Citation Nr: 1751613 Decision Date: 11/13/17 Archive Date: 11/22/17 DOCKET NO. 13-31 526 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for hypertension. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for a left knee disorder. 4. Entitlement to service connection for sleep apnea. 5. Entitlement to service connection for gastroesophageal reflux disease (GERD). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Cheng, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1976 to May 1986 and from April 2000 to March 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2009 and September 2012 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned during a travel Board hearing in December 2016. A transcript of the hearing is of record. The Board notes that a September 2012 rating decision had denied service connection for the Veteran's claimed left knee disorder, finding there was no new and material evidence. However, after a review of the claims file, the Board notes that after the Veteran's service connection claim for his left knee disorder was initially denied in a December 2009 rating decision, he submitted a notice of disagreement, through his representative, in January 2010, less than the year requirement to merit being finalized. As the December 2009 RO denial of the left knee disorder claim has not been finalized, this issue before the Board is that of entitlement to service-connection, and not whether new and material evidence has been presented. The issues of entitlement to service connection for a left knee disorder and sleep apnea are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. An August 2007 rating decision denied reopening a claim for entitlement to service connection for hypertension, finding there was no new and material evidence submitted; the Veteran was notified of the decision and of his appellate rights, but he did not appeal. 2. The evidence received since the August 2007 rating decision is not cumulative or redundant of evidence previously of record, relates to unestablished facts necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim. 3. The Veteran's hypertension is proximately due to or the result of the service connected tension headaches. 4. The Veteran's GERD is proximately due to or the result of the service connected tension headaches and associated chronic NSAIDs usage. CONCLUSIONS OF LAW 1. The August 2007 rating decision that denied service connection for hypertension is final. 38 U.S.C.A. § 7105 (c) (West 2014); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). 2. The evidence received since the August 2007 rating decision denial is new and material, and the requirements for reopening the claim for service connection for hypertension have been met. 38 U.S.C. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2017). 3. The criteria for service connection for hypertension have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2017). 4. The criteria for service connection for GERD have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Application to Reopen Generally, a claim that has been denied in an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c). The exception is that if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. "New evidence" is evidence that has not previously been reviewed by VA adjudicators. "Material evidence" is existing evidence, that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the credibility of the newly presented evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510 (1992). New and material evidence is not required as to each previously unproven element of a claim. There is a low threshold for reopening claims. 38 C.F.R. § 3.156(a); Shade v. Shinseki, 24 Vet. App. 110 (2010). The Board must review all of the evidence submitted since the last final disallowance of the claim on any basis in order to determine whether the claim may be reopened. Hickson v. West, 12 Vet. App. 247 (1999). A January 1999 rating decision first denied the Veteran's claim for entitlement to service connection for hypertension since service treatment records (STRs) for the period of 1976 to 1986 could not be obtained for review. The enlistment examination was of record. The RO acknowledged that the Veteran stated he was being treated for hypertension throughout service; however, the available STRs were negative for hypertension. The RO also noted that the Veteran had not furnished any medical evidence showing treatment for hypertension within one year of discharge from service. As such, the RO found there was no link between the Veteran's hypertension and the Veteran's service. The decision was based upon incomplete service treatment records (STRs) and post service treatment records from St. Joseph Hospital noting hypertension in 1998. The Veteran did not appeal the decision and no new and material evidence was received within one year of the notification of the denial. After the Veteran filed for the hypertension claim again in January 2006, a September 2006 rating decision did not reopen the Veteran's claim for entitlement to service connection for hypertension after finding there was no new and material evidence submitted. The Veteran requested to reopen the hypertension claim again in July 2007 but an August 2007 rating decision did not reopen the Veteran's claim for entitlement to service connection for hypertension after finding again that there was no new and material evidence submitted. The Veteran did not appeal the August 2007 rating decision and no new and material evidence was received within one year of the notification of the denial. Evidence reviewed at the time included incomplete STRs, VA treatment records from VA Medical Center Salisbury and Sacramento/Martinez, private treatment records and a September 1, 1998 letter from Dr. Caldwell. The evidence included mention of post-service treatment of the Veteran's hypertension and Dr. Caldwell's finding that the Veteran's hypertension began during his military stay and has continued since discharge. Pertinent evidence added to the claims file since the August 2007 rating decision includes a September 2009 letter from Dr. Floyd who noted the Veteran was initially diagnosed with hypertension in 1983 while he was in the military. Dr. Floyd opined that it was reasonable to conclude that the Veteran's hypertension is service connected. A March 2011 letter from a fellow service member, D.M., stated that she served with the Veteran in the Army twice from 1981 to 1984. She indicated the Veteran was her Sergeant at Ft. Story and after she went overseas to Germany. She stated that in Germany, the Veteran's diet changed drastically, indicating that the Veteran always loved fried food and would talk about going to Virginia to get fried chicken. She stated the Veteran suddenly only ate baked foods and avoided salty foods. When she asked the Veteran about the change of diet, the Veteran had indicated at the time that it was because his blood pressure was up and the doctor had ordered the diet change. A February 2013 letter from a fellow service member, L.A.F., who served with the Veteran in Germany from 1982 to 1985, indicated that during that time frame, the Veteran had high blood pressure and had monitors three times a week for at least six months. Another February 2013 letter from a fellow service member, J.C., stated that he served with the Veteran from 2000 to 2003 as recruiters in Hendersonville, North Carolina. J.C. specifically recalled that the Veteran had suffered from high blood pressure throughout their recruiting tour. He indicated that the Veteran, at the advice of the doctor and Recruiting Station's Commander, to stay at home when his blood pressure was at elevated levels. Additional treatment records from the International Clinic were also associated with the claims file. In April 2010, a Dr. Al-Sayegh from the International Clinic noted that in 1978, the Veteran had visited the doctor several times due to headaches associated with nausea and he was discovered to have high blood pressure and subsequently found to have essential hypertension with no organ damage. Dr. Al-Sayegh noted that the Veteran's increased blood pressure peaks were related to stress and night time shifts during active service. In the December 2016 Board hearing, the Veteran reported he started to have problems with high blood pressure in the first and second period of service. The Veteran stated that he was diagnosed with borderline hypertension in the stroke area by Dr. Caldwell after leaving the military in 2003. He indicated that he was informed that his blood pressure was really high and that he needed it under control. The Veteran indicated during the hearing that Dr. Caldwell had reviewed his medical records and said that this could have occurred while in the military. The Veteran also submitted a February 2017 medical opinion in support of his hypertension claim in August 2017. After a review of the Veteran's claims file and thorough rationale, the February 2017 reviewing examiner opined that it was at least as likely as not that Veteran's current hypertension was secondary to, related to and/or aggravated by his service-connected tension headaches with associated chronic pain. Additional VA treatment records from 2006 to 2017 were associated with the claims file and noted the Veteran's continued medication for his hypertension. The Board finds that new and material evidence has been presented to reopen the claim. The March 2011 letter from D.M., the February 2013 letters from L.A.F. and J.C., the April 2010 note from Dr. Al-Sayegh, the December 2016 Board hearing, and the February 2017 medical opinion regarding the Veteran's hypertension are "new" in the sense that it was not previously considered by the prior final decision. The Board also finds that the newly submitted evidence is not cumulative or duplicative of evidence previously considered and is thus "material" for purposes of reopening the Veteran's claims. Additionally, the evidence received since the August 2007 rating decision denial includes evidence that the Veteran's hypertension is caused by his military service or a service-connected disorder. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). When aggravation of a nonservice-connected disability is proximately due to or the result of a service-connected disability, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board notes that it has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the Board discuss every piece of evidence in the record. The Board will summarize the relevant evidence, as deemed appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to the claim. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). A. Hypertension i. Factual Background In an October 1975 STR enlistment examination, the Veteran denied any high or low blood pressure and the Veteran was found normal upon clinical evaluation. As indicated above, only a copy of incomplete STRs have been associated with the claims file. See September 2006 Formal Finding of Federal Records Unavailability. February 1993 treatment records from WNC Hypertension Prevention & Treatment Center noted an impression of hypertension. A January 1995 treatment record from St. Joseph's Hospital noted the Veteran experienced occasional headaches and noted an assessment of hypertension. A September 1998 letter from Dr. Caldwell from the WNC Hypertension Prevention & Treatment Center noted that the Veteran had been under his practice since February 1993. The provider noted the Veteran had apparently been monitored at the Fort Gordon Hospital at which time his blood pressure was significantly elevated to the 170/120 range at the highest, and that there were many reported readings of 140 to 150 systolic, with diastolics of 100. The provider noted the Veteran had not been on medication upon the initial evaluation. The provider indicated that he placed the Veteran on Cardizem-CD 240 mg one per day and that the Veteran had been medication compliant. The provider also noted the Veteran had been seen in the office on a regular basis for routine follow-up. The provider noted that the Veteran had no evidence of any end organ damage from his hypertension and that there had been significant improvement of his pressure. On August 1998, the Veteran's blood pressure was noted as 130/100 and appeared to be tolerating his hypertension medication quite well. The provider noted that the records from his office and records from the Fort Gordon Hospital clearly demonstrated that the Veteran had hypertension during his military stay and continued to be bothered with this problem since his discharge from the military. A March 2000 treatment record from the WNC Hypertension Prevention & Treatment Center noted the Veteran had been under Dr. Caldwell's care from March 27, 2000 to March 28, 2000 for his high blood pressure. Records also noted an assessment of hypertension. A September 2000 treatment record from the WNC Hypertension Prevention & Treatment Center noted the Veteran was seen for his blood pressure which was noted as 138/90. A January 2001 treatment record from the WNC Hypertension Prevention & Treatment Center noted the Veteran's hypertension and prescribed medication. An October 2001 treatment record from the WNC Hypertension Prevention & Treatment Center noted the Veteran's headache and hypertension. A November 2001 treatment record from the WNC Hypertension Prevention & Treatment Center noted the Veteran had been under Dr. Caldwell's care for hypertension from November 7, 2001 to November 8, 2001 and was able to return to work on November 9, 2001. An April 2002 treatment record from the WNC Hypertension Prevention & Treatment Center noted the Veteran's hypertension and prescribed medication. A July 2002 treatment record from the WNC Hypertension Prevention & Treatment Center noted the Veteran's impression of hypertension and prescribed medication. A July 2004 STR shows a report of medical examination that noted the Veteran had hypertension controlled by medication. VA treatment records from 2004 to 2017 have shown continued medication and treatment for the Veteran's hypertension. A September 2009 letter from Dr. Floyd of the Carolina Medical Group noted that the Veteran's hypertension was initially diagnosed in 1983 while he was in the military and that it was reasonable to conclude that his hypertension is service connected. A March 2011 letter from a fellow service member, D.M., stated that she served with the Veteran in the Army twice from 1981 to 1984. She indicated the Veteran was her Sergeant at Ft. Story and after she went overseas to Germany. She stated that in Germany, the Veteran's diet changed drastically, indicating that the Veteran always loved fried food and would talk about going to Virginia to get fried chicken. She stated the Veteran suddenly only ate baked foods and avoided salty foods. When she asked the Veteran about the change of diet, the Veteran had indicated at the time that it was because his blood pressure was up and the doctor had ordered the diet change. A February 2013 letter from a fellow service member, L.A.F., who served with the Veteran in Germany from 1982 to 1985, indicated that during that time frame, the Veteran had high blood pressure and had monitors three times a week for at least six months. Another February 2013 letter from a fellow service member, J.C., stated that he served with the Veteran from 2000 to 2003 as recruiters in Hendersonville, North Carolina. J.C. specifically recalled that the Veteran had suffered from high blood pressure throughout their recruiting tour. He indicated that the Veteran, at the advice of the doctor and Recruiting Station's Commander, to stay at home when his blood pressure was at elevated levels. Dr. Al-Sayegh from the International Clinic noted that in 1978, the Veteran had visited the doctor several times due to headaches associated with nausea and he was discovered to have high blood pressure and subsequently found to have essential hypertension with no organ damage. Dr. Al-Sayegh noted that the Veteran's increased blood pressure peaks were related to stress and night time shifts during active service. In the December 2016 Board hearing, the Veteran reported that he started to have problems with high blood pressure in the first and second period of service. The Veteran stated that he was diagnosed with borderline hypertension in the stroke area by Dr. Caldwell after leaving the military in 2003. He indicated that he was informed that his blood pressure was really high and that he needed it under control. The Veteran indicated during the hearing that Dr. Caldwell had reviewed his medical records and said that this could have occurred while in the military. The Veteran also submitted a February 2017 private medical opinion in support of his hypertension claim in August 2017. After a review of the Veteran's claims file, and conducting thorough rationale with citation to medical treatises and literature, the reviewing examiner opined that it was at least as likely as not that Veteran's current hypertension is secondary to, related to and/or aggravated by his service-connected tension headaches with associated chronic pain. The examiner noted the Veteran had a current, formal diagnosis of hypertension from Fort Gordon Hospital and had been prescribed daily hypertension medications. The examiner stated that it had been established by service connection and Veteran symptomatology that the Veteran suffers from chronic painful stimuli due to his service connected disability of tension headaches. The examiner noted that the medical literature had documented that the cardiovascular/pain regulatory system interactions were altered in patients with chronic pain and that several studies had indicated that BP-related hypoalgesia is diminished in chronic pain patients, thus documenting chronic pain dysfunction in these interacting cardiovascular-pain systems. The examiner further elaborated that logistic regression in the pain group revealed that chronic pain intensity was a significant predictor of hypertensive status independent of the effects of age, race/ethnicity, and parental hypertension, thus statistically significant and that these results suggested that chronic pain may be associated with the increased risk of hypertension. The examiner noted that chronic pain intensity has been recognized as a predictor of a hypertensive disease in a plethora of medical literature and as the Veteran's service-connected painful disability disorders have been deemed "chronic," his blood pressures would be in a constant state of elevation; thus resulting in a hypertensive disease. ii. Analysis The Board finds the February 2017 examiner's opinion probative and affords it significant weight. The examiner's opinion was offered based on full review of the medical record. Additionally, the examiner's opinion is based on the application of sufficient facts and data to reliable principles and methods. Further, the examiner's opinion provides specific conclusions and precise reasons for the statements. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). There is no contrary medical opinion in the record. Thus, the February 2017 opinion stands unchallenged as competent and probative medical evidence on the crucial question of medical nexus. The Board notes that there are additional positive opinions of record indicating that the Veteran's hypertension is related directly to active service. However, these opinions do not have supporting rationales and are based on the Veteran's statements, as opposed to medical literature or available treatment records. As such, the Board affords the most probative weight to the February 2017 VA examiner's opinion, considering there is sufficient rationale provided. Nevertheless, given the only record of opinions are in favor of service connection, and at least one positive opinion is adequate, a remand for another VA examination could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304 (c) ("The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination"); Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (VA may not order additional development for the sole purpose of obtaining evidence unfavorable to a claimant). As such, resolving reasonable doubt in favor of the Veteran, the Board finds that the record shows that it is at least as likely as not that the Veteran's hypertension is secondary to, related to and/or aggravated by his service-connected tension headaches with associated chronic pain. Therefore, service connection is warranted for hypertension. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. GERD i. Factual Background In an October 1975 STR enlistment examination, the Veteran denied any stomach, liver, or intestinal trouble, or frequent indigestion, and the Veteran was found normal upon clinical evaluation. A March 2004 VA treatment record noted the Veteran's prior medical history was positive for GERD and that at the time of the record, the Veteran had an assessment of GERD. A June 2004 VA treatment record noted the Veteran had diarrhea on Prilosec but was doing better with Zantac. The provider noted there were no GERD symptoms but still noted an assessment of GERD. A September 2004 VA treatment record noted the Veteran was taking Zantac and Motrin on an as need basis and was still being bothered by GERD. The record also noted an assessment of GERD. A January 2006 VA treatment record noted the Veteran took Prilosec for his GERD. An April 2010 treatment record from the International Clinic noted the Veteran's chronic medications for reflux disease. June 2010 and September 2010 treatment records from the United States Military Hospital in Kuwait (USMHK) noted the Veteran's esophageal reflux and that the Veteran was seen for refill of GERD medication. An August 2011 VA treatment record noted the Veteran's assessment of GERD and continued medication for the disability. Additionally VA treatment records from 2011 to 2017 noted the Veteran's continued medication and treatment for GERD. In the December 2016 Board hearing, the Veteran reported that he did not have reflux disease until he started taking a lot of Motrin for his left knee pain. The Veteran indicated that there is a doctor that opined that his reflux disease is due Motrin. The Veteran reported that he is taking Prilosec for his GERD and that he refrained from eating spicy foods. The Veteran reiterated that he had symptoms of stomach issues because of the Motrin he took for his left knee since he was on active duty. In a February 2017 private medical opinion, the Veteran reported that due to his service-connected headache disability, he has had chronic pain and had been prescribed in service and out of service multiple nonsteroidal anti-inflammatory drugs (NSAIDs), such as Ibuprofen. The Veteran reported that since taking prescribed and over the counter NSAIDs, he noticed he was unable to eat spicy foods or lay down within a couple of hours of eating, or he had the sensation of food coming back up in his throat and bad heartburn. He reported that he has had progressively worse reflux and indigestion since taking NSAIDs and had been prescribed and used Pantoprazole 40mg daily and also took Pepcid, Tums, and Pepto-Bismol as needed. The examiner noted the Veteran's current and formal diagnosis of GERD and noted that the evidence supports that the chronic pain associated with frequent headaches was intractable despite continued treatment with various NSAIDs. After a review of the Veteran's claims file, and conducting a thorough rationale with citation to medical treatises and literature, the reviewing examiner opined that the Veteran's GERD is more likely than not secondary to, aggravated by, and/or related to his service-connected tension headaches with chronic NSAIDs usage. The examiner explained that the medical literature established an association between NSAID treatment and GERD. The examiner elaborated that patients who chronically took NSAIDs had a significantly greater lower esophageal sphincter (LES) pressure and a less severe intraesophageal pH profile when compared to patients who did not use NSAIDs. The examiner noted that this illustrates the pathophysiological changes that occur in the stomach when exposed to long term NSAIDS. The examiner explained that greater LES pressure and a less severe pH profile indicate that NSAIDs contribute to the delayed closing of the LES that subsequently permits the passage of gastric content into the esophagus. The examiner noted that NSAIDs have been shown via valid pharmacological research studies to be a significant risk factor for GERD symptoms. ii. Analysis The Board finds the February 2017 examiner's opinion probative and affords it significant weight. The examiner's opinion was offered based on full review of the medical record. Additionally, the examiner's opinion is based on the application of sufficient facts and data to reliable principles and methods. Further, the examiner's opinion provides specific conclusions and precise reasons for the statements. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). There is no contrary medical opinion in the record. Thus, the February 2017 opinion stands unchallenged as competent and probative medical evidence on the crucial question of medical nexus. As such, resolving reasonable doubt in favor of the Veteran, the Board finds that the record shows that it is at least as likely as not that the Veteran's GERD is secondary to, related to and/or aggravated by his service-connected tension headaches with chronic NSAIDs usage. Therefore, service connection is warranted for GERD. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER New and material evidence having been received to reopen the claim of service connection for hypertension, the claim is reopened. Service connection for hypertension is granted. Service connection for GERD is granted. REMAND Regarding the issue of a left knee disorder, the Board finds that a VA examination is necessary. The Board acknowledges a February 2017 private examiner that opined that it was more likely than not that the Veteran's left knee disorder was related to active service, specifically due to the Veteran's claimed paratrooper duties. However, a review of the Veteran's claims file shows several inconsistencies. Military personnel records show that although the Veteran was attached to the Airborne Division, the Veteran held a supportive role as a supply specialist. There is no indication in the record that the Veteran was a paratrooper or that he performed jumps in his capacity as a supply specialist. He was not awarded any parachutist tabs, or a parachutist badge. Although the February 2017 private examiner referred to a formal log of the para-jumps the Veteran was involved in, such a log has not been associated with the claims file. The Board also notes that during the December 2016 Board hearing, the Veteran failed to mention his paratrooper duties and instead claimed that his left knee disorder was due to lifting and toting rounds of howitzers to and from the breach on rough terrain in field artillery. The Board further acknowledges there are additional positive opinions associated with the record. Specifically, in a March 2010 VA treatment record, the provider noted that the Veteran's left knee pain was from jumping out of planes during active service. In a May 2014 private opinion from the Grace Medical Group, a Dr. Darby opined that the Veteran's knee disability was more likely than not occurred while the Veteran was on active duty status and that the Veteran's current level of osteoarthritis of both knees indicated the Veteran may have been suffering 12 to 15 years from the disability, which would appear to be the time of his military active duty times. The Board notes that the March 2010 and May 2014 opinions failed to provide adequate rationale for the opinions. Furthermore, although the May 2014 private examiner noted the Veteran knee disorder stemmed back to his second period of service, this opinion was in contrast to buddy statements provided in March 2011 and February 2013 that noted the Veteran's painful left knee were observed in the early 1980s, during the first period of active service. As the positive opinions of record have no basis, failed to provide sufficient rationale, and/or are inconsistent with the statements of record, the Board finds that a VA examination of the left knee is necessary. See 38 C.F.R. § 3.304 (c) ("The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination"); Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (VA may not order additional development for the sole purpose of obtaining evidence unfavorable to a claimant). Regarding the issue of sleep apnea, there are also inadequate positive opinions associated to the record. Specifically, in a May 2014 private opinion from the Grace Medical Group, a Dr. Darby opined that the Veteran's sleep more likely than not occurred while the Veteran was on active duty status. The examiner failed to provide a rationale in support of the opinion. In a December 2016 Board hearing, the Veteran reported that the doctor's opinion was based on testimony of witnesses who saw the Veteran's symptoms of sleep apnea during active service. However, any opinions related to the Veteran's sleep apnea did not reference such testimony and such testimony has not been associated with the claims file. The only probative opinion of record associated with sleep apnea was a February 2017 private opinion in which the examiner opined that the Veteran sleep apnea is secondary to the Veteran's left knee disorder. Considering the Board has remanded the issue of a left knee disorder for further development, and the issue of sleep apnea is deemed secondary to a left knee disorder, the sleep apnea claim is inextricably intertwined with the left knee disorder claim. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Thus, as such claim is inextricably intertwined, the claim for secondary service connection for sleep apnea must be remanded as well. Harris, 1 Vet. App. 80. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he submit the "formal log of the para-jumps he was involved in" that was referenced by the February 2017 examiner, as well as the witness testimony regarding his sleep apnea symptoms during active service that he referenced at his December 2016 hearing. 2. Thereafter, schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of his left knee disorder and sleep apnea. After reviewing the record and examining the Veteran, the examiner should provide an opinion as to the following: a) Whether it is at least as likely as not that any current left knee disorder either began during or is otherwise related to active service. b) Whether it is at least as likely as not that any current sleep apnea either began during or is otherwise related to active service. c) Whether it is at least as likely as not that any current sleep apnea was caused by or aggravated by a service-connected disorder. A complete rationale for any opinion offered should be provided. 3. Then, readjudicate the claims remaining on appeal. If any benefit sought on appeal remains denied, the Veteran and representative should be provided a supplemental statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. The Veteran 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. §§ 5109B, 7112. ______________________________________________ THOMAS H. O'SHAY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs