114; Schafrath, 1 Vet. App. at 593. In conclusion, the Board finds that a 10 percent rating, but not higher, is warranted for the service-connected residuals of a duodenal ulcer with a history of gastritis, duodenitis, and hiatal hernia. "Staged ratings" are not warranted because the schedular criteria for a 10 percent rating, but not higher, were met throughout the entire period under appellate review. See Hart, 21 Vet. App. at 505. The Board's findings above are based on schedular evaluation. To afford justice in exceptional situations, an extraschedular rating may also be provided. 38 C.F.R. § 3.321(b). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111, 115 (Vet.App. 2008). Therefore, initially, the level of severity and symptomatology of a veteran's service-connected disability must be compared with the established criteria found in the rating schedule for that disability. Id. If the rating criteria reasonably describe the disability level and symptomatology, the disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate and no referral is required. Id. In the present case, referral for extraschedular consideration is not warranted as the applicable rating criteria reasonably describe the Veteran's disability level and symptomatology, as discussed in detail above. The manifestations of the Veteran's residuals of a duodenal ulcer with a history of gastritis, duodenitis, and hiatal hernia do not present an unusual or exceptional disability picture. Therefore, the Board is not required to remand the Veteran's claim for consideration of extraschedular ratings under 38 C.F.R. § 3.321(b)(1). See Thun v. Peake, 22 Vet. App. 111, 115 (2008). ORDER The appeal on the claim of service connection for a right shoulder disorder is dismissed. A 10 percent rating, but not higher, for the service-connected residuals of a duodenal ulcer with a history of gastritis, duodenitis, and hiatal hernia, is granted, subject to the regulations governing the payment of VA monetary benefits. REMAND Upon review, the Board finds that further development is necessary on the claims of service connection for (1) a bilateral knee disorder, and (2) a sleep impairment (claimed as chronic insomnia). The Board previously remanded these issues to the RO in April 2009. With regard to the claimed bilateral knee disorder, the Board in April 2009 instructed the RO to schedule the Veteran for a VA examination to determine the nature and etiology of any current (nonservice-connected) bilateral knee disability. Upon remand, the Veteran underwent a VA examination in January 2010. The VA examiner opined that a current bilateral knee disability was less likely than not incurred in or aggravated by the Veteran's service, including complaints of and treatment for bilateral knee pain during service, and less likely than not proximately due to or the result of any of a service-connected disabilities. Upon review, the Board finds that the VA examination opinion is not adequate to decide the issue. Service connection may be granted for a disability that is proximately due to or the result of a service-connected disability, which includes the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Thus, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b). Here, the January 2010 VA examination adequately addresses the issue of whether a service-connected disability caused a nonservice-connected bilateral knee disorder. However, the opinion is not adequate to decide the issue of whether a service-connected disability has aggravated a bilateral knee disorder. See 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Thus, referral for an addendum opinion is necessary. Similarly, with regard to the claim of service connection for a sleep disorder, the central issue is whether a service-connected disability has caused or aggravated a sleep disorder. As an initial matter, the Board finds that the Veteran has specifically claimed insomnia. He has also described symptoms of sleep apnea and restless leg syndrome, which are disorders reflected in the medical evidence of record. More recently, the Court of Appeals for Veterans Claims has stressed that the scope of a claim should be construed based on the reasonable expectations of a non-expert, self-represented claimant, and the evidence developed during the claims process. If a Veteran claims service connection for a specific disorder, any disorder reasonably encompassed by the Veteran's claim must be considered. The Veteran may identify the scope of his claim by reference "to a body part or system that is disabled or by describing symptoms of the disability." The factors to consider are the Veteran's description of his claim, the symptoms he describes; and all the information he submits or VA obtains in support of the claim. See Clemons v. Shinseki, 23 Vet. App. 1 (2009); Brokowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009). In light of these considerations, the Board finds that the scope of the present claim reasonably encompasses a claim of service connection for a sleep disorder, to include insomnia, sleep apnea, and restless leg syndrome. See Clemons, 23 Vet. App. 1; Brokowski, 23 Vet. App. at 86-88. The Veteran underwent a VA examination in October 2005 to address the issue. The VA examiner opined that the Veteran's service-connected disabilities "have no relationship to" his sleep apnea. The VA examiner reasoned that "there is no medical links relating these conditions." The Board finds that the October 2005 VA examination is not adequate to address the issue on appeal for two reasons. First, the VA examiner did not provide an opinion regarding the claimed insomnia. Second, at the time of the October 2005 VA examination, depression was not a service-connected disability. (The Veteran was granted service connection in a June 2007 rating decision.) An October 2006 private treatment record indicates that "stress" is an aggravating factor of the Veteran's sleep apnea. Thus, there is an indication that a psychiatric disorder may have aggravated a sleep disorder. Accordingly, a new VA examination is warranted. Accordingly, the issues are REMANDED for the following action: 1. After completing any initial development deemed warranted based upon a review of the entire record, to include associating any pertinent outstanding records with the claims folder, the RO should arrange for the Veteran's claims folder to be reviewed by the VA examiner who prepared the January 2010 VA examination report (or a suitable substitute if such examiner is unavailable), for the purpose of preparing an addendum opinion. All necessary special studies or tests should be accomplished. The examiner is requested to provide an opinion, in light of the prior examination results, as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that a current bilateral knee disorder has been aggravated by (i.e., permanently worsened beyond the natural progression of the disease) a service-connected disability. In making this determination, the examiner is asked to discuss the Veteran's own assertions regarding his symptomatology. The examiner should prepare a printed (typewritten) report setting forth all examination findings, along with a complete rationale for all opinions and conclusions reached. It is imperative that the examiner offer a detailed analysis for all conclusions and opinions reached supported by specific references to the Veteran's claims file, including the in-service and post-service medical records, and the Veteran's lay assertions. 2. The RO should also arrange for the Veteran to undergo an appropriate VA examination to determine the nature and likely etiology of the claimed sleep disorder. The entire claims file, including a copy of this remand, must be made available to the examiner(s) for review. Accordingly, the examiner is asked to review the pertinent evidence, including the Veteran's lay assertions, and also undertake any indicated studies. Then, based on the record review and examination results, the examiner should provide a current diagnosis and specifically indicate whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that the Veteran has a current sleep disorder, to include insomnia, sleep apnea, and/or restless leg syndrome, that was incurred during the Veteran's active service (i.e., had its onset therein), became manifest within a one-year period following his discharge from service, or is otherwise causally related to his active service. If the VA examiner determines that a current sleep disorder did not have its onset directly during the Veteran's active service, the VA examiner is asked to provide an opinion as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that a current sleep disorder either (a) was caused by, or (b) has been aggravated by (i.e., permanently worsened beyond the natural progression of the disease), a service-connected disability, including depression. In making these determinations, the examiner is asked to provide a distinct opinion for each diagnosed sleep disorder. The examiner is also requested to address a private treatment record from October 2006 listing "stress" as an aggravating factor of the Veteran's sleep apnea. The examiner should also discuss the Veteran's assertions regarding his symptomatology since service. The examiner(s) should prepare a printed (typewritten) report setting forth all examination findings, along with a complete rationale for all opinions and conclusions reached. It is imperative that the examiner(s) offer a detailed analysis for all conclusions and opinions reached supported by specific references to the Veteran's claims file, including the in-service and post-service medical records, and the Veteran's lay assertions. 3. After completing the requested actions, and any additional notification and/or development warranted by the record, the RO should readjudicate the remanded claims in light of all pertinent evidence and legal authority and addressing all relevant theories of entitlement. If any benefit sought on appeal remains denied, the RO should furnish to the Veteran and his representative, if any, an appropriate Supplemental Statement of the Case (SSOC) that includes clear reasons and bases for all determinations, and affords the appropriate time period to respond. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ D. C. Spickler Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs