Citation Nr: 1426734 Decision Date: 06/12/14 Archive Date: 06/26/14 DOCKET NO. 09-00 668 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Whether new and material evidence has been received to reopen service connection for migraine headaches. 2. Entitlement to service connection for migraine headaches, including as secondary to service-connected disabilities. 3. Entitlement to service connection for asthma, including as secondary to service-connected disabilities. 4. Entitlement to service connection for tinnitus, including as secondary to service-connected disabilities. 5. Entitlement to service connection for erectile dysfunction, including as secondary to service-connected disabilities. 6. Entitlement to an initial disability rating (evaluation) in excess of 10 percent for ulnar neuropathy of the right upper extremity. 7. Entitlement to an initial disability rating (evaluation) in excess of 10 percent for ulnar neuropathy of the left upper extremity. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from June 1987 to October 1987, and from January 1991 to April 1991. This appeal comes to the Board of Veterans' Appeals (Board) from July and December 2007 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. Entitlement to service connection for migraine headaches was previously denied by the RO in October 1997 and the Veteran did not initiate an appeal of the decision or submit any new and material evidence with respect to this claim within the applicable one-year period. See 38 C.F.R. § 3.156(b) (2013); Jennings v. Mansfield, 509 F.3d 1362, 1368 (Fed. Cir. 2007). Finally decided claims cannot be reopened in the absence of new and material evidence. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2013); Barnett v. Brown, 8 Vet. App. 1 (1995) (citing 38 U.S.C.A. §§ 5108, 7104(b)). Regardless of any RO determination as to the matter of new and material evidence, the Board is bound to decide the threshold issue of whether the evidence is new and material before addressing the merits of a claim. Barnett, supra. The case was previously before the Board in January 2012, wherein, in pertinent part, the issues of service connection for asthma, tinnitus, and erectile dysfunction, and the issues of higher initial ratings for bilateral ulnar neuropathy were remanded. The Board finds that additional development is required before the issue of service connection for erectile dysfunction can be adjudicated. Pursuant to the remand instruction the RO/Appeals Management Center (AMC) requested that the Veteran submit a list of all medical care providers from whom he had received pertinent treatment and provided him with the appropriate authorizations for VA to obtain any private records on his behalf; scheduled VA examinations to assist in determining the etiology of the claimed asthma and tinnitus; and scheduled a VA examination to assist in determining the current severity of the bilateral ulnar neuropathy. As discussed below, the Board finds that the March 2012 VA examination reports were thorough and adequate and in compliance with the Board's remand instructions; therefore, Board finds there has been substantial compliance with the prior Board remand orders. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders); D'Aries v. Peake, 22 Vet. App. 97 (2008). In the January 2012 decision, the Board also denied the claim to reopen service connection for migraine headaches on the basis that new and material evidence had not been received. The Veteran appealed the Board's January 2012 decision to the U.S. Court of Appeals for Veterans Claims (Court). In March 2013, pursuant to a Joint Motion for Remand, the Court vacated the Board's January 2012 decision to the extent that it declined to reopen a claim for service connection for migraine headaches and remanded the claim to the Board for readjudication. The parties to the Joint Motion for Remand specifically agreed that they did not wish the Court to disturb the remainder of the Board's decision. As discussed in detail below, the Board is reopening and granting service connection for migraine headaches; thus, any question as to whether the Board has complied with the March 2013 Joint Motion for Remand is rendered moot. In November 2013, the Board requested medical expert opinions from the Veterans Health Administration (VHA) with regard to the claims for service connection for tinnitus, migraine headaches, and asthma. These opinions were obtained and the case was returned to the Board for appellate consideration and is now ready for disposition with respect to the issues of service connection for migraine headaches, asthma, and tinnitus, and higher initial ratings for the bilateral ulnar neuropathy. A claim for a total rating based on individual unemployability due to service-connected disability (TDIU) is part of an increased rating issue when such claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). In a January 2011 rating decision, the RO granted a TDIU effective November 27, 2006 (the date the Veteran's claim for a TDIU was received). The Veteran has not filed a notice of disagreement with the effective date assigned; as such, the issue of TDIU for an earlier period is not in appellate status before the Board. See Rudd v. Nicholson, 20 Vet. App. 296 (2006). In September 2011, the Veteran testified at a Board videoconference hearing at the local RO in Denver, Colorado, before the undersigned Veterans Law Judge sitting in Washington, DC. A transcript of the hearing is of record. In reviewing this case, the Board has not only reviewed the Veteran's physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. The issue of service connection for erectile dysfunction is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. An unappealed October 1997 rating decision, in pertinent part, denied service connection for migraine headaches on the basis that there was no record of treatment in service for migraine headaches; no evidence of any link between the current complaints and the Veteran's service, including no evidence that the headaches were caused by exposure to environmental agents in the Persian Gulf. 2. The evidence received since the October 1997 rating decision relates to an unestablished fact of a causal relationship between the currently diagnosed migraine headaches and the Veteran's service-connected disabilities. 3. The Veteran's currently diagnosed migraine headaches were permanently worsened by the service-connected posttraumatic stress disorder (PTSD). 4. The Veteran's currently diagnosed asthma was permanently worsened by the service-connected PTSD and allergic rhinitis. 5. The Veteran's currently diagnosed tinnitus is causally related to the service-connected hypertension. 6. For the entire initial rating period on appeal, the Veteran's bilateral upper extremity ulnar neuropathy has been manifested by numbness and tingling in both arms, hands, and last three fingers on each hand, decreased sensation to light touch and pinprick, paresthesias, mild dysesthesias, pain, weakness, some hypoactive peripheral nerve reflexes, and normal EMG results, more nearly approximating mild incomplete paralysis of the ulnar nerve. 7. For the entire initial rating period on appeal, the Veteran's bilateral upper extremity ulnar neuropathy has not more nearly approximated moderate incomplete paralysis of the ulnar nerve. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen service connection for migraine headaches. 38 U.S.C.A. § 5108 (West 2002 & Supp. 2013); 38 C.F.R. § 3.156 (2013). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for migraine headaches as secondary to service-connected PTSD have been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2013). 3. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for asthma as secondary to service-connected PTSD and allergic rhinitis have been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2013). 4. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for tinnitus as secondary to service-connected hypertension have been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2013). 5. The criteria for a disability rating in excess of 10 percent for ulnar neuropathy of the right upper extremity have not been met or more nearly approximated for the entire initial rating period on appeal. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8516 (2013). 6. The criteria for a disability rating in excess of 10 percent for ulnar neuropathy of the left upper extremity have not been met or more nearly approximated for the entire initial rating period on appeal. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8516 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). First, the Board finds the Veteran's service connection claim for migraine headaches to be reopened by way of the submission of new and material evidence. The Board is remanding the issue of service connection for erectile dysfunction. Additionally, the Board is granting the claims for service connection for migraine headaches, asthma, and tinnitus, which constitutes a full grant of the benefits sought on appeal with respect to these claims; therefore, no further discussion regarding VCAA notice or assistance duties is required with respect to these claims. With respect to the other issues decided herein, the Board finds that the notice requirements of VCAA have been satisfied. Here, the Veteran was provided notice in December 2006 and March 2007, prior to the initial adjudication of the claim for service connection in July 2007. The Veteran was notified of the evidence not of record that was necessary to substantiate the claims, as well as of VA and the Veteran's respective duties for obtaining evidence. Further, the issues of higher initial ratings for the bilateral ulnar neuropathy come before the Board on appeal from the decision which also granted service connection; therefore, there can be no prejudice to the Veteran from any alleged failure to give adequate 38 U.S.C.A. § 5103(a) notice for the service connection claims. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice arises from receipt of a notice of disagreement). Thus, the Board concludes that VA satisfied its duties to notify the Veteran. VA satisfied its duty to assist the Veteran in the development of the claim. First, VA satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include service treatment records, service personnel records, private treatment records, VA treatment records, VA examination reports, VHA medical opinions, a copy of the Broad hearing transcript, a copy of the decision review officer (DRO) hearing transcript, an article submitted by the Veteran, and lay statements. Second, VA satisfied its duty to obtain a medical opinion when required. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). With respect to the appeal for higher initial ratings for bilateral ulnar neuropathy, the Veteran was provided with VA examinations in June 2007, November 2010, and March 2012 (the reports of which have been associated with the claims file). At the September 2011 Board hearing, the Veteran testified that the symptoms associated with the bilateral ulnar neuropathy had worsened since the November 2010 VA examination. The Veteran underwent another VA examination in March 2012 and neither the Veteran nor the representative has reported worsening since the most recent VA examination. The Board finds that the June 2007, November 2010, and March 2012 VA examinations are thorough and adequate and provide a sound basis upon which to base a decision with regard to the Veteran's claims. The VA examiners personally interviewed and examined the Veteran, including eliciting a history, and specifically addressed the symptoms listed in the relevant criteria in the potentially applicable diagnostic codes. The Veteran testified at a September 2011 Board hearing before the under undersigned Veterans Law Judge and a transcript is of record. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, during the Board hearing, the Veterans Law Judge advised the Veteran as to the issues on appeal. The Veteran testified regarding symptoms, limitations, and problems associated with the bilateral ulnar neuropathy. As the Veteran presented evidence of symptoms and limitations due to the bilateral ulnar neuropathy and there is additionally medical evidence reflecting the severity of the bilateral ulnar neuropathy, there is both lay and medical evidence reflecting on the degree of disability, there is no overlooked, missing or outstanding evidence as to these issues. Moreover, neither the Veteran nor the representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2). As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate the issues based on the current record. As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Reopening Service Connection for Migraine Headaches The Veteran seeks to reopen the previously denied claim of service connection for migraine headaches. The claim, initially filed in March 1995, was originally denied in an October 1997 rating decision. The Veteran did not initiate an appeal of the decision and he also did not submit any new and material evidence with respect to this claim within the applicable one-year period. See 38 C.F.R. § 3.156(b); Jennings, 509 F.3d at 1368. As such, the decision became final as to the evidence then of record, and is not subject to revision on the same factual basis. 38 U.S.C.A. § 7105(b); 38 C.F.R. §§ 3.104, 20.302, 20.1103. Unappealed rating decisions by the RO are final with the exception that a claim may be reopened by submission of new and material evidence. 38 U.S.C.A. §§ 5108, 7105(c); 38 C.F.R. § 3.156. When a veteran seeks to reopen a claim based on new evidence, VA must first determine whether the additional evidence is "new" and "material." Smith v. West, 12 Vet. App. 312 (1999). New evidence means existing evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. If VA determines that new and material evidence has been added to the record, the claim is reopened and VA must evaluate the merits of a veteran's claim in light of all the evidence, both new and old. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); Barnett, 83 F.3d at 1383; Butler v. Brown, 9 Vet. App. 167, 171 (1996). When making determinations as to whether new and material evidence has been received, the credibility of the evidence is presumed, unless it is inherently false or untrue or, if it is in the nature of a statement or other assertion, it is beyond the competence of the person making the assertion. Justus v. Principi, 3 Vet. App. 510, 513 (1992); Duran v. Brown, 7 Vet. App. 216 (1995). Regardless of any RO determinations that new and material evidence has been submitted to reopen service connection, the Board must still determine whether new and material evidence has been submitted in this matter. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001) (reopening after a prior unappealed RO denial). In the October 1997 rating decision, the RO, in pertinent part, denied service connection for migraine headaches on the basis that the condition was not incurred in or caused by service and there was no evidence that the Veteran's headaches were caused by exposure to environmental agents in the Persian Gulf. The RO noted that, as there was a diagnosed condition (headaches), consideration under the presumptive provisions of 38 C.F.R. § 3.317 (compensation for disability due to undiagnosed illness and medically unexplained chronic multisymptom illnesses) was not appropriate. The pertinent evidence of record at the time of the October 1997 rating decision includes the Veteran's lay statements, service treatment records, service personnel records, VA treatment records dated from March 1992 to June 1997, and VA examination reports dated in July 1992, September 1996, and October 1996. The Board has reviewed the evidence of record received since the October 1997 rating decision and finds that it qualifies as new and material evidence to warrant reopening service connection for migraine headaches. In a January 2014 VHA medical opinion, the VHA examiner opined, in view of the Veteran's medical history and the evidence in the medical literature, that it is at least as likely as not that the Veteran's migraine headaches were permanently increased in severity beyond their natural progression due to his service-connected PTSD. The Board finds that this evidence, received after the October 1997 rating decision, is new. It was not previously of record, and is neither cumulative nor redundant of evidence previously considered by the RO. Such evidence is also material in that it relates to evidence of a causal link (nexus) between the current migraine headaches and the service-connected PTSD (a necessary element for secondary service connection). 38 C.F.R. § 3.310. As noted above, when making determinations as to whether new and material evidence has been presented, the credibility of the evidence is generally presumed. See Justus, 3 Vet. App. at 513; Duran, 7 Vet. App. 216. This new evidence raises a reasonable possibility of substantiating the claim; thus, this evidence is new and material and the requirements to reopen the claim under 38 C.F.R. § 3.156(a) have been satisfied. Accordingly, as the Board has determined that new and material evidence has been received to reopen service connection for migraine headaches. In arriving at the above conclusions with regard to the claim, the Board finds that the provisions of 38 C.F.R. § 3.156(b) and (c) are not applicable. There was no evidence received during the one-year appeal period for the October 1997 rating decision; therefore, 38 C.F.R. § 3.156(b) does not apply. Nor have additional service records been received since the October 1997 rating decision; therefore, 38 C.F.R. § 3.156(c) does not apply. As discussed below, the matter of service connection for migraine headaches will now be addressed on a de novo basis. Because the Veteran has had opportunity to address the merits of this claim, the Board may proceed with a final adjudication because there is no prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384, 393 (1993). Service Connection for Migraine Headaches, Asthma, and Tinnitus Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). 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 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). In this case, the Veteran has been diagnosed with migraine headaches, asthma, and tinnitus, none of which are listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions based on "chronic" symptoms in service and "continuous" symptoms since service at 38 C.F.R. § 3.303(b) do not apply. The Veteran had service in the Southwest Asian Theater during the Persian Gulf War. As the Veteran's migraine headaches, asthma, and tinnitus have been attributed to clinically diagnosed disorders, and are not chronic multi-symptom illnesses, the provisions of 38 U.S.C.A. § 1117 (West 2002) and 38 C.F.R. § 3.317 (2013) are not for application. As adjudicated below, the Board is granting service connection for migraine headaches, asthma, and tinnitus based on secondary service connection under 38 C.F.R. § 3.310; therefore, the additional service connection theory of direct service connection pursuant to the same benefit is rendered moot, and there remain no questions of law or fact as to the fully granted service connection issues. For this reason, the theory of direct service connection will not be further discussed with regard to service connection for migraine headaches, asthma, and tinnitus. See 38 U.S.C.A. § 7104 (West 2002) (stating that the Board decides questions of law or fact). The contention liberally construed for the Veteran is that his currently diagnosed migraine headaches, asthma, and tinnitus are related to active service. In a March 1995 claim, the Veteran contended that he had headaches and an asthma-related condition that was directly related to the Persian Gulf War. In a July 2008 notice of disagreement, the Veteran contended that his tinnitus was secondary to service-connected hypertension and its medication. At the September 2011 Board hearing, the Veteran testified that he initially manifested migraines in 1990 or 1991, was initially diagnosed with asthma in 1991, which he self-treated during active service, and that he was exposed to sand and chemical weapons while serving in Southwest Asia. Migraine Headaches The evidence of record demonstrates that the Veteran currently has migraine headaches. See November 2007 VA treatment record active diagnosis list. In a January 2014 VHA medical opinion, the VHA examiner opined that, in view of the Veteran's medical history and the evidence in the medical literature, it is at least as likely as not that the Veteran's migraines were permanently worsened due to the service-connected PTSD. The January 2014 VHA examiner opined that PTSD is associated with a marked increase in somatic symptoms, including headaches and migraines. The January 2014 VHA examiner noted that migraines are commonly precipitated by stress and changes in stress levels, providing a plausible link between migraines and PTSD. As noted above, service connection may be established on a secondary basis for a disability which has been permanently worsened by a service-connected disability. 38 C.F.R. § 3.310(a); see Allen, 7 Vet. App. at 448. The Board finds that the evidence of record sufficiently indicates that the Veteran's current migraine headaches were permanently worsened by the service-connected PTSD; therefore, resolving reasonable doubt in favor of the Veteran, service connection for migraine headaches, as secondary to the service-connected PTSD, is warranted. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. The grant of secondary service connection renders moot other theories of service connection. Asthma The evidence of record demonstrates that the Veteran currently has asthma. See March 2012 VA respiratory conditions examination report. In a December 2013 VHA medical opinion, the VHA examiner opined that it is as likely as not that the Veteran's asthma permanently increased in severity beyond its natural progression due to service-connected disabilities. The December 2013 VHA examiner noted that there is an association between PTSD and asthma, and allergic rhinitis and worse asthma, if these disabilities are not adequately controlled. The December 2013 VHA examiner noted that a review of the medical literature supports this association. The evidence of record reflects currently diagnosed asthma. The probative medical evidence of record also demonstrates that the asthma was permanently worsened by the service-connected PTSD and allergic rhinitis; therefore, resolving reasonable doubt in favor of the Veteran, service connection for asthma, as secondary to the service-connected PTSD and allergic rhinitis, is warranted. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. The grant of secondary service connection renders moot other theories of service connection. Tinnitus The evidence of record demonstrates that the Veteran has currently diagnosed tinnitus. See June 2007 VA examination report. In a February 2014 VHA medical opinion, the VHA examiner noted that tinnitus is a subjective disorder and that, while it is associated with many disorders and medications, causation usually cannot be definitely determined. The VHA examiner noted exceptions of aspirin and quinine (which may cause transient tinnitus in high dose where the symptom resolves when the dose is decreased), ototoxic medications, and severe noise trauma in susceptible individuals. The VHA examiner noted that injury can be demonstrated by changes on audiometric or otoacoustic testing, but that, without objective evidence of injury from available records, causation from primary or secondary factors cannot be expected to explain the Veteran's subjective complaints. The VHA examiner opined that there was no recorded or otologic documentation that tinnitus symptomology originated during active service, nor that tinnitus was caused by any service-connected disabilities or increased beyond the normal aging progression due to any service-connected disabilities. The VHA examiner, while noting that ototoxic medications can cause tinnitus, did not opine as to whether any of the medications the Veteran is taking for his service-connected disabilities caused or aggravated his tinnitus. A March 2012 VA examiner noted that the Veteran is currently taking hydrochlorothiazide (for high blood pressure) and fluoxetine (for depression), which are potentially ototoxic medications. The evidence of record reflects that the Veteran is a former medical professional. See September 2011 Board hearing transcript. The Veteran testified that he began as a certified nursing assistant and ended his medical career as a paramedic and registered nurse. At the September 2011 Board hearing, the Veteran opined that his tinnitus is more likely to be associated with high blood pressure, antibiotics, or environmental exposure. The Veteran testified that he felt the medications for hypertension caused or worsened his tinnitus. The Board finds that the Veteran, as a former medical professional, has the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of his current tinnitus. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that requires a medical opinion to diagnose and to relate to service or differentiate from in-service symptoms and diagnosis). The Board finds that the Veteran is competent to provide evidence of an etiological nexus between his service-connected hypertension and tinnitus. The Board finds that the evidence of record is at least in equipoise as to whether the Veteran's current tinnitus is causally related to the service-connected hypertension; therefore, resolving reasonable doubt in favor of the Veteran, service connection for tinnitus, as secondary to the service-connected hypertension, is warranted. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. The grant of secondary service connection renders moot other theories of service connection. Initial Ratings for Bilateral Ulnar Neuropathy Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4 (2013). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1 (2013). Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2 (2013). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. When, after careful consideration of the evidence, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where, as here, the question for consideration is the propriety of the initial evaluations assigned, evaluation of the evidence since the grant of service connection and consideration of the appropriateness of staged ratings is required whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board has considered whether staged ratings are warranted; however, as will discuss in more detail below, the Board finds that staged ratings are not appropriate in this situation. The Board has reviewed all the evidence in the claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the issues. The Veteran is in receipt of 10 percent disability ratings under Diagnostic Code 8516 for ulnar neuropathy of the left and right upper extremities for the entire initial rating period. The Board notes that the Veteran is left side dominant. See September 2011 Board hearing transcript p. 12. Under Diagnostic Code 8516, a 10 percent rating is warranted for mild incomplete paralysis of the ulnar nerve. A 30 percent rating for the major side and a 20 percent rating for the minor side is warranted for moderate incomplete paralysis of the ulnar nerve. A 40 percent rating for the major side and a 30 percent rating for the minor side is warranted for severe incomplete paralysis of the ulnar nerve. A 60 percent rating for the major side and a 50 percent rating for the minor side is warranted for complete paralysis of the ulnar nerve. 38 C.F.R. § 4.124a. Complete paralysis of the ulnar nerve is characterized by the "griffin claw" deformity, due to flexor contraction of the ring and little fingers with marked atrophy in dorsal interspace and thenar and hypothenar eminences; loss of extension of the ring and little fingers, including being unable to spread the fingers (or reverse) and inability to adduct the thumb; and weakened flexion of the wrist. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral the rating should include the application of the bilateral factor. Id. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve. 38 C.F.R. § 4.124. The words "mild," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6 (2013). The Veteran contends generally that the service-connected bilateral upper extremity ulnar neuropathy has manifested in more severe symptoms than those contemplated by the initial 10 percent disability ratings assigned. In a June 2007 written statement, the Veteran contended he has constant numbness and tingling in the ulnar aspect of the bilateral arms and hands, including the last three fingers on each hand. At a July 2008 DRO hearing, the Veteran testified that he had decreased sensation over the outer aspects of his fingers to past the elbow of both arms, weakness in his hands, and decreased sensation in his middle finger. The Veteran testified that his left upper extremity was worse than his right. The Veteran reported that his grip strength was diminished. At the September 2011 Board hearing, the Veteran testified that his ulnar neuropathy was equally as bad bilaterally and that his symptoms had increased since the beginning of 2011. The Veteran testified that he wakes up with total numbness and tingling throughout both upper extremities, particularly his hands and forearms. The Veteran testified that it was very difficult for him to pick up a coin off the table. The Veteran contended that his bilateral ulnar neuropathy more nearly approximates moderate incomplete paralysis of the ulnar nerves. The Veteran testified that his symptoms were the same in both extremities. After a review of the lay and medical evidence of record, the Board finds that, for the entire rating period, the bilateral upper extremity ulnar neuropathy has been productive of no more than mild incomplete paralysis of the ulnar nerve, which is commensurate with the 10 percent disability ratings assigned under Diagnostic Code 8516. As such, the Board finds that disability ratings in excess of 10 percent for bilateral upper extremity ulnar neuropathy are not warranted for any part of the initial rating period. A June 2007 VA examination report notes that the Veteran had subjective evidence of ulnar neuropathies bilaterally, normal and equal bilateral deep reflexes, and decreased sensation along the ulnar distribution of both forearms and into both hands associated with the small and ring fingers of each hand. The VA examiner noted no evidence of any muscle wasting or obvious muscle weakness, but because of pain and discomfort, the Veteran is unable to use his muscle strength to its fullest. A June 2007 VA treatment record notes that the Veteran reported that recently his bilateral paresthesias symptoms have been persistent with migration of the paresthesias from the palmar aspect of the bilateral hands over the midline with associated bilateral elbow pain. The Veteran denied any significant paresthesias on the proximal arms, weakness, or numbness. The treatment record noted no weakness upon physical examination. September 2007 VA treatment records note that the Veteran reported numbness in the left hand had worsened over the previous two days. The treatment records note that the Veteran's had increased ulnar nerve distribution symptoms, equal grip strength, and decreased sensation in the fourth and fifth digits of the medial hand. An October 2007 VA treatment record notes that the Veteran reported bilateral paresthesias in the ulnar distribution without significant weakness or pain. The treatment record notes sensory deficits in the bilateral hands (with the right greater than the left) that are most pronounced over the fourth and fifth digits, but involve the other fingers as well, as well as pain over the left elbow. An October 2007 VA treatment record notes that the Veteran's EMG results were essentially normal with no evidence of left cervical radiculopathy, ulnar neuropathy, or carpal tunnel syndrome. VA treatment records from November 2007 to December 2010 note that an extensive workup regarding the bilateral hand paresthesias, including three EMGs, had not revealed any neuronal abnormality. The treatment records note that Lyrica had improved the Veteran's symptoms slightly, but they were still bothersome. The treatment records note that the Veteran had no associated weakness. A June 2008 VA EMG report notes a normal electrophysiological examination with no evidence of left ulnar neuropathy or any peripheral neuropathy. An October 2008 VA treatment record notes that the Veteran continued to have bilateral hand paresthesias with no associated weakness. The VA treatment record notes that the Veteran had symmetric bilateral upper extremity deep tendon reflexes as well as equal strength bilaterally. A June 2009 VA treatment record noted that the Veteran's bilateral hand paresthesias had slightly worsened since gabapentin had become ineffective and that the Veteran's medication had been switched to Lyrica. At a February 2010 VA Gulf War registry examination, the Veteran reported numbness and tingling in the upper extremities, specifically in the bilateral middle, fourth, and fifth fingers. The Veteran reported being unable to handle small items or feel differences in surfaces. The Veteran reported being unable to button clothes at times. The examination report notes normal muscle bulk, strength, and tone in the upper extremities with 5/5 grip strength bilaterally. Reflexes in the upper extremities were noted as normal and symmetrical and sensation was intact to vibration and light touch. October 2010 VA treatment records note that the Veteran's bilateral hand numbness and paresthesias was constant but stable. The VA treatment record notes normal motor strength, muscle tone, and deep tendon reflexes. The VA treatment record notes decreased sensation to light touch and pinprick in both hands. At a November 2010 VA examination, with regard to the left ulnar neuropathy, the Veteran reported stocking glove complaints of continuous paresthesias to the left hand and arm. The Veteran reported paresthesias and pain that was worse at the ulnar aspect of the left hand with pain radiating into the ulnar aspect of the forearm and elbow; palmar pain and paresthesias; and mild finger paresthesias. The Veteran reported continuous left elbow pain associated with the paresthesias. The Veteran reported being unable to identify objects held in his left hand due to decreased sensation, difficulty with writing, occasionally dropping items, and intermittent decrease in grip strength. With respect to the right ulnar neuropathy, the Veteran reported that the right ulnar neuropathy was not as severe as the left. The Veteran reported constant paresthesias of the medial aspect of the right hand with radiation into the forearm. The Veteran reported that his right thumb was numb on a daily basis and that he had intermittent decrease in grip strength causing him to drop items on a weekly basis. The Veteran reported a decreased ability to identify objects held in his right hand, a decrease in manual dexterity, and difficulty with fine motor activities such as buttons. The November 2010 VA examiner noted that the Veteran was capable of performing activities of daily living including eating, cooking, dressing, undressing, driving, writing, bathing, and hygiene, but noted that dressing was difficult when the Veteran had to use buttons. The VA examiner noted the Veteran had increased fatigue in both arms if he lifted more than 10 pounds. The VA examiner noted symptoms of paresthesias, numbness, weakness, and pain associated with the peripheral nerves. Upon physical examination of the Veteran at the November 2010 VA examination, the VA examiner noted hypoactive (1+) bilateral bicep, triceps, and brachioradialis peripheral nerve reflexes. The VA examiner noted decreased pain/pinprick sensation in the right thumb and third to fifth digits of both the dorsal and palmar aspects of the right upper extremity; decreased light touch sensation to the ulnar aspect of the right hand, thumb, and third to fifth digits of both the dorsal and palmar aspects of the right upper extremity; normal vibration and position sensation; and no dysesthesias. The VA examiner noted decreased pain/pinprick and light touch sensation to the ulnar aspect of the left hand, thumb, and third to fifth digits of both the dorsal and palmar aspects of the left upper extremity; normal vibration and position sensation; and no dysesthesias. The November 2010 VA examination report notes normal motor strength and tone with no muscle atrophy. The VA examiner noted a diagnosis of bilateral upper extremity paresthesias without objective electrodiagnostic findings to support a diagnosis of acute or chronic ulnar neuropathy. The VA examiner noted that the Veteran's subjective complaints of worsened bilateral ulnar neuropathy were not supported by EMG findings and were of unclear etiology. A July 2011 VA treatment record notes numbness and tingling in the medial left fingers, hand, and forearm and in the lateral right fingers and hand. An August 2011 VA treatment record notes that the Veteran reported the bilateral upper extremity neuropathy had worsened and that leaning on his elbows causes a sharp stabbing pain. The Veteran reported constant numbness over the lateral aspects of both arms as well as all the fingers. The VA treatment record notes a sharply decreased sensation over the ulnar area of both hands with normal light touch, pinprick, temperature, and vibration sensation bilaterally. The VA treatment record notes normal muscle strength and tone bilaterally. At a March 2012 VA examination, the Veteran reported numbness and tingling in his hands (and entire bilateral arms) that is worse in his left arm and that causes him to have difficulty feeling small objects. The Veteran reported being unable to work because he cannot feel screws or coins and no longer able to start an IV as a paramedic. The Veteran reported that he is able to drive, perform household chores, and can work with a TV remote. The VA examiner noted mild numbness, paresthesias, and dysesthesias associated of the bilateral upper extremities. Normal (5/5) muscle strength in the bilateral upper extremities was recorded upon muscle strength testing. Deep tendon reflexes were also noted as normal (2+) upon physical examination. The Veteran was noted to have decreased light touch sensation in the right hand/fingers, but otherwise normal sensation for light touch in the upper extremities. The March 2012 VA examiner noted no trophic changes attributable to peripheral neuropathy. The VA examination report notes that the Veteran's ulnar nerve was normal bilaterally with no incomplete or complete paralysis. The March 2012 VA examiner noted that the Veteran's peripheral nerve condition does not impact the Veteran's ability to work. Based on the above, the Board finds that the criteria for initial disability ratings in excess of 10 percent for bilateral upper extremity ulnar neuropathy have not been met or more nearly approximated. 38 C.F.R. §§ 4.3, 4.7, 4.124a. For the entire initial rating period, the Veteran's bilateral ulnar neuropathy has been manifested by numbness and tingling in the bilateral arms, hands, and last three fingers on each hand; decreased sensation to light touch and pinprick; paresthesias; mild dysesthesias; pain; weakness; some hypoactive peripheral nerve reflexes; and normal EMG results, more closely approximating mild incomplete paralysis of the ulnar nerve. The Board finds that the bilateral upper extremity ulnar neuropathy has not more nearly approximated moderate incomplete paralysis of the ulnar nerve for any part of the appeal period. First, while, throughout the appeal period and to health care provides, the Veteran has reported symptoms of numbness and paresthesias associated with the bilateral ulnar neuropathy, the March 2012 VA examiner noted, taking into account the Veteran's statements, that the numbness, paresthesias, and dysesthesias was mild. The March 2012 VA examiner noted that the Veteran's ulnar nerve was normal bilaterally with no incomplete or complete paralysis. As noted above, the evidence of record also reflects that the Veteran had full muscle strength and tone throughout the entire appeal period with no muscle atrophy. Further, while the evidence of record does reflect that the Veteran experiences pain, there is no indication that this pain is constant. Associated bilateral elbow pain is noted in a June 2007 VA treatment record; however, an October 2007 VA treatment record notes no significant pain associated with the bilateral paresthesias. The Veteran did not endorse pain as a symptom at the February 2010 VA Gulf War registry examination. The November 2010 VA examination report notes pain associated with the bilateral ulnar neuropathy, but the March 2012 VA examination report does not. The evidence of record reflects that, rather than being constant, the Veteran experiences some intermittent pain associated with the bilateral ulnar neuropathy. Additionally, with the exception of the November 2010 VA examination report that notes hypoactive bilateral bicep, triceps, and brachioradialis peripheral nerve reflexes, the Veteran has consistently been found to have normal reflexes throughout the initial rating period. Based on the lay and medical evidence of record, the Board finds that the Veteran's bilateral ulnar neuropathy has not more nearly approximated moderate incomplete paralysis of the ulnar nerve at any point during the initial rating period. For the reasons discussed above, the Board finds that the Veteran's disability picture more nearly approximates the criteria for mild incomplete paralysis of the ulnar nerve, as reflected by the symptoms and the level of impairment; therefore, disability ratings in excess of 10 percent for the service-connected bilateral upper extremity ulnar neuropathy are not warranted for any period. See 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation would have been warranted for the bilateral upper extremity ulnar neuropathy for any part of the rating period. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). 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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's bilateral upper extremity ulnar neuropathy are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran's bilateral ulnar neuropathy has been manifested by numbness and tingling in both arms, hands, and last three fingers on each hand, decreased sensation to light touch and pinprick, paresthesias, mild dysesthesias, pain, weakness, some hypoactive peripheral nerve reflexes, and normal EMG results. The schedular rating criteria specifically provides for disability ratings based on impairment of different nerves (here Diagnostic Code 8516 for impairment of the ulnar nerve). Diagnostic Code 8516 rates on the basis of neuropathy (nerve abnormality), neuritis (inflammation of the nerve), and neuralgia (nerve pain). In this case, comparing the Veteran's disability level and symptomatology of the bilateral upper extremity ulnar neuropathy to the rating schedule, the degree of disability throughout the entire period under consideration is contemplated by the rating schedule and the assigned ratings are, therefore, adequate. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with the back disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER As new and material evidence has been received, the appeal to reopen service connection for migraine headaches is granted. Service connection for migraine headaches, as secondary to service-connected PTSD, is granted. Service connection for asthma, as secondary to service-connected PTSD and allergic rhinitis, is granted. Service connection for tinnitus, as secondary to service-connected hypertension, is granted. An initial disability rating in excess of 10 percent for ulnar neuropathy of the right upper extremity is denied. An initial disability rating in excess of 10 percent for ulnar neuropathy of the left upper extremity is denied. REMAND Service Connection for Erectile Dysfunction The Board finds that further development is required prior to adjudicating the Veteran's claim for service connection for erectile dysfunction. See 38 C.F.R. § 19.9 (2013). Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Pursuant to the Board's January 2012 remand instructions, the Veteran was provided with a VA examination in March 2012 to assist in determining the nature and etiology of the claimed erectile dysfunction. The VA examiner was asked to opine as to whether it is at least as likely as not that the erectile dysfunction is caused or aggravated by medications taken for service-connected disabilities. The March 2012 VA examiner opined that the Veteran's current erectile dysfunction is less likely as not caused by his service-connected medications (antihypertensive Lisinopril or antidepressant fluoxetine) because the Veteran stated that he has been experiencing erectile dysfunction since 2000 that was first diagnosed in 2007, which the VA examiner indicated began prior to the service-connected disabilities, diagnoses, and treatment. First, the Board finds that the March 2012 VA examination report is inadequate because it is based on the inaccurate factual predicate that the Veteran's service-connected hypertension and depression were first diagnosed and treated after 2000. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). July 1992 VA examination reports note diagnoses of hypertension and PTSD. In a November 1993 rating decision, the Veteran was granted service connection for hypertension and PTSD, effective May 1991 (the day after separation from active service). Further, the March 2012 VA examiner opined only as to whether the erectile dysfunction was caused by the medications taken for the service-connected disabilities, and not as whether the erectile dysfunction was aggravated by (permanently worsened by) the medications. The Court has held that it is not clear that a medical opinion that a claimed disorder is not "caused by" a service-connected disability but is "related to factors other than the" service-connected disability, encompasses the question of aggravation under 38 C.F.R. § 3.310. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). To the contrary, such an opinion does not rule out the possibility that a claimed disorder was also aggravated to some degree by a service-connected disability. See id. (finding a Board's VA examination adequacy finding clearly erroneous where the claimant alleged an aggravation theory of entitlement, but the VA examiner's opinion focused solely on direct causation). Thus, the Board finds that an additional VA opinion is necessary as there remains some question as to the etiology of the erectile dysfunction. See McLendon, 20 Vet. App. 79. Accordingly, the issue of service connection for erectile dysfunction, including as secondary to the service-connected hypertension and PTSD, is REMANDED for the following action: 1. Arrange for the claims file to be reviewed by the VA examiner who prepared the March 2012 VA male reproductive system conditions examination report (or a suitable substitute if that VA examiner is unavailable) for the purpose of preparing an addendum opinion to the examination report. If it is determined that another examination is needed to provide the required opinion, the Veteran should be afforded the appropriate VA examination to assist in determining the etiology of any current erectile dysfunction. The VA examiner should offer the following opinions: Is it as likely as not (50 percent or greater probability) that erectile dysfunction was incurred active service? Is it as likely as not (50 percent or greater probability) that erectile dysfunction was caused by the service-connected disabilities or medications used to treat any service-connected disabilities? Is it as likely as not (50 percent or greater probability) that erectile dysfunction was aggravated (permanently worsened in severity beyond a natural progression) by the service-connected disabilities or medications used to treat any service-connected disabilities? In answering these questions, the VA examiner should note that the Veteran was diagnosed with hypertension and PTSD at July 1992 VA examinations, and service connection for the same was granted effective May 1991. The examiner should provide a rationale and basis for all opinions expressed. 2. Then, readjudicate the remaining issue of service connection for erectile dysfunction, including as secondary to service-connected hypertension and PTSD. If the claim remains denied, provide the Veteran and the representative with a supplemental statement of the case and allow an appropriate time for response. The Veteran has the right to submit additional evidence and argument on the matter 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. 2013). ______________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs