Citation Nr: 1635784 Decision Date: 09/13/16 Archive Date: 09/20/16 DOCKET NO. 12-09 208 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for a lung disability. 2. Entitlement to service connection for obstructive sleep apnea. 3. Entitlement to service connection for a cervical spine disability. 4. Entitlement to service connection for posttraumatic stress disorder (PTSD). 5. Entitlement to service connection for an acquired psychiatric disability other than PTSD. 6. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD T. J. Anthony, Associate Counsel INTRODUCTION The Veteran had active service from September 1971 to November 1975. These matters are before the Board of Veterans' Appeals (Board) on appeal of October 2010 and February 2012 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St Paul, Minnesota. The Board remanded these matters in March 2015. In August 2014, the Veteran and his spouse testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. The issues of entitlement to service connection for a lung disability, obstructive sleep apnea; entitlement to service connection for an acquired psychiatric disability other than PTSD; and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The most probative evidence of record does not show that the Veteran has a current cervical spine disability that is at least as likely as not causally or etiologically related to his active service or any incident therein, to include head trauma. 2. The probative evidence of record does not show that the Veteran had a diagnosis of PTSD during the appeal period or in proximity to the claim. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a cervical spine disability are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). 2. The criteria for entitlement to service connection for PTSD are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist Pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA's duty to notify was satisfied by a letter dated in July 2010. See 38 U.S.C.A. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA has also satisfied its duty to assist the Veteran. The Veteran's service treatment records, service personnel records, VA treatment records, identified private treatment records, and Social Security Administration records, as well as lay statements from the Veteran and others have been associated with the record. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The duty to assist also includes the provision of a VA examination when necessary to decide a claim. 38 C.F.R. § 3.159(c)(4). In this case, the Veteran was provided a VA examination in December 2011 and a VA addendum opinion in February 2012 as to his cervical spine disabilities, and VA examinations in September 2010, August 2011, February 2013, and June 2015, and a VA addendum opinion in April 2013 as to his acquired psychiatric disabilities to include his claimed PTSD. The examiners who conducted the VA examinations and provided the VA addendum opinions reviewed the record, considered the Veteran's reported symptomatology and medical history, and addressed the likely etiology of the Veteran's disabilities, providing supporting explanation and rationale for all conclusions reached. In regard to the Veteran's claimed PTSD, the September 2010 VA examiner provided information as to why the Veteran did not meet the diagnostic criteria for PTSD under the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), and the June 2015 VA examiner provided information as to why the Veteran did not meet the diagnostic criteria for PTSD under the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5). The examinations and addendum opinions are thorough, and all necessary evidence and testing was considered by the examiners. Therefore, the Board finds the examinations and the addendum opinion to be adequate for decision-making purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). There is no indication in the record that any additional evidence, relevant to the claims adjudicated in this decision, is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Compliance with Board Remand As noted in the Introduction, the Board remanded this case in March 2015. In relevant part, the March 2015 Board remand directed the AOJ to obtain the Veteran's Social Security Administration records; contact the Veteran to further identify and consent to release of records from C. Phillips relevant to the cervical spine disability claim, and then obtain any records identified in response to that communication; provide a VA examination as to his acquired psychiatric disabilities, to include the claimed PTSD; and then readjudicate the claim and issue a supplemental statement of the case, if warranted. Pursuant to the March 2015 Board remand, the AOJ obtained the Veteran's Social Security Administration records; sent the Veteran a letter in April 2015 asking him to identify and authorize for release any VA and non-VA providers, to include C. Phillips; obtained the private treatment records that the Veteran identified in response to the April 2015 letter; provided the Veteran a VA psychiatric examination in June 2015 that was consistent with and responsive to the March 2015 Board remand directives; and readjudicated the claims in a July 2015 supplemental statement of the case. Accordingly, the Board finds that VA at least substantially complied with the March 2015 Board remand. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Other Due Process Considerations As noted in the Introduction, the Veteran was afforded a hearing before the undersigned Veterans Law Judge (VLJ) in August 2014. At the hearing, the VLJ asked the Veteran specific questions concerning the symptoms of and treatment for his disabilities. In addition, the VLJ solicited information as to the existence of any outstanding evidence. No pertinent evidence that might have been overlooked and that might substantiate the claims decided herein was identified by the Veteran or his representative. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016). Legal Criteria Generally, service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2015). To establish service connection for a disability, the Veteran must show: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, to include arthritis, may also be established on a presumptive basis by showing that the disease manifested to a compensable degree within one year from the date of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). If not shown as chronic during service or if a diagnosis of chronicity is legitimately questioned, continuity of symptomatology after service is required. 38 C.F.R. § 3.303(b). Continuity of symptoms may establish service connection only for those diseases listed in 38 C.F.R. § 3.309(a). 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). In addition, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). 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 also be service connected. 38 C.F.R. § 3.310(b). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In the absence of proof of a current disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service Connection for a Cervical Spine Disability The Veteran contends that he has a current cervical spine disability that is related to head trauma he suffered in service. See, e.g., August 2014 Board hearing transcript. The Veteran has reported that he started having neck pain immediately after suffering the in-service head trauma. See VA Form 21-4138, Statement in Support of Claim, received in April 2012. The medical treatment evidence of record shows that the Veteran has been diagnosed, through radiographic imaging, with osteoarthritis and degenerative disc disease of the cervical spine. Therefore, there is competent evidence of a current cervical spine disability. As to an in-service injury, a review of the Veteran's service treatment records reveals that the Veteran hit his head against a windshield when he was involved in a motor vehicle accident in March 1974. He reported a number of symptoms following the motor vehicle accident, including tightness and tenderness in the neck area. On examination, the Veteran had mild spasm in the cervical paraspinal muscles bilaterally. He had no abnormality of the cervical spine and no loss in cervical spine lordosis. The impression was of headaches on a post-concussive basis versus pain secondary to cervical strain. A final diagnosis of vasovagal syncope with bruise on leg was later provided. Thereafter, the Veteran continued to complain of headaches. However, an EEG scan and a skull film were within normal limits. Tension headaches were suspected. The Board notes that, although the March 1974 motor vehicle accident is documented in the service treatment records, the Veteran has denied having been in a motor vehicle accident in service. See November 2011 Informal Conference Report; August 2014 Board hearing transcript. The Veteran's service treatment records further show that the Veteran complained of headaches after hitting his head on a hatch in June 1974. An August 1974 note reflects that the Veteran's headaches "went away" after one week and were "not troublesome now." The Veteran had normal spine examinations in November 1975, September 1977, March 1984, and July 1985. His spine was noted to be abnormal due to a history of lumbar spine laminectomies in August 1988 and February 1992. He did not report any cervical spine disabilities on reports of medical history dated in November 1975, September 1977, March 1984, July 1985, August 1988, and February 1992. Accordingly, there is evidence of an in-service injury in the form of head trauma with manifestations of headaches and neck tenderness and tightness, and the issue remaining for consideration is whether the current cervical spine disabilities are etiologically related to the in-service injuries. To determine whether such an etiological relationship exists, the Board turns to the competent medical evidence of record. Initially, the Board acknowledges the Veteran's belief that his current cervical spine disabilities are related to his in-service head trauma and that he has continued to have pain since the in-service head trauma. The Board notes that the Veteran is competent to report symptoms such as pain. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not considered competent to medically attribute his current cervical spine disabilities to a specific cause, as doing so requires medical knowledge and expertise that the Veteran has not been shown to possess. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Therefore, his statements do not constitute competent evidence that may be probative in showing an etiological relationship between the in-service injuries and the current cervical spine disabilities. In this case, the competent evidence of record as to a possible etiological relationship between the current cervical spine disabilities and the in-service injuries consists of a statement from the Veteran's chiropractor dated in March 2011, the December 2011 VA examination report, and the February 2012 VA addendum opinion. In the March 2011 letter, the Veteran's chiropractor notes a history of treating the Veteran for dizziness; migraines; breathing difficulty; finger numbness; and pain in the upper, mid, and lower back and neck since March 2009. The chiropractor then opines, "These subluxations in the upper cervical area were, I believe, due to an injury that occurred in 1972, wherein he hit the top of his head." The chiropractor does not provide any further rationale for the opinion. The December 2011 VA examiner reviewed the record, interviewed the Veteran, and examined the Veteran. The examiner noted the Veteran's in-service head trauma from the motor vehicle accident, which resulted in a diagnosis of cervical strain, and from hitting his head on a hatch, which resulted in a predominant complaint of headaches. The examiner provided diagnoses of degenerative disc disease and osteoarthritis of the cervical spine and opined that the disabilities are not caused by or the result of the in-service head traumas. As a rationale for the opinion, the examiner explained that acute strain of the cervical spine is an injury to the muscles and ligaments of the neck. Such injuries are almost always self-limiting and last several days to several months. The examiner noted, "There is no significant medical evidence or rationale supporting a causal relationship between one or several limited episodes of cervical strain and the eventual development of degenerative disc disease of the cervical spine." The examiner added, "Moreover, [the Veteran] has multilevel degenerative disc disease of the lumbar spine. His [degenerative disc disease] is not localized only to the cervical spine, but to his entire spine. He has been seen several times for [a] lower back condition and has not been seen for [an] upper neck condition." The VA examiner who provided the February 2012 VA addendum opinion reviewed the record. He opined that the Veteran's cervical spine degenerative disc disease is less likely as not caused by, the result of, or aggravated by the in-service motor vehicle accident. As a rationale, the examiner explained that the Veteran had no neck symptoms following the motor vehicle accident and had a normal neck examination after the motor vehicle accident. The examiner noted, "It is expected that if he had a significant enough neck injury to later cause[degenerative disc disease] of the neck, he would have had [symptoms] at that time." Accordingly, the record contains conflicting medical opinions. The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Further, the credibility and weight to be attached to these opinions are within the province of the adjudicator. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). As such, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In this case, the Board affords more probative value to the December 2011 VA examiner's opinion and to the February 2012 VA addendum opinion than to the March 2011 opinion from the Veteran's chiropractor for the following reasons. Although the Veteran's chiropractor's opinion reflects an understanding that the Veteran hit his head on a hatch in service, it does not reflect that the chiropractor had an opportunity to review the record, to include the Veteran's service treatment records. Therefore, there is no indication that the chiropractor understood the nature of and treatment for the injury, to include the fact that the injury resulted primarily in a complaint of headaches. The chiropractor's opinion also does not reflect consideration of the Veteran's cervical strain diagnosed after the in-service motor vehicle accident shown in the service treatment records. Moreover, the chiropractor did not provide rationale for the positive nexus opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (the thoroughness and detail of a medical opinion is a factor in assessing the probative value of the opinion). On the other hand, the December 2011 VA examiner and the VA clinician who provided the February 2012 VA addendum opinion reviewed the record and offered thorough rationales for the opinions given that reflect consideration of the specific diagnoses and treatment provided following the in-service head traumas, as well as the Veteran's normal neck examinations following the head traumas. The rationales provide medical insight into the nature of the in-service head injuries and the likelihood that the current cervical spine disabilities may be etiologically related to those head injuries. See Prejean v. West, 13 Vet. App. at 448-9; Nieves-Rodriguez, 22 Vet. App. 295 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). The Board therefore accepts the examiners' opinions as probative evidence that it is not at least as likely as not that the Veteran's current cervical spine disabilities are causally or etiologically related to the Veteran's active service or any incident therein, to include the head traumas shown in the service treatment records. To the extent that the record shows that the Veteran has been diagnosed with osteoarthritis of the cervical spine, the Board has also considered whether the Veteran is entitled to service connection for a back disability on a presumptive basis as a "chronic disease." See 38 C.F.R. §§ 3.303(b). Arthritis is included in the list of "chronic diseases" under 38 C.F.R. § 3.309(a) and may be service connected on a presumptive basis if manifested to a compensable degree within one year of separation from service. However, the Veteran has not argued, and the record does not show, that he was diagnosed with arthritis of the cervical spine or any other "chronic disease" listed under 38 C.F.R. § 3.309(a) during service or within one year of separation from service. In this case, the record shows that the Veteran had a normal evaluation of the spine at the time of his separation from active service in November 1975. The record does not show a diagnosis of osteoarthritis of the cervical spine until many years after the Veteran's separation from active service. Therefore, service connection is not warranted on a presumptive basis under the provisions of 38 C.F.R. §§ 3.303(b), 3.307, and 3.309. In summary, the most probative evidence of record does not show that the Veteran has a current cervical spine disability that is at least as likely as not causally or etiologically related to his active service or any incident therein, to include head trauma. In light of the above, the Board concludes that the preponderance of the evidence is against the claim. As such, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection for PTSD The Veteran contends that he has PTSD due to in-service stressors. See, e.g., September 2010 VA initial PTSD examination. The Veteran has reported that he has nightmares relating to incidents he witnessed while serving in the Republic of Vietnam, to include combat-related situations. See August 2014 Board hearing transcript. His DD Form 214 reflects that he obtained, among other awards, the combat action ribbon. Therefore, his reports of engaging in combat are considered credible. Service connection for PTSD requires (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f). For cases certified to the Board after August 4, 2014, such as this case, the diagnosis of PTSD must be in accordance with the DSM-5. 38 C.F.R. § 4.125(a); Schedule for Rating Disabilities-Mental Disorders and Definition of Psychosis for Certain VA Purposes, 79 Fed. Reg. 45,093 (Aug, 4, 2014) (Applicability Date) (updating 38 C.F.R. § 4.125 to reference DSM-5). A review of the Veteran's service treatment records reveals that he had normal psychiatric evaluations at medical examinations in November 1975, September 1977, March 1984, July 1985, August 1988, and February 1992. In addition, the Veteran denied frequent trouble sleeping, depression or excessive worry, loss of memory, nervous trouble of any sort, and any other condition not specifically listed on reports of medical history dated in November 1974, September 1977, March 1984, July 1985, and August 1988. On a February 1992 report of medical history, the Veteran endorsed frequent trouble sleeping. However, he specified that the trouble sleeping was due to a prior back surgery. The records reflect that the Veteran was provided treatment for physical complaints, to include head trauma and colds. They do not show treatment for PTSD or any other psychiatric condition. VA treatment records dating during the appeal period reflect a diagnosis of depression. The records make reference to the Veteran having "PTSD symptoms" and show that the Veteran has participated in therapy for PTSD. However, they do not reflect that the Veteran has been provided a diagnosis of PTSD under the diagnostic criteria set forth in the DSM-IV or DSM-5 at any time during the appeal period or in proximity to the claim. The September 2010 VA initial PTSD examiner reviewed the record, interviewed the Veteran, administered psychiatric testing, and conducted a mental status examination. The examiner noted the Veteran's reported in-service stressors, and found that one of the stressors satisfied the criterion A1 and criterion A2 for diagnosis of PTSD under the DSM-IV. However, the examiner further noted that the Veteran did not meet diagnostic criterion B, relating to persistent re-experiencing of the traumatic event, and that criterion C, relating to persistent avoidance of stimuli associated with the trauma, was met, but only in relation to symptoms that did not "appear to be even indirectly related to military stressors." Accordingly, the examiner found that the Veteran did not meet the full criteria for a PTSD diagnosis under the DSM-IV. Instead, the examiner diagnosed the Veteran with major depressive disorder, recurrent, currently in partial remission. The June 2015 VA examiner reviewed the record, interviewed the Veteran, administered psychiatric testing, and conducted a mental status examination. The Veteran's score on the PTSD Checklist M was consistent with a diagnosis of PTSD. The examiner considered those results in assessing the Veteran's psychiatric diagnoses, but concluded that the Veteran does not meet the criteria for a PTSD diagnosis under the DSM-5. Specifically, as to diagnostic criterion C under the DSM-5, relating to persistent avoidance of stimuli associated with the traumatic event, the Veteran denied any need to avoid or withdraw from events due to his in-service stressors. In addition, as to diagnostic criterion D under the DSM-5, relating to negative alterations in cognition and mood associated with the traumatic event, the Veteran reported only one symptom-blaming himself and feelings of guilt over one in-service stressor-when at least two symptoms are required for a diagnosis of PTSD. The examiner diagnosed the Veteran with mild major depressive disorder. Thus, the record shows that the Veteran has reported that he suffers from PTSD. However, he has not been diagnosed with PTSD by a competent medical source. In that regard, the Board has considered the Veteran's assertions that he has PTSD. Although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 428, the specific issue under discussion here falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4. Establishing PTSD as a disability for VA purposes requires diagnostic testing and a diagnosis conforming to the criteria as set forth in the Diagnostic and Statistical Manual for Mental Disorders. 38 C.F.R. §§ 4.125, 4.130. The Veteran has not been shown to possess the medical expertise or knowledge required to diagnose a disability such as PTSD. Therefore, because the Veteran is a lay witness, his statements do not constitute competent evidence of a diagnosis of PTSD conforming to either the DSM-IV or the DSM-5. The Board instead affords probative value to the medical evidence of record, which shows that VA examiners and physicians have considered the Veteran's reported psychiatric symptoms and have declined to provide a formal diagnosis of PTSD. The VA examiners instead provided diagnoses for other psychiatric disabilities. The Board also acknowledges that the Veteran's score on the PTSD Checklist M testing at the June 2015 VA examination was consistent with a diagnosis of PTSD. However, the findings on the PTSD Checklist M are outweighed by the more specific diagnostic testing conducted by the VA examiner, which revealed that the Veteran does not meet the full diagnostic criteria for PTSD under the DSM-5. Accordingly, the probative evidence of record shows that the Veteran did not have a diagnosis of PTSD under the criteria set forth in the DSM-IV or the DSM-5 during the appeal period or in proximity to the claim for service connection. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). As noted above, in the absence of proof of a current disability, there can be no valid claim for entitlement to service connection. Brammer, 3 Vet. App. at 225. In view of the foregoing, the Board concludes that the preponderance of the evidence is against the claim for entitlement to service connection for PTSD. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107(b); see also Gilbert, 1 Vet. App. 49. ORDER Entitlement to service connection for a cervical spine disability is denied. Entitlement to service connection for PTSD is denied. REMAND The Board finds that the issues remaining on appeal must be remanded for further development before a decision may be made on the merits. Service Connection for a Lung Disability The Veteran contends that, during his active service, he was tasked with removing asbestos from the sleeping quarters of his ship, and that he now has a lung disability related to that asbestos exposure. See, e.g., August 2014 Board hearing transcript. The medical treatment evidence of record shows that the Veteran has been diagnosed with lung conditions of chronic obstructive pulmonary disease (COPD), bronchiectasis with chronic bronchitis, and asthma. The Veteran was provided a VA examination as to the lung disability claim in October 2010. The October 2010 VA examiner reviewed the record, interviewed the Veteran, and examined the Veteran. The examiner noted respiratory diagnoses shown in the medical evidence of record of pneumonia, sleep apnea, COPD, and asthma. The examiner also noted the Veteran's report of removing asbestos from pipes during his active service. The examiner further noted that a February 2010 treatment note states there was "a strand of fibrosis, right lung base," found on x-ray, but that a February 2010 chest CT documented bibasilar atelectatic lung parenchymal changes but no fibrosis. The examiner concluded that the Veteran's current COPD, asthma, bronchiectasis, sleep apnea, pneumonia, and chronic bronchitis are not the result of or aggravation by his reported in-service exposure to asbestos. As a rationale for the opinion, the examiner explained that chest x-rays and CT scans of record do not show pleural plaques, which are diagnostic of previous asbestos exposure. In addition, the February 2010 chest CT and a July 2010 chest CT did not reveal fibrosis or other evidence of findings consistent with prior asbestos exposure. However, a review of the record reveals that, in February 2015, a chest x-ray showed moderate COPD and pulmonary fibrosis. Based on that x-ray, the Veteran was assessed with "mild underlying chronic obstructive pulmonary disease/pulmonary fibrosis." Given the finding of fibrosis in the February 2015 chest x-ray, the October 2010 VA examiner's negative nexus opinion, which was based at least in part on the absence of fibrosis in the February 2010 and July 2010 chest CTs, is no longer consistent with the evidence of record. Therefore, the case must be remanded so that a VA addendum opinion may be obtained in consideration of the February 2015 chest x-ray findings. See Barr, 21 Vet. App. at 312. Service Connection for Obstructive Sleep Apnea The Veteran contends that he has obstructive sleep apnea that is related to his active service. The record reflects that the Veteran has been diagnosed with obstructive sleep apnea through sleep studies conducted in January 2003, September 2009, December 2010, and January 2011. In an Informal Hearing Presentation dated in June 2016, the Veteran's representative asserts that the Veteran's obstructive sleep apnea is proximately due to his service-connected traumatic brain injury. In support of the assertion, the representative provides in the Informal Hearing Presentation excerpts from multiple internet-based articles, to include one article from the National Institutes of Health's website, as well as internet links to the full articles. The articles are general in nature and do not comment on the Veteran's particular case. In addition, there is no indication that the representative has the medical knowledge and training necessary to render an opinion on a complex medical issue such as the likely etiology of the Veteran's obstructive sleep apnea. See Kahana, 24 Vet. App. 428; Jandreau, 492 F.3d at 1376-77. Therefore, the representative's assertions and the articles are not probative evidence of a causal link between the Veteran's service-connected traumatic brain injury and his obstructive sleep apnea. However, they do provide an indication that there may be such a link. The Board therefore concludes that, as no VA examiner has yet provided an opinion as to whether the Veteran's obstructive sleep apnea may be causally or etiologically related to his service-connected traumatic brain injury, the matter must be remanded so that a VA addendum opinion may be obtained. See Barr, 21 Vet. App. at 312. Service Connection for an Acquired Psychiatric Disability Other Than PTSD The Veteran was provided VA psychiatric examinations in August 2011, February 2013, and June 2015, and with a VA addendum opinion in April 2013 as to his psychiatric disabilities other the PTSD. The August 2011 VA examiner opined that the Veteran experienced depressive symptoms for the prior five or six years due to declining physical heath and, "There is no plausible or logical connection between the Veteran's recent depressive symptoms and his military service 1971-1975." The February 2013 VA examiner noted that the Veteran's mental health problems appear to have started when his medical conditions became debilitating, and opined that the Veteran's depression is secondary to his difficulty adjusting to the effects of his chronic medical problems on his day-to-day functioning. The VA examiner who provided the April 2013 VA addendum opinion opined that it is less likely than not that the Veteran's major depressive disorder is the result of the Veteran's service-connected conditions. As a rationale for the opinion, the examiner explained, "His mental health symptoms are, in my opinion, a consequence of his health problems which result in his inability to work. Those conditions include: COPD, obstructive sleep apnea, morbid obesity, chronic back pain, and dyspnea. It is not possible for me to determine whether his cephalgia, posttraumatic vascular headaches, right little finger injury with distal nerve involvement, tinnitus or [sensorineural hearing loss] are factors . . . ." The June 2015 VA examiner offered an opinion that it is not at least as likely as not that the Veteran's major depressive disorder is caused by or the result of reported in-service stressors. The examiner further opined that the Veteran's major depressive disorder is most likely secondary to multiple medical problems after 2009-2010. However, the examiner did not specify which of the Veteran's medical problems caused or aggravated the major depressive disorder. Accordingly, there are multiple VA opinions of record that attribute the Veteran's major depressive disorder to his physical health problems. However, none of the opinions state whether the major depressive disorder may be attributed specifically to the Veteran's service-connected disabilities. As such, the opinions are inadequate for decision-making purposes, and the matter must therefore be remanded so that an adequate VA addendum opinion may be obtained as to whether it is at least as likely as not that the Veteran's major depressive disorder is proximately due to, caused by, or aggravated by a service-connected disability or disabilities. See Barr, 21 Vet. App. at 312. Entitlement to a TDIU As to the Veteran's claim for entitlement to a TDIU, the Board finds that the outcome of the Veteran's service connection claims that are remanded herein could have a significant impact on his TDIU claim. As such, the TDIU issue is inextricably intertwined with those issues. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined). Therefore, the Board finds that the other claims being remanded must be adjudicated by the AOJ prior to appellate consideration of entitlement to a TDIU. Other Considerations The record reflects that the Veteran consistently receives treatment for the conditions at issue on appeal at VA treatment facilities. On remand, updated VA treatment records should therefore be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding VA treatment records relevant to the matters being remanded and associate the records with the record. 2. Transfer the record and a copy of this Remand to the examiner who conducted the October 2010 VA respiratory examination or, if that examiner is not available, to a similarly qualified VA clinician for preparation of an addendum opinion. The examiner must indicate that the record was reviewed. If the clinician determines that further in-person examination of the Veteran is needed to provide the requested opinion, such examination should be scheduled. The examiner should provide an opinion as to: Whether it is at least as likely as not (50 percent probability or greater) that the Veteran has a lung disability that is causally or etiologically related to his active service, specifically to include as due to in-service exposure to asbestos. A complete rationale should be provided for all opinions given. The examiner must comment on the February 2015 VA treatment notes reflecting that a February 2015 chest x-ray showed moderate chronic obstructive pulmonary disease and pulmonary fibrosis, and that the Veteran was assessed as having mild underlying chronic obstructive pulmonary disease/pulmonary fibrosis. 3. Transfer the record and a copy of this Remand to a VA clinician who is qualified to provide the opinions requested below. The examiner must indicate that the record was reviewed. If the clinician determines that further in-person examination of the Veteran is needed to provide the requested opinion, such examination should be scheduled. The examiner should provide an opinion as to: a) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran's obstructive sleep apnea is proximately due to or the result of the Veteran's service-connected traumatic brain injury. b) If not, whether it is at least as likely as not (50 percent probability or greater) that the Veteran's obstructive sleep apnea is aggravated by the Veteran's service-connected traumatic brain injury. Aggravation is defined as a permanent worsening beyond the natural progression of the disease. The issue of aggravation must be considered directly. An opinion to the effect that one disability "is not caused by or a result of" another disability does not answer the question of aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). A complete rationale should be provided for all opinions given. Any opinion given must reflect consideration of the internet-based medical literature noted in the Veteran's representative's June 2016 Informal Hearing Presentation. 4. Transfer the record and a copy of this Remand to a VA clinician who is qualified to provide the opinions requested below. The examiner must indicate that the record was reviewed. If the clinician determines that further in-person examination of the Veteran is needed to provide the requested opinion, such examination should be scheduled. The examiner should provide an opinion as to: a) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran has an acquired psychiatric disability other than PTSD, to include major depressive disorder, that is proximately due to or the result of the Veteran's service-connected disabilities. b) If not, whether it is at least as likely as not (50 percent probability or greater) that the Veteran has an acquired psychiatric disability other than PTSD, to include major depressive disorder, that is aggravated by the Veteran's service-connected traumatic brain injury. Aggravation is defined as a permanent worsening beyond the natural progression of the disease. The issue of aggravation must be considered directly. An opinion to the effect that one disability "is not caused by or a result of" another disability does not answer the question of aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). A complete rationale should be provided for all opinions given. An opinion that the Veteran's has an acquired psychiatric disability other than PTSD that is due to an increase in the severity of his physical health problems does not address the questions presented. The examiner is asked to discuss the Veteran's service-connected disabilities specifically. If any of the requested opinions cannot be provided without resort to speculation, the examiner must explain why the opinion cannot be offered, and state whether the inability is due to the absence of any evidence or is due to the limits of scientific or medical knowledge. 5. After completion of the above, readjudicate the issues on appeal, with review of the expanded record, including the evidence entered since the most recent supplemental statement of the case. In so doing, determine whether a TDIU may be granted, to include, if warranted, referral of the matter of whether a TDIU should be awarded on an extra-schedular basis, pursuant to 38 C.F.R. § 4.16(b), to the Director of the Compensation and Pension Service. If any benefit sought remains denied, furnish the Veteran and his representative with another supplemental statement of the case. A reasonable period should be allowed for response before the appeal is returned to the Board. The appellant has the right to submit additional evidence and argument on the 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 2014). ______________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs