Citation Nr: 18143464 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 16-14 721 DATE: October 19, 2018 ORDER New and material evidence having been received, the petition to reopen a claim of entitlement to service connection for diarrhea, also claimed as irritable bowel syndrome (IBS), is granted. New and material evidence having been received, the petition to reopen a claim of entitlement to service connection for gastroesophageal reflux disorder (GERD), also claimed as a stomach disability, is granted. New and material evidence having been received, the petition to reopen a claim of entitlement to service connection for a liver disability, to include hepatitis C, cirrhosis, and cancer, is granted. REMANDED Entitlement to service connection for diarrhea, also claimed as IBS, is remanded. Entitlement to service connection for a gastric disability, to include GERD, peptic ulcer disease (PUD), and hiatal hernia, is remanded. Entitlement to service connection for a liver disability, to include hepatitis C, cirrhosis, and cancer, is remanded. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for sleep disturbances due to bloating is remanded.   FINDINGS OF FACT 1. In an April 2006 rating decision, the RO denied service connection for diarrhea, on the basis that although there was record of treatment in service for watery stool, there was no evidence of permanent residual or chronic disability. The Veteran did not file a notice of disagreement; therefore, the decision became final. 2. In a September 2008 rating decision, the RO denied service connection for diarrhea on the basis that the evidence submitted was not new and material. The Veteran did not file a notice of disagreement; therefore, the decision became final. 3. Evidence received since the September 2008 rating decision raises a reasonable possibility of substantiating the underlying claim of service connection for diarrhea. 4. In an April 2006 rating decision, the RO denied service connection for GERD on the basis that although there was record of treatment in service for a viral episode/gastroenteritis, there was no evidence of permanent residual or chronic disability. The Veteran did not file a notice of disagreement; therefore, the decision became final. 5. In a September 2008 rating decision, the RO denied service connection for GERD on the basis that the evidence submitted was not new and material. The Veteran did not file a notice of disagreement; therefore, the decision became final. 6. Evidence received since the September 2008 rating decision raises a reasonable possibility of substantiating the underlying claim of service connection for a gastric disability. 7. In an April 2006 rating decision, the RO denied service connection for hepatitis C on the basis that the evidence did not show that the Veteran’s hepatitis C was incurred in or caused by service. The Veteran did not file a notice of disagreement; therefore, the decision became final. 8. Evidence received since the April 2006 rating decision raises a reasonable possibility of substantiating the underlying claim of service connection for hepatitis C. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen a claim of entitlement to service connection for diarrhea, claimed as IBS. 38 U.S.C. §§ 5108, 7105(c) (2012); 38 C.F.R. § 3.156 (2017). 2. New and material evidence has been received to reopen a claim of entitlement to service connection for GERD, claimed as a stomach disability. 38 U.S.C. §§ 5108, 7105(c) (2012); 38 C.F.R. § 3.156 (2017). 3. New and material evidence has been received to reopen a claim of entitlement to service connection for hepatitis C. 38 U.S.C. §§ 5108, 7105(c) (2012); 38 C.F.R. § 3.156 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1967 to October 1970. This matter comes to the Board of Veterans’ Appeals (Board) from a November 2012 rating decision, which denied reopening claims of entitlement to service connection for GERD, diarrhea, hepatitis C, and sleep disturbances, on the basis that the evidence submitted was not new and material. In March 2015, the Veteran testified before a Decision Review Officer at the RO in Portland, Oregon. A copy of the transcript is of record. In a February 2016 statement of the case, the RO reopened the claims of entitlement to service connection for GERD, diarrhea, hepatitis C, and sleep disturbances on the basis that new and material evidence had been received, but continued to deny the claims on their merits. Despite the RO’s action, the Board must perform its own de novo review of whether new and material evidence has been received to reopen the claims of entitlement to service connection for GERD, diarrhea, hepatitis C, and sleep disturbances, before addressing the claims on their merits. See 38 U.S.C. § 7104 (2012); see also Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Claims to Reopen Governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing and, after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. Rating actions from which an appeal is not timely perfected become final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. A final decision cannot be reopened unless new and material evidence is presented. 38 U.S.C. § 5108. In general, if new and material evidence is presented or secured with respect to a finally adjudicated claim, VA shall reopen and review the claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means 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 prior 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 new and material evidence has been submitted, the Board must consider the specific reasons for the prior denial. Evans v. Brown, 9 Vet. App 273, 283 (1996); Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). The provisions of 38 C.F.R. § 3.156(a) create a low threshold, with the phrase “raises a reasonable possibility of substantiating the claim” enabling rather than precluding reopening and not constituting a third requirement that must be met before the claim is reopened. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). For establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for diarrhea, also claimed as irritable bowel syndrome (IBS). In an April 2006 rating decision, the RO denied service connection for diarrhea, on the basis that although there was record of treatment in service for watery stool, there was no evidence of permanent residual or chronic disability. The Veteran was notified of the decision in an April 2006 letter, but did not file a timely notice of disagreement; therefore, the decision became final. In November 2007, the Veteran attempted to reopen his claim of entitlement to service connection for diarrhea. In a September 2008 rating decision, the RO denied service connection on the basis that new and material evidence had not been submitted. The RO explained that although additional service treatment records had been received, the records did not show evidence of a chronic disability to account for diarrhea in service. The Veteran was notified of the decision in a September 2008 letter, but did not file a timely notice of disagreement; therefore, the decision became final. In March 2010, the Veteran attempted to reopen his claim of entitlement to service connection for diarrhea. Since the September 2008 rating decision, evidence added to the claims file includes VA treatment records, service personnel records, and VA examination reports. VA treatment records associated with the Veteran’s claims file in April 2015 reflect that in November 1988, the Veteran sought treatment for stomach discomfort and reported a twelve year history chronic gastritis with diarrhea and gas. Here, the Board finds that new and material evidence within the meaning of 38 C.F.R. § 3.156(a) has been received since the last, final September 2008 rating decision. The Veteran has been diagnosed with irritable bowel syndrome. He has provided lay statements that he has had diarrhea on and off since service. The November 1988 report is new and supports the Veteran’s claim of a chronic condition. Thus, new evidence submitted since the RO’s September 2008 rating decision, when considered with the previous evidence of record, relates to unestablished facts (i.e., a chronic disability since service) necessary to substantiate the claim. Therefore, new and material evidence has been received since the RO’s September 2008 decision, and reopening the claim of entitlement to service connection for diarrhea is warranted. The Veteran’s appeal is granted only to this extent. Although the Veteran’s military personnel file was obtained in September 2015, which was after the original claim became final, those records do not relate to the claim. Therefore, the original claim may not be reconsidered pursuant to 3.156(c). See Blubaugh v. McDonald, 773 F.3d 1310, 1314 (Fed. Cir. 2014). 2. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for gastroesophageal reflux disorder (GERD), also claimed as a stomach disability. In an April 2006 rating decision, the RO denied service connection for GERD, on the basis that although there was record of treatment in service for a viral episode/gastroenteritis, there was no evidence of permanent residual or chronic disability. The Veteran was notified of the decision in an April 2006 letter, but did not file a timely notice of disagreement; therefore, the decision became final. In November 2007, the Veteran attempted to reopen his claim of entitlement to service connection for GERD. In a September 2008 rating decision, the RO denied service connection on the basis that new and material evidence had not been submitted. The RO explained that although additional service treatment records had been received showing that the Veteran was diagnosed with peptic ulcer disease in service, there was no evidence that the Veteran’s current GERD was related to service. The Veteran was notified of the decision in a September 2008 letter, but did not file a timely notice of disagreement; therefore, the decision became final. In March 2010, the Veteran attempted to reopen his claim of entitlement to service connection for GERD. Since the September 2008 rating decision, evidence added to the claims file includes VA treatment records, service personnel records, and VA examination reports. Service personnel records received in September 2015 reflect that in September 1983, the Veteran requested a copy of his military records. He reported that he had been to the Miami VAMC on several occasions for consultation for a stomach disorder/ulcer problem. He noted that it appeared his consultation sheets were on file, but that his treatment records had been lost or misfiled. An October 2015 VA examination report reflects that the examiner opined that the Veteran’s GERD was not caused by or incurred in service and that while the Veteran was diagnosed with posttraumatic stress disorder (PTSD), PTSD was not specifically known to be a cause of GERD. However, the examiner also noted that alcohol might be aggravating the Veteran’s GERD symptoms, but was unlikely to cause permanent damage. An October 2015 VA PTSD examination report reflects that the Veteran reported that he consumed alcohol to quell his symptoms of PTSD, help him sleep, calm him, avoid intrusive recollections, and feel more trust for others. The examiner found that the Veteran’s alcohol use disorder appeared secondary to his PTSD, in that the Veteran drank in a misguided attempt to quell his symptoms, such as sleeplessness and irritability. Here, the Board finds that new and material evidence within the meaning of 38 C.F.R. § 3.156(a) has been received since the last, final September 2008 rating decision. The Veteran has been diagnosed with several gastric disabilities post-service, to include peptic ulcer disease, GERD, and hiatal hernia. He has provided lay statements that he sought treatment shortly after service for symptoms that began during service and new records associated with the Veteran’s claim file reflect he sought treatment for a stomach/ulcer condition prior to September 1983. Furthermore, the Veteran is service-connected for PTSD, and new evidence associated with the Veteran’s claims file reflects that his gastric disability may be aggravated by his alcohol disorder secondary to his service-connected PTSD. Thus, new evidence submitted since the RO’s September 2008 rating decision, when considered with the previous evidence of record, relates to unestablished facts (i.e., a chronic disability since service or aggravation of an injury by a service-connected disability) necessary to substantiate the claim. Therefore, new and material evidence has been received since the RO’s September 2008 decision, and reopening the claim of entitlement to service connection for a gastric disability is warranted. The Veteran’s appeal is granted only to this extent. Although the Veteran’s military personnel file was obtained in September 2015, which was after the original claim became final, those records do not relate to the claim. Therefore, the original claim may not be reconsidered pursuant to 3.156(c). See Blubaugh, 773 F.3d at 1314. 3. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a liver disability, to include hepatitis C, cirrhosis, and cancer. In an April 2006 rating decision, the RO denied service connection on the basis that the evidence did not show that the Veteran’s hepatitis C was incurred in or caused by service. The Veteran was notified of the decision in an April 2006 letter, but did not file a timely notice of disagreement; therefore, the decision became final. In March 2010, the Veteran attempted to reopen his claim of entitlement to service connection for hepatitis C. Since the April 2006 rating decision, evidence added to the claims file includes VA treatment records, private treatment records, service personnel records, VA examination reports, and a private opinion. In a private opinion dated in May 2015, a clinician indicated that the Veteran’s risk factors for hepatitis C include inoculations via non-sterile air guns during service, in-service cuts with bruises, and a remote history of intranasal cocaine use, but that studies have shown that transmission of hepatitis C via intranasal cocaine use alone was not a significant risk factor. The clinician explained that use of non-sterile needles is a significant risk factor as hepatitis C is spread through contact with blood and bodily fluids. The clinician noted that while one could not provide a conclusive cause of the Veteran’s hepatitis C, one could also not ignore the Veteran’s in-service risk factors as a cause of his hepatitis C. Thus, based on a review of the Veteran’s claims file, research, and experience, the clinician opined that the Veteran’s hepatitis C was at least as likely as not was the result of risk factors encountered while he was in service. Here, the Board finds that new and material evidence within the meaning of 38 C.F.R. § 3.156(a) has been received since the last, final April 2006 rating decision. The Veteran has been diagnosed with hepatitis C and a private clinician has opined that the Veteran’s hepatitis C was caused by risk factors from the Veteran’s active service. Thus, new evidence submitted since the RO’s April 2006 rating decision, when considered with the previous evidence of record, relates to unestablished facts (i.e., an in-service injury) necessary to substantiate the claim. Therefore, new and material evidence has been received since the RO’s April 2006 decision, and reopening the claim of entitlement to service connection for hepatitis C is warranted. The Veteran’s appeal is granted only to this extent. Although the Veteran’s military personnel file was obtained in September 2015, which was after the original claim became final, those records do not relate to the claim. Therefore, the original claim may not be reconsidered pursuant to 3.156(c). See Blubaugh, 773 F.3d at 1314. REASONS FOR REMAND 1. Entitlement to service connection for an intestinal disability, claimed as diarrhea and irritable bowel disease (IBS), is remanded. The Board finds that a remand is warranted so that a new VA examination and medical opinion can be obtained as to the nature and etiology of any diagnosed intestinal disability, to include diarrhea and IBS. The Veteran contends that service connection is warranted for diarrhea and IBS. Specifically, he contends that his diarrhea, bloating, and constipation began during service and has continued since. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for an intestinal disability. Service treatment records reflect that the Veteran sought treatment in December 1968, April 1969, and January 1970 for intestinal complaints, to include diarrhea. On his May 1970 separation examination, the Veteran indicated that he had had piles or rectal disease, and the examiner noted that he had been treated for piles in service. A May 2012 VA examination report reflects a diagnosis of remote intestinal infection in 1970, with the Veteran reporting bloating, mild anal leakage, and alternating constipation and diarrhea since that time. The examiner noted that the Veteran had an acute intestinal infection in service that resolved with treatment and a notation of bloating. The examiner opined that there was no known current intestinal infection due to service or as residuals from service. Rather, the examiner opined that the Veteran’s bloating, diarrhea, and nausea were as least as likely as not due to his chronic hepatitis C, obesity, and sedentary lifestyle, with no evidence of any other underlying condition. In a September 2012 addendum opinion, the examiner clarified that the 1970 gastrointestinal infection was acute and there was no indication that an acute infection caused or aggravated the Veteran’s current diarrhea or constipation, nor that an uncomplicated gastrointestinal infection would cause lifelong diarrhea and constipation. The Board finds the May and September 2012 opinion inadequate. It is not clear whether the examiner considered the Veteran’s diagnosed IBS and while the examiner considered the Veteran’s report of diarrhea in 1970, it is not clear that the examiner considered reports of gastroenteritis in December 1968 and enterocolitis, with diarrhea and abdominal cramps, in April 1969. An October 2015 VA examination report reflects that the Veteran was diagnosed with IBS several years prior, but that he reported bloating and diarrhea in service and on and off since service. The examiner noted the Veteran was seen for a couple of viral stomach-flu type illnesses during service, with some vague abdominal complaints in 1970 which apparently resolved at the time of discharge in May 1970, as Veteran denied any intestinal or stomach problems. The examiner opined that it was unlikely that the Veteran’s more recent onset of IBS symptoms would be related to an apparently self-limited gastrointestinal illness in 1970, and that the documentation did not suggest that there was an ongoing chronic condition. The Board also finds the October 2015 examiner’s opinion inadequate. While the examiner indicated that the Veteran’s abdominal complaints in 1970 had resolved at the time of discharge, it is not clear whether the examiner considered the Veteran’s report of piles or rectal disease on his May 1970 separation examination or his testimony that his symptoms never went away after service. See DRO Hr’g Tr. 7. Therefore, the Board finds that a remand is warranted so that a new VA examination and medical opinion can be obtained as to the nature and etiology of any diagnosed intestinal disability, to include diarrhea and IBS. Finally, because a decision on the remanded issue of entitlement to service connection for hepatitis could significantly impact a decision on the issue of entitlement to service connection for diarrhea, the issues are inextricably intertwined. A remand of the claim for entitelment to service connection for diarrhea is required. 2. Entitlement to service connection for a gastric disability, to include gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), and hiatal hernia, also claimed as a stomach disability, is remanded. The Board finds that a remand is warranted so that an adequate VA opinion can be obtained as to the nature and etiology of any diagnosed gastric disability, to include GERD, PUD, and hiatal hernia, or whether the Veteran’s gastric disorder is caused or aggravated by his alcohol use disorder associated with his PTSD. The Veteran contends that service connection is warranted for a gastric disability. Specifically, he contends that his heartburn symptoms began during service and continued since then. (Conversely, he testified at his DRO hearing that his symptoms shortly after service and have continued since then. See DRO Hr’g Tr. 7, 9.) He further contends that exposure to a tropical disease or herbicide agents may have caused his gastric disability. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a gastric disability. The Veteran’s service treatment records are silent for complaints of or treatment for a gastric disability, although an April 1969 service treatment record noted abdominal cramps. Post-service treatment records reflect that in October 1984, the Veteran reported heartburn for 15 years, and he was diagnosed with PUD. In November 1988, the Veteran reported a 12 year history of chronic gastritis with abdominal pain and heartburn. In a March 2008 statement, the Veteran indicated that he checked piles or rectal disease on his May 1970 separation examination, but that he had not had either, and that checking that box was his attempt to explain his diarrhea, stomach, and intestinal flare-ups during service. A May 2012 VA examination report reflects that the Veteran reported heartburn symptoms beginning in service, with treatment by donnitol in 1971 for the same symptoms. While the examiner noted diagnoses of GERD in 1971 and hiatal hernia in 2005, the examiner found that the Veteran’s service treatment records were silent for a diagnosis and opined that the Veteran’s GERD with hiatal hernia were not at least as likely as not due to or contributed to by service. Service personnel records received in September 2015 reflect that in September 1983, the Veteran requested a copy of his military records. He reported that he had been to the Miami VAMC on several occasions for a consultation for a stomach disorder/ulcer problem. He noted that it appeared his consultation sheets were on file, but that his treatment records had been lost or misfiled. An October 2015 VA examination report reflects that the examiner found two brief episodes of flu-like symptoms and a report of vague abdominal discomfort in service, but that the May 1970 discharge examination was silent for stomach or intestinal complaints, leading to the conclusion that any in-service complaints had resolved. The examiner noted that in the 1980s, the Veteran reported a long history of chronic gastritis and GERD, although no actual heartburn or GERD symptoms were found in his service treatment records. The examiner noted the Veteran had an apparent history of peptic ulcer disease between discharge and 1984, but there were no records for that timeframe. The examiner explained that risk factors for GERD include obesity and hiatal hernia, which the Veteran was found to have by endoscopy. Furthermore, while the Veteran had been diagnosed with PTSD, PTSD was not specifically known to be a cause of GERD. Therefore, the examiner opined that the Veteran’s GERD was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. However, the examiner noted that alcohol might be aggravating the Veteran’s GERD symptoms, but was unlikely to cause permanent damage. The Board finds the May 2012 and October 2015 examiner’s opinions inadequate, as the absence of a diagnosis in service is not an appropriate rationale. Further, neither examiner appeared to consider the Veteran’s statement pertaining to his report of piles or rectal disease in service as evidence of stomach flare-ups during service. It does not appear that the October 2015 examiner considered the October 1983 record in which the Veteran reported seeking treatment for his gastric disability, and neither the May 2012 or October 2015 provided an opinion as to whether the Veteran’s gastric disability is proximately due to his herbicide agent exposure. The Board notes that the Veteran is service-connected for PTSD and an October 2015 VA PTSD examination report reflects that the examiner found that the Veteran’s alcohol use disorder appeared secondary to his PTSD, in that the Veteran drank in a misguided attempt to quell his symptoms, such as sleeplessness and irritability. The October 2015 gastric VA examiner opined that the Veteran’s alcohol use might be aggravating his gastric disability. Speculative language such as “might” does not create an adequate nexus for the purposes of establishing service connection, but is sufficient to indicate a secondary nexus. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). The Board finds that a remand is warranted so that an adequate VA opinion can be obtained as to the nature and etiology of any diagnosed gastric disability, to include GERD, PUD, and hiatal hernia, or whether the Veteran’s gastric disorder is caused or aggravated by his alcohol use disorder associated with his PTSD. 3. Entitlement to service connection for a liver disability, to include hepatitis C, cirrhosis, and cancer is remanded. The Board finds that a remand is warranted so that an adequate VA examination and medical opinion can be obtained as to the nature and etiology of any diagnosed liver disability, to include hepatitis C, cirrhosis, and liver cancer, and whether any diagnosed condition is caused by or aggravated by his PTSD and alcohol use. The Veteran contends that service connection is warranted for hepatitis C. Specifically, he contends that he had no significant risk factors for contracting hepatitis C other than those which occurred during service, to include air gun immunizations and cuts and bruises while in service. In a May 2012 VA examination report, the examiner opined that the risk related to air gun immunizations in transmitting hepatitis C was remote and improbable, and that contracting hepatitis C from lacerations on old, dirty shrapnel was even less likely. In a private opinion dated in May 2015, a clinician opined that based on a review of the Veteran’s claims file, research, and experience, that the Veteran’s hepatitis C was at least as likely as not was the result of risk factors encountered while he was in service, to include air-gun immunizations and cuts and bruises, and unlikely that his hepatitis C was transmitted via intranasal cocaine use. The clinician further opined that alcohol use could aggravate hepatitis C, but then attributed the Veteran’s cirrhosis and liver cancer to both his hepatitis C and alcohol use. An October 2015 VA examiner opined that while transmission via air gun immunizations was within the realm of possibility, there was a lack of scientific evidence to document transmission of hepatitis C actually having occurred through air gun immunizations. Rather, the Veteran’s main risk factor for hepatitis C was repeated post-service intranasal cocaine use. The examiner further indicated that PTSD and the use of alcohol were not known risk factors for hepatitis C. While the October 2015 VA examiner indicated that PTSD and alcohol use were not a risk factor for hepatitis C, the examiner did not indicate whether the Veteran’s PTSD and alcohol use disorder aggravated the Veteran’s hepatitis C or caused or aggravated his cirrhosis or liver cancer. The October 2015 private clinician indicated that the Veteran’s liver cirrhosis and cancer were related to his hepatitis C, but then conversely linked the onset of his liver cirrhosis and cancer to his alcohol use. In light of the absence of an adequate opinion, the Board finds that a remand is warranted so that an adequate VA examination and medical opinion can be obtained as to the nature and etiology of any diagnosed liver disability, to include hepatitis C, cirrhosis, and liver cancer, and whether any diagnosed condition is caused by or aggravated by his PTSD and alcohol use. 4. Whether new and material evidence has been received to reopen claims of entitlement to service connection for sleep disturbances due to bloating is remanded. Finally, with respect to reopening the claim of entitlement to service connection for sleep disturbances due to bloating, this claim was denied by the RO in a September 2008 rating decision, on the basis that the evidence did not show sleep disturbances in service. The Veteran was notified of the decision in a September 2008 letter, but did not file a notice of disagreement; therefore, the decision became final and the claim cannot be reopened unless new and material evidence is received. The Board notes that the Veteran is service-connected for PTSD, and sleep disturbances due to his PTSD have been included under the criteria for his rating. The Veteran contends that he has trouble sleeping due to his gastric disability and bloating. A May 2012 VA examiner opined that the Veteran’s bloating, diarrhea, and nausea were as least as likely as not due to his chronic hepatitis, obesity, and sedentary lifestyle, with no evidence of any other underlying condition. Because a decision on the remanded issues of entitlement to service connection for hepatitis C and a gastric disability, to include GERD, PUD, and hiatal hernia, could significantly impact a decision on the issues of whether new and material evidence has been received to reopen a claim of entitlement to service connection for sleep disturbances due to a gastric disability and bloating, the issues are inextricably intertwined. A remand of the claim for whether new and material evidence has been received to reopen claim of entitlement to service connection for sleep disturbances due to a gastric disability and bloating is required. Although the Veteran was notified previously of the type of evidence that is needed to reopen the claims, to date, he has not submitted any evidence that would provide a basis to reopen the claims. Therefore, the Veteran is advised again to submit new and material evidence if he wants to have these previously denied claims reopened. The matters are REMANDED for the following actions: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diagnosed intestinal disability, to include diarrhea and IBS. The examiner must opine whether any diagnosed intestinal disability at least as likely as not (1) is related to or began during active service, to include treatment for intestinal complaints in December 1968, April 1969, and January 1970, or report of piles or rectal disease on the Veteran’s May 1970 separation examination, with consideration of the Veteran’s statement that he may have been exposed to a tropical disease during service and was exposed to Agent Orange, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. If the examiner finds that any diagnosed intestinal disability was not incurred in or otherwise related to service, and if the Veteran is service-connected for hepatitis C, the examiner must opine as to whether any diagnosed intestinal disability is at least as likely as not (1) proximately due to a different disability, to include hepatitis C, or (2) aggravated beyond its natural progression by a different disability. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any gastric disability, to include GERD, PUD, and hiatal hernia. The examiner must opine whether any diagnosed gastric disability at least as likely as not (1) is related to or began during active service, to include on the basis of the Veteran’s lay statements concerning onset of his gastric disability, exposure to a tropical disease in Vietnam, or Agent Orange exposure, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. If the examiner finds that any diagnosed gastric disability was not incurred in or otherwise related to service, to include herbicide agent exposure, the examiner must opine whether any diagnosed gastric disability is at least as likely as not (1) proximately due to service-connected disability, to include PTSD and alcohol use disorder, or (2) aggravated beyond its natural progression by service-connected disability. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diagnosed liver disability, to include hepatitis C, cirrhosis, and liver cancer. The examiner must opine (1) whether any diagnosed liver disability, to include cirrhosis or liver cancer, is at least as likely as not proximately due to a different disability, to include PTSD and alcohol use disorder, or (2) whether any diagnosed liver disability, to include hepatitis C, cirrhosis, or liver cancer, was aggravated beyond its natural progression by a different disability, to include PTSD and alcohol use disorder. C. BOSELY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Owen, Associate Counsel