Citation Nr: 18145200 Decision Date: 10/26/18 Archive Date: 10/26/18 DOCKET NO. 15-30 666 DATE: October 26, 2018 ORDER The petition to reopen the previously denied claim of entitlement to service connection for alcohol abuse disorder is granted, to this extent only. The petition to reopen the previously denied claim of entitlement to service connection for cocaine and cannabis abuse disorder is granted, to this extent only. The petition to reopen the previously denied claim of entitlement to service connection for right foot disability to include blisters with toenail issues and bunions, status post-bunionectomy, is denied. Service connection for nerve disorder of the right foot, including peroneal mononeuropathy, is denied.   REMANDED Entitlement to a rating in excess of 50 for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for bilateral hearing loss, to include as secondary to service-connected TBI, is remanded. Entitlement to service connection for gastroesophageal reflux disorder (GERD), to include as secondary to service-connected PTSD, is remanded. Entitlement to service connection for alcohol abuse disorder is remanded. Entitlement to service connection for cocaine and cannabis abuse disorder is remanded. Entitlement to a compensable rating for traumatic brain injury (TBI) residuals, to include migraines headaches, vision disorder, and seizure disorder, bilateral hearing loss, and cognitive disorder, is remanded. Entitlement to service connection for a back disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. An unappealed March 2011 rating decision denied service connection for alcohol abuse disorder; new and material evidence was not received prior to expiration of the appeal period; subsequently received evidence includes evidence that is not cumulative or redundant and relates to an unestablished fact necessary to reopen the claim. 2. An unappealed September 2011 rating decision denied service connection for cocaine and cannabis abuse disorder; new and material evidence was not received prior to expiration of the appeal period; subsequently received evidence includes evidence that is not cumulative or redundant and relates to an unestablished fact necessary to reopen the claim 3. An unappealed August 2012 rating decision denied service connection for right foot disability to include blisters with toenail issues and bunions, status post-bunionectomy; new and material evidence was not received prior to expiration of the appeal period; subsequently received evidence includes evidence that is cumulative or redundant and does not relate to an unestablished fact necessary to reopen the claim. 4. The Veteran’s peroneal mononeuropathy, right foot, preexisted service entry and was not as likely as not aggravated beyond normal progression during active service. CONCLUSIONS OF LAW 1. . The March 2011 rating decision denying the claim for service connection for alcohol abuse disorder is final; and new and material evidence has been received to reopen the claim. 38 U.S.C. §§ 5103, 5103A, 5108, 7105(c); 38 C.F.R. §§ 3.102, 3.156(a), 20.1103. 2. The September 2011 rating decision denying the claim for service connection for cocaine and cannabis abuse disorder is final; and new and material evidence has been received to reopen the claim. 38 U.S.C. §§ 5103, 5103A, 5108, 7105(c); 38 C.F.R. §§ 3.102, 3.156(a), 20.1103. 3. The August 2012 rating decision denying the claim for service connection right foot disability to include blisters with toenail issues and bunions, status post-bunionectomy, is final; and new and material evidence has not been received to reopen the claim. 38 U.S.C. §§ 5103, 5103A, 5108, 7105(c); 38 C.F.R. §§ 3.102, 3.156(a), 20.1103. 4. The criteria for service connection for nerve disorder of the right foot, including peroneal mononeuropathy, are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.306(a), (b). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 2008 to May 2010. The issues of entitlement to service connection for TBI and entitlement to TDIU were previously remanded by the Board in May 2017. In the April 2018 statement, the Veteran’s representative also submitted additional information to be added to his claims file. In the same correspondence, the Veteran’s representative submitted a waiver of consideration by the Agency of Original Jurisdiction (AOD) of said evidence. Service Connection Compensation may be awarded for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131. Service connection basically means that the facts, shown by evidence, establish that an injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in- service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a), (d). For explicitly recognized chronic diseases (38 C.F.R. § 3.309(a)), service incurrence or aggravation may be established under 38 C.F.R. § 3.303(b) by demonstrating continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For arthritis, the disability is considered to have been incurred in or aggravated by service although not otherwise established during the period of service if manifested to a compensable degree within one year following service in a period service. 38 U.S.C. §§ 1101, 1131; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). A claim that has been denied in an unappealed Regional Office (RO) decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which “does not require new and material evidence as to each previously unproven element of a claim.” Shade v. Shinseki, 24 Vet. App. 110 (2010). In establishing whether new and material evidence has been submitted, the credibility of evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Regardless of whether the RO found that new and material evidence had been submitted to reopen a claim for service connection, it is well established that the Board must determine on its own whether new and material evidence has been submitted to reopen a claim. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). 1. Alcohol Abuse Disorder The Veteran has claimed entitlement to service connection for alcohol abuse disorder. This claim was previously denied in a March 2011 rating decision because the evidence showed that alcohol abuse disorder was not related to active service, or any incidents therein. The AOJ reasoned that the disorder was willful misconduct on part of the Veteran’s. The Board concludes that the March 2011 rating decision is final because VA received no appeal or new and material evidence prior to expiration of the appeal period. The Board further concludes that subsequently received evidence includes evidence that is not cumulative or redundant and relates to an unestablished fact necessary to reopen the claim. The evidence received since the March 2011 rating decision includes VA and private medical treatment records. The evidence also includes treatment notes from mental health group counseling, which speak about the link between substance abuse and PTSD. See VA treatment records, October 21, 2013. The presented evidence speaks directly to an element which was not of record, mainly the etiology of the Veteran’s alcohol abuse disorder. See Kent v. Nicholson, 20 Vet. App. 1, 10 (2006) (finding that “the question of what constitutes material evidence to reopen a claim for service connection depends on the basis on which the prior claim was denied”). Therefore, presumed credible, new and material evidence has been received. Accordingly, the petition to reopen is granted.   2. Cocaine and Cannabis Abuse Disorder The Veteran has claimed entitlement to service connection for cocaine and cannabis abuse disorder. This claim was previously denied in a September 2011 rating decision because was the evidence showed that the disorder was not related to his active service, or any incidents therein. The AOJ also reasoned that the disorder was willful misconduct on part of the Veteran’s. The Board concludes that the September 2011 rating decision is final because VA received no appeal or new and material evidence prior to expiration of the appeal period. The Board further concludes that subsequently received evidence includes evidence that is not cumulative or redundant and relates to an unestablished fact necessary to reopen the claim. The evidence received since the September 2011 rating decision, which is the last final denial, includes VA and private medical treatment records. The evidence also includes treatment notes from mental health group counseling, which speak about the link between substance abuse and PTSD. See VA treatment records, October 21, 2013. The presented evidence speaks directly to an element which was not of record, mainly the etiology of the Veteran’s cocaine and cannabis abuse disorder. See Kent v. Nicholson, 20 Vet. App. 1, 10 (2006) (finding that “the question of what constitutes material evidence to reopen a claim for service connection depends on the basis on which the prior claim was denied”). Therefore, presumed credible, new and material evidence has been received to reopen the claim. Accordingly, the petition to reopen is granted. 3. Right Foot Disability The Veteran seeks service connection for right foot disability claimed blisters with toenail issues, and bunions, status post-bunionectomy. The Board concludes that an August 2012 rating decision that denied service connection for right foot disability is final. 38 U.S.C. §§ In this regard, the Board (b), (c); 38 C.F.R. § observes that a right foot claim was denied in an August 2012 rating decision. The RO notified the Veteran of that decision and how to appeal in an August 2012 letter. VA received no appeal or new and material evidence prior to expiration of the appeal period. Therefore, the decision became final. 38 U.S.C. §§ 7105(b), (c); 38 C.F.R. §§ 3.160(d), 20.201, 20.302, 20.1103. The Board further concludes new and material evidence has not been presented to reopen the claim as the subsequently received evidence includes evidence that is cumulative or redundant and does not relate to an unestablished fact necessary to reopen the claim. 38 U.S.C. § 5108, 38 C.F.R. § 3.156(a). The claim was previously denied because, although there was a current diagnosis of bunions, these were not related to in-service treatment for blisters and toenail problems per a July 2012 VA examination report, which noted that they are two separate diagnosis and treatment does not cause bunions. The recent evidentiary submissions do not cure any prior evidentiary defect. Competent evidence linking the previously denied disorders to service has not been presented. To the extent that the Veteran asserts he has a disability that began in or is related to service, this is not new evidence. Hence, new and material evidence has not been received to reopen the previously denied right foot claim. Accordingly, the petition to reopen is denied. 4. Peroneal Mononeuropathy, Right Foot The Veteran asserts that his peroneal mononeuropathy, right foot, is related to his active service. The question for the Board is whether the Veteran has a current diagnosis of a right foot disorder that either began during active service, or is etiologically related to an in-service disease or injury. The Board concludes that the Veteran had peroneal mononeuropathy on service entrance examination in January 2008 and, therefore, the presumption of soundness does not apply as preexisting disorder is shown. The Board further concludes that nerve disorder of the right foot claimed is not at least as likely as not aggravated (non-temporary increase in severity) beyond normal progression by service. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.306(a), (b). A Veteran is presumed to have been sound upon entry into the military, except as to conditions noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111 (emphasis added). In this case, a right foot disorder is documented in the Veteran’s enlistment examination and, therefore, it a pre-existing condition. See STRs, February 2008. In deciding a claim based on aggravation, after having determined the presence of a preexisting condition, the Board must first determine whether there has been any measured worsening of the disability during service, and then whether this constitutes an increase, permanent in nature, in the disability. Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). Aggravation may not be conceded where the disability underwent no increase in severity during service, on the basis of all the medical evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306 (b). A letter dated January 2008 from the US Department of Health and Human Services, Indian Health Service, from Dr. PW reflects that the Veteran had a right ankle injury in late 2005 from running, diagnosed as traumatic right peroneal mononeuropathy, which was surgically repaired in 2006. He had physical therapy and obtained complete function of his right ankle and foot. The right ankle and foot were described as normal. STRs show that the Veteran reported on service entrance examination dated February 2008 that he had a right ankle injury in 2005, which resulted in right foot traumatic peroneal mononeuropathy, and had surgical repair with excellent results in 2006. The nerve damage was noted to have been repaired. The Veteran was noted to have has excellent recovery, not to have a disability, and was cleared for service by a January 8, 2008 letter. See STRs. Here, the Board notes that the Veteran did not undergo a separation examination, as he was incarcerated at the time of his separation. A January 8, 2008 letter from Department of Health and Human Services, Indian Health Service, noted that the Veteran underwent surgery in September 2006, underwent some physical therapy, and seemed to have recovered complete function of his right ankle and foot. The physician stated that he considered the Veteran to have an essentially normal right foot and ankle. See STRs. The Veteran underwent a VA medical examination in October 2010. See VA examination, October 2010. The Veteran reported no aggravation of the right foot disorder during active service. Right ankle dorsiflexion was limited to 5 degrees and right ankle plantar flexion was normal (same as left side). The Veteran related that his peroneal mononeuropathy problem was reported before service, and he did not aggravate this problem in service. The available STRs reflect no right foot nerve complaints or abnormal findings. The Veteran was discharged from active duty in May 2010. A January 2012 VA physical therapy consultation note reflects that the Veteran reported to the physical therapist that he experienced no change (the Veteran reported neither improvement nor worsening/progression in the nerve condition) since the initial improvement he had experienced for about 12-18 months after the 2006 surgery to the physical therapist. The treatment lasted for 15 minutes, and was told to perform some strengthening exercises at home. The therapist deemed that no return visit will be scheduled. See VA treatment records, January 10, 2012. Private treatment records reflect no complaints or findings for abnormal right foot, peroneal nerve. A December 2013 VA medical opinion reflects that the Veteran’s right common peroneal nerve injury existed prior to his enlistment, and was not aggravated beyond its natural progression in active service. The examiner stated that the 2008 enlistment examination showed with clear and unmistakable evidence that the Veteran had been surgically treated for a right common peroneal nerve injury prior to enlistment. The Veteran’s surgery was completed in September 2006, and he received medical clearance to enlist in January 2008. No complaints of foot drop/right foot condition or other active musculoskeletal complaints when he began medical care at VA in September 2010. The examiner noted that at the October 2010 examination, the Veteran reported no aggravation of the right foot disorder during active service, the examiner added that during the 2010 examination, right ankle dorsiflexion was limited to 5 degrees and right ankle plantar flexion was normal (same as left side), and that it was the same for the current examination. The physical examination report showed that the Veteran experienced decreased muscle strength (3/5) on dorsiflexion in the right ankle, had mild numbness in the right lower extremity, and had decreased skin sensation along the distribution of the right common peroneal nerve distal to right knee and along margins of surgical scar. The Veteran’s gait did not appear normal, as it was “somewhat forced in less than genuine with trace right foot drop.” The examiner diagnosed mild incomplete paralysis of the right external popliteal nerve. The examiner stated that, since his surgery, he experienced persistent symptoms of numbness to light touch along the area of right lateral lower leg scar (from peroneal surgery) which extended distally into the right lateral ankle and right lateral foot area, but that these have not worsened. There were no complaints of ongoing issues due to a right peroneal nerve condition and no medical evaluation was sought by Veteran for any right foot condition due to a right peroneal injury until he was seen for evaluation by physical therapy in January 2012. The examiner added that the Veteran reported no change (the Veteran reported neither improvement nor worsening/progression in the nerve condition) since the initial improvement he had experienced for about 12-18 months after the 2006 surgery to the physical therapist. The Board finds in this case that the Veteran’s pre-existing right foot disorder did not undergo an increase in severity during service. The December 2013 VA medical opinion reflects that the pre-existing right foot disorder was not aggravated during service beyond the normal progression of the disease, which is consistent with the Veteran’s account of his symptoms before, during, and after service, as well as with the clinical treatment records showing only complaints of right foot pain after service in January 2012. The Board accepts that the Veteran is competent to report his symptoms, including worsening symptoms. However, to the extent that he reports his condition was aggravated during active service, the Board finds that the assertion is not persuasive given (1) the history and medical findings shown on VA examination in October 2010 and December 2013, which are negative for aggravation, and (2) the many years intervening service and the Veteran’s first documented complaints of right foot nerve problems. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Veteran’s statements have diminished probative value. The Board assigns greater probative value to the December 2013 VA medical opinion as it was prepared by a skilled, neutral medical professional after examining the Veteran and reviewing the record. Also, it is supported by a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The Veteran has not presented a favorable medical opinion to weigh in this matter. The Veteran does not assert, and the evidence of record does not suggest, that he had continuous right foot disorder symptoms since his separation from service. In any event, continuity of symptoms is only for consideration in regard to disorders recognized as “chronic” under 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Peroneal mononeuropathy is not a chronic disorder in 38 C.F.R. § 3.309 (a), so considerations of chronicity do not apply. On balance, the evidence is against the claim. Accordingly, the claim is denied. There is no doubt to resolve. 38 U.S.C. § 5107(b). REASONS FOR REMAND To ensure that VA has met its duty to assist, the following claims are remanded for additional development: Entitlement to a rating in excess of 50 for posttraumatic stress disorder (PTSD); entitlement to service connection for bilateral hearing loss, to include as secondary to service-connected TBI; entitlement to service connection for GERD, to include as secondary to service-connected PTSD; entitlement to service connection for alcohol and drug (cocaine and cannabis) abuse disorder; entitlement to a compensable rating for TBI residuals, to include migraines headaches, vision disorder, and seizure disorder, bilateral hearing loss, and cognitive disorder; entitlement to service connection for a back disorder; and entitlement to TDIU. 1. TBI The Veteran asserts that his service-connected TBI is worse than currently evaluated. Service connection for TBI was granted in an April 2017 rating decision. See rating decision, April 2017. Specifically, the Veteran’s attorney contends that the Veteran experiences myriad of TBI residuals. The Veteran underwent a VA TBI examination in February 2017. See VA examination, February 2017. The Veteran’s attorney contends that the examiner stated that the Veteran experienced one TBI, while in fact the Veteran experienced multiple separate TBIs between September 2008 and September 2009. Specifically, the Veteran asserts that he experiences a headache disorder, a vision disorder, a seizure disorder, and a cognitive disorder associated with his TBI. The attorney also argues that the examiner incorrectly stated that the TBI residuals Veteran experienced have resolved, and that the Veteran had neither TBI symptoms nor residuals. The attorney also stated that the examiner did not discuss “deficits in attention and processing speed and executive function” noted on neurocognitive testing performed in November 2016. Once VA undertakes the effort to provide an examination, even if not statutorily obligated to do so, VA must provide an adequate one or notify the claimant when one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, an addendum must be obtained from the February 2017 examiner to address the aforementioned issues. 2. Back Disorder The Veteran asserts that his back disorder is due to his active service. The Veteran’s post-service medical treatment records show that the Veteran has diagnoses of degenerative disc disease, spinal canal stenosis, and mild spinal degenerative disc disease. See VA treatment records, attached to attorney statement, April 2018. Because the Veteran has stated that he experienced back issues nine months after he left active service, his mother describing her observations of his back pain, his combat service, and currently-diagnosed back issues, a VA examination is warranted to specifically address the nature and etiology of his back disorder. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A(d) (an examination or medical opinion is warranted when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability; the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim).   3. Bilateral Hearing Loss The Veteran asserts that he experiences hearing loss, or hearing issues, as a result of active service, to include as due to his service-connected TBI. The Board acknowledges that the Veteran was deemed not to experience hearing loss for VA purposes (see 38 C.F.R. § 3.385). See VA examination, October 2014. However, the Veteran asserts that he does not necessarily experience hearing loss for VA purposes, but rather that he has a hearing impairment as a result of his service-connected TBI. The October 2014 VA examiner did not opine as to any hearing issues, outside of hearing loss for VA purposes, that the Veteran asserts he experiences, or on the etiology of said issues (if any are found to be present). Once VA undertakes the effort to provide an examination, even if not statutorily obligated to do so, VA must provide an adequate one or notify the claimant when one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, a new VA examination is warranted to specifically address the nature and etiology of his bilateral hearing loss, to include its relationship to the service-connected TBI. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A(d) (an examination or medical opinion is warranted when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability; the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim). 4. GERD The Veteran asserts that he experiences GERD as a result of active service, to include as due to his service-connected PTSD. In an April 2018 statement, the Veteran’s attorney stated that the Veteran’s GERD is secondary to stress, anxiety, depression, and/or PTSD, or was aggravated by his stress, anxiety, depression, and/or PTSD. See Attorney statement, April 2018. Also in April 2018, the Veteran’s attorney submitted a medical article titled “The Association Between Reflux Esophagitis and Psychosocial Stress.” See Attorney submission, April 2018. The Veteran underwent a VA GERD examination in June 2017. See VA examination, June 2017. The examiner did not discuss whether the symptoms or treatment of the Veteran’s service-connected conditions caused or aggravated the Veteran’s GERD. Once VA undertakes the effort to provide an examination, even if not statutorily obligated to do so, VA must provide an adequate one or notify the claimant when one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303 (2007). As such, an addendum must be obtained from the June 2017 examiner to consider the additional theories of GERD etiology. 5. PTSD; Alcohol Abuse Disorder; and Cocaine and Cannabis Abuse Disorder The Veteran asserts that he experiences alcohol abuse disorder and cocaine and cannabis abuse disorder (substance abuse disorder) that are the result of his active service, to include as secondary to his service-connected PTSD and/or TBI. The claim for increase for PTSD is inextricably intertwined with the claims for alcohol and drug abuse. The evidence of record includes treatment notes from mental health group counseling, which speak about the link between substance abuse and PTSD. See VA treatment records, October 21, 2013. The May 2015 VA examiner stated that the Veteran’s alcohol use disorder preceded his active service. The examiner also stated that the Veteran’s cannabis abuse disorder was not secondary to his PTSD. See VA examination, May 2015. The examiner did not opine as to the issue of aggravation, or as to the issue of cocaine abuse disorder. The Board finds that, based on the Veteran’s medical treatment records and VA examinations, it is unclear whether the Veteran’s substance abuse disorder is indicative of a separate disorder or are manifestations and/or symptoms of his service-connected PTSD and/or service-connected TBI. In addition, the Veteran’s attorney has argued that the Veteran’s substance abuse disorders, PTSD, and TBI residuals “must all be attributed to each other and used to assess the level of impairment from his service connected mental condition.” See attorney statement, December 17, 2015. Once VA undertakes the effort to provide an examination, even if not statutorily obligated to do so, VA must provide an adequate one or notify the claimant when one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, the Veteran should be scheduled for a new VA examination to determine the nature and etiology of any existing substance abuse disorders. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 6. TDIU The issue of entitlement to TDIU is inextricably intertwined with the other issues currently remanded. Therefore, consideration is deferred. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Obtain the Veteran’s complete VA treatment records to include those records dated since December 2017. 2. Ask the Veteran to complete a VA Form 21-4142 for any medical providers that treated his claimed disorders. Make two requests for the authorized records from those persons/places identified, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an appropriate VA examination to determine the etiology of his substance abuse disorders. A complete and detailed rationale should be given for all opinions and conclusions expressed. The examiner should review the claims file and provide an opinion clarifying the following: (a.) Opine whether it is as likely as not (50 percent or greater probability) that the Veteran’s alcohol abuse disorder began during active service. (b.) Opine whether it is as likely as not (50 percent or greater probability) that the Veteran’s cocaine and cannabis abuse disorder began during active service. (c.) Opine whether it is as likely as not (50 percent or greater probability) that the Veteran’s alcohol abuse disorder is due to his service-connected PTSD or TBI. (d.) Opine whether it is as likely as not (50 percent or greater probability) that the Veteran’s cocaine and cannabis abuse disorder is due to his service-connected PTSD or TBI. (e.) Opine whether the alcohol abuse disorder is a symptom of his service-connected PTSD, or a separate disorder. (f.) Opine whether the cocaine and cannabis abuse disorder is a symptom of his service-connected PTSD, or a separate disorder. (g.) Opine if there is clear and unmistakable evidence (i.e., obvious, manifest, undebatable evidence) demonstrating that the Veteran’s alcohol abuse disorder existed prior to his entry into active duty. (h.) Opine if there is clear and unmistakable evidence (i.e., obvious, manifest, undebatable evidence) demonstrating that the Veteran’s cocaine and cannabis disorder existed prior to his entry into active duty. (i.) Is there clear and unmistakable evidence (i.e., obvious, manifest, undebatable evidence) demonstrating that the Veteran’s alcohol abuse disorder was NOT aggravated (the underlying disability was NOT increased in severity) beyond its normal progression during the Veteran’s active service, as based on sound medical principles? Temporary or intermittent flare-ups of a pre-service condition, without evidence of worsening of the underlying condition, are not sufficient to be considered aggravation. (j.) Is there clear and unmistakable evidence (i.e., obvious, manifest, undebatable evidence) demonstrating that the Veteran’s cocaine and cannabis abuse disorder was NOT aggravated (the underlying disability was NOT increased in severity) beyond its normal progression during the Veteran’s active service, as based on sound medical principles? Temporary or intermittent flare-ups of a pre-service condition, without evidence of worsening of the underlying condition, are not sufficient to be considered aggravation. (k.) Specifically consider the conflicting opinions concerning the etiology of the Veteran’s substance abuse disorders. 4. Schedule the Veteran for an appropriate VA examination to determine the etiology of his bilateral hearing loss. A complete and detailed rationale should be given for all opinions and conclusions expressed. The examiner should review the claims file and provide an opinion clarifying the following: (a.) Opine whether it is least as likely as not (a 50 percent or greater probability) that the Veteran’s bilateral hearing disorder is related to his active service, to include his service-connected TBI. Discuss the Veteran’s assertions that he experienced continuity of symptomatology since active service. (b.) Obtain a detailed clinical history from the Veteran and provide a thorough account and analysis of the manner in which the Veteran’s bilateral hearing disorder affects him in his everyday life, including the impact that it has on his ability to secure and follow a substantially gainful occupation. 5. Return the file to the examiner who conducted the June 2017 VA GERD examination for an addendum opinion, if available. The examiner must review the claims file and note that review in the examination report. The examiner must provide the rationale for all opinions expressed. If medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. If the examiner is unable to provide the required opinions, the examiner should explain why that is. The examiner should address the following questions: (a.) Opine as to whether the Veteran’s GERD is at least as likely as not (50 percent or greater probability) aggravated (chronically worsened) by his service-connected PTSD, or symptoms of PTSD, to include stress, anxiety, depression. Here, the examiner must specifically consider the medical article submitted by the Veteran’s attorney, “The Association Between Reflux Esophagitis and Psychosocial Stress.” (b.) If aggravation is found, the physician should address the following medical issues to the extent possible: i. The baseline manifestations of the Veteran’s GERD found prior to aggravation; and ii. The increased manifestations which, in the examiner’s opinion, are proximately due to the service-connected PTSD. 6. Return the file to the examiner who conducted the February 2017 VA TBI examination for an addendum opinion, if available. The Veteran should be scheduled for another VA examination, if deemed necessary. The examiner must review the claims file and note that review in the examination report. The examiner must provide the rationale for all opinions expressed. If medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. If the examiner is unable to provide the required opinions, the examiner should explain why that is. The examiner should address the following questions: (a.) Identify the nature and severity of all manifestations of the Veteran’s head injury residuals, including the levels of impairment resulting from the facets of cognitive impairment and other residuals of TBI. The examiner should also clarify if the Veteran has a headache disorder, a vision disorder, a seizure disorder, and a cognitive disorder associated with his TBI. 7. Schedule the Veteran for a VA examination to address the nature and etiology of his back disorder. The examiner must review the claims file and note that review in the examination report. The examiner must provide the rationale for all opinions expressed. If medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. If the examiner is unable to provide the required opinions, the examiner should explain why that is. The examiner should address the following questions: (a.) Diagnose all present back disorder(s). (b.) Opine whether the Veteran’s back disorder(s) is at least as likely as not (50 percent or greater probability) related to his active service. 8. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 9. Readjudicate the matters. In doing so, consider the provision of Diagnostic Code 8045 that directs the adjudicator to separately evaluate any TBI residual with a distinct diagnosis that may be evaluated under another Diagnostic Code. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Lech, Counsel