Citation Nr: 18146778 Decision Date: 11/01/18 Archive Date: 11/01/18 DOCKET NO. 16-23 297 DATE: November 1, 2018 ORDER The previously denied claim of entitlement to service connection for an acquired psychiatric condition, to include depression and a nervous disorder, is reopened. The claim of entitlement to service connection for bilateral hearing loss is denied. The claim of entitlement to service connection for an enlarged liver with indicated fatty infiltration and cysts (claimed as cysts), to include as related to contaminant exposure at Camp LeJeune, is denied. The claim of entitlement to service connection for hepatitis C is denied. REMANDED The claim of entitlement to service connection for sleep apnea as secondary to post traumatic stress disorder (PTSD). is remanded. The claim of entitlement to service connection for acid reflux, to include as secondary to post traumatic stress disorder (PTSD). is remanded. The claim of entitlement to service connection for erectile dysfunction as secondary to post traumatic stress disorder (PTSD) is remanded. The claim of entitlement to service connection for post-traumatic stress disorder is remanded. The claim of entitlement to service connection for an acquired psychiatric condition, to include depression and a nervous condition is remanded. The claim of entitlement to special monthly compensation based on loss of use of a creative organ is remanded. FINDINGS OF FACT 1. New and material evidence was received to reopen the previously denied claim of entitlement to service connection for an acquired psychiatric disorder, to include a nervous disorder and depression. 2. During the period on appeal, the Veteran’s auditory thresholds in either ear in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz (Hz) were not 40 decibels or greater; nor were the auditory thresholds for at least three of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hz 26 decibels or greater; nor were his speech recognition scores using the Maryland CNC Test less than 94 percent. 3. The Veteran’s enlarged liver with indicated fatty infiltration and cysts (claimed as cysts) did not manifest during active service, within one year thereafter, and is not otherwise related to his active service or contaminated water at Camp LeJeune. 4. The Veteran’s hepatitis C did not manifest during active service, within one year thereafter, and is not otherwise related to his active service. CONCLUSIONS OF LAW 1. The criteria to reopen the previously denied claim of entitlement to service connection for an acquired psychiatric disorder, to include depression and a nervous disorder have been met. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103 (2018). 2. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310, 3.385 (2018). 3. The criteria for entitlement to service connection for enlarged liver with indicated fatty infiltration and cysts (claimed as cysts) have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2018). 4. The criteria for entitlement to service connection for hepatitis C have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably with active duty service in the United States Marine Corps from June 1972 through June 1974. His service records reflect that he was stationed in Camp LeJeune. The Veteran’s claim of service connection for a nervous condition and depression has been re-characterized as a claim for an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that VA must construe a claim for service connection to include any disability that may reasonably be encompassed by the claimant’s description of the claim, the symptoms the claimant describes, and the information the claimant submits or the Secretary obtains in support of the claim). 1. Whether new and material evidence was received to reopen the previously denied claim of entitlement to service connection for a nervous disorder and a psychiatric disorder. The Veteran seeks service connection for an acquired psychiatric disorder, to include depression and a nervous condition. A final decision cannot be reopened unless new and material evidence is presented. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Evidence is considered “new” if it was not previously submitted to agency decision makers; “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 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 evidence is new and material, the “credibility of the evidence is to be presumed.” Justus v. Principi, 3 Vet. App. 510, 513 (1992). New and material evidence is not required as to each previously unproven element of a claim in order to reopen. Shade v. Shinseki, 24 Vet. App. 110, 120 (2010). There is a low threshold for determining whether evidence raises a reasonable possibility of substantiating a claim. Id. at 117-18. Here, the Veteran was denied service connection for a nervous condition and an acquired psychiatric condition in rating decisions dated April 1985 and December 1988. The RO notified the Veteran of both decisions and of his right to appeal, but he did not initiate an appeal of the decisions within one year of either. Nor was any new and material evidence received within a year. 38 C.F.R. § 3.156(b). As a result, the prior decisions became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103. Accordingly, the claim may now be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). New evidence associated with the file, includes, inter alia, stressor statements and accounts of in-service incidents, the claimed impact of such, as well as various treatment records documenting various mental health diagnoses and medications. See, e.g., March 2018 Statement in Support of Claim; February 2015 VA Mental Health Treatment Notes. Presuming the credibility of the evidence for the purposes of this analysis, the Board finds the new evidence associated with the record has the possibility of substantiating the claim of entitlement to service connection for an acquired psychiatric disability. Accordingly, the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Service Connection To establish direct service connection, there must be competent evidence showing: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the in-service injury incurred or aggravated during service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303; Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disability that is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. Certain chronic diseases may be presumed to have been incurred in or aggravated by service if manifested to a compensable degree within one year of discharge from service. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. §§ 3.307(d), 3.309(a). A showing of chronicity requires a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” 38 C.F.R. § 3.303(b). When a disease listed at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was shown in service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Id.; Savage v. Gober, 10 Vet. App. 488, 495-96 (1997); Walker v. Shinseki, 708 F.3d 1331, 1336, 1339 (Fed. Cir. 2013) (explaining that “shown as such in service” means “clearly diagnosed beyond legitimate question”). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker, 708 F.3d at 1338-39. Service-connection may also be granted for specific diseases associated with exposure to contaminants in the water supply at Camp Lejeune listed in 38 C.F.R. § 3.309. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307. In such instances, service-connection may be established despite no evidence of such disease during the period of service. This presumption of service-connection will only attach if the listed diseases manifest to a degree of 10 percent or more any time after service. The diseases listed are: kidney cancer, liver cancer, non-Hodgkin’s lymphoma, adult leukemia, multiple myeloma, Parkinson’s disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. Fourteen diseases have been placed into the category of limited/suggestive evidence of an association with the contaminating water-supply system at Camp Lejeune. These fourteen diseases are: esophageal cancer, lung cancer, breast cancer, bladder cancer, kidney cancer, adult leukemia, multiple myeloma, myelodysplastic syndromes, renal toxicity, hepatic steatosis, female infertility, miscarriage with exposure during pregnancy, scleroderma and neurobehavioral effects. Generally, a claimant has the responsibility to present and support a claim for benefits. All information, lay evidence and medical evidence in a case is to be considered by the Board in deciding the claim. When there is an approximate balance of positive and negative evidence regarding any material issue, the claimant is to be given the benefit of the doubt. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue.”). The Board has an obligation to provide reasons and bases supporting its decision, but there is no need to discuss, in detail, every piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board’s analysis is to focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). 2. The claim of entitlement to service connection for bilateral hearing loss The Veteran seeks service connection for bilateral hearing loss. For purposes of applying the laws administered by VA, impaired hearing will be considered a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Service connection for impaired hearing is only established when audiometric testing meets the specified pure tone and speech recognition criteria. Service connection is not precluded for a current hearing loss disability where hearing was within normal limits on audiometric testing at separation from service. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Rather, when audiometric test results at a veteran’s separation from service do not meet the requirements of 38 C.F.R. § 3.385, a veteran may nevertheless establish service connection for current hearing disability by submitting medical evidence that the current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155 (1993). Where the requirements for hearing loss disability pursuant to 38 C.F.R. § 3.385 are not met until several years after separation from service, the record must include evidence of exposure to disease or injury in service that would adversely affect the auditory system and post-service test results meeting the criteria of 38 C.F.R. § 3.385. Hensley, 5 Vet. App at 155. If the record shows (a) acoustic trauma due to significant noise exposure in service and audiometric test results reflect an upward shift in tested thresholds while in service, though still not meeting the requirements for “disability” under 38 C.F.R. § 3.385, and (b) post service audiometric testing produces findings which meet the requirements of 38 C.F.R. § 3.385 ; then the rating authorities must consider whether there is a medically sound basis to attribute the post service findings to the injury in service, or whether these findings are more properly attributable to intervening causes. Id. at 159. On the May 1974 audiological evaluation upon separation, puretone thresholds, in dB, were recorded as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 0 5 5 10 LEFT 10 5 5 0 20 After filing the claim, the Veteran was afforded a VA examination in March 2015. The audiological evaluation noted puretone thresholds, in dB, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 25 15 10 15 LEFT 15 15 10 20 20 The validity of the puretone test results were noted by the VA examiner to be valid for rating purposes. The Veteran was noted to have a 96 percent speech discrimination score, bilaterally, with bilateral normal acoustic immittance, bilateral abnormal ipsilateral acoustic reflexes, and abnormal contralateral acoustic reflexes. The Veteran was diagnosed with normal hearing, bilaterally. The VA examiner provided a positive nexus opinion for the Veteran’s tinnitus. On appeal, the Veteran contends he should be afforded a new VA examination, as he was told to press buttons indicating he heard the sounds even when he did not hear them. See May 2015 Correspondence from Counsel. Counsel contends that where VA provides the veteran an examination in a service connection claim, even if not statutorily obligated to do so, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board acknowledges that there is a duty to provide a thorough examination, but finds the pleadings from counsel are insufficient to conclude that the VA examiner induced false puretone results or that the VA examination is otherwise inadequate. The Board notes that there is not a sworn or certified firsthand statement supporting the contention, and the VA examination is signed, and states that the results were valid for rating purposes. To the extent that the Veteran’s contention and the VA examination conflict, the Board finds the VA examiner to be more credible. Additionally, the VA examiner does not appear to have shown bias towards the Veteran; the Board notes that the VA examiner provided a positive diagnosis of tinnitus and a positive nexus opinion for such, and noted some level of abnormalities in the Veteran’s hearing. Additionally, there is not clear error suggested in conflicting documentation—there is no other evidence of record supporting the Veteran’s claim of hearing loss—no treatment records, and his audiogram upon separation from service does not show hearing loss, as defined under 38 C.F.R. § 3.385. The March 2015 VA examination is considered valid and adequate, and the Veteran’s contention as to the inadequacy of the examination is rejected. The Veteran does not have a current hearing loss disability for VA purposes, as defined under 38 C.F.R. § 3.385. As the Veteran does not meet the threshold requirement of having a current disability, the Board does not need to address whether there was an in-service incurrence or a medical nexus. Service connection for hearing loss is denied. 38 C.F.R. § 3.303. 3. The claim of entitlement to service connection for an enlarged liver with indicated fatty infiltration and cysts (claimed as cysts) The Veteran seeks service connection for an enlarged liver with indicated fatty infiltration and cysts. The Veteran has been diagnosed with polycystic liver disease, and imaging of record has noted enlargement, cysts, and fatty infiltration. See, e.g., March 2007 VA treatment note. The Veteran’s service treatment records are silent for any complaints or diagnoses related to the claimed condition. There is no indication in the record that the condition manifested until over 30 years after the Veteran left active service. An April 2016 VA examination reviewed whether the claimed condition was related to contaminated water supply at Camp LeJeune. The VA examiner noted that the Veteran’ factors of having a hepatitis C infection and a history of ethanol abuse were strongly implicated in hepatitic damage as noted in the Veteran’s case. The VA examiner noted that clinical review of the environmental data would indicate that the environmental exposure that the Veteran was expected to incur given a two-year period of exposure was less likely than not to cause his liver enlargement and the fatty infiltration with the cyst. The VA examiner noted that the far more medically likely risk factors were his history of chronic hepatitis C infection, a history of alcohol abuse, which were likely toxic events that would trigger the claimed condition. The Board finds no evidence to support a finding that the Veteran’s liver condition manifested during active service, within one-year thereof, and the diagnosed condition is not on the list of presumptive diseases associated with contaminated water exposure from Camp LeJeune under 38 C.F.R. § 3.309(f). Nor is there a positive nexus opinion indicating that the condition is so associated, or competent evidence indicating the claimed condition is otherwise related to his active service. The VA examination provided a negative nexus opinion; there is no positive medical opinion associated with the record. The VA examiner’s observations regarding the Veteran’s other conditions, to which the examiner linked the claimed condition are well supported by numerous medical entries. Secondary service connection to hepatitis C is not warranted because, as discussed below, his hepatitis C does not warrant service connection either. 38 C.F.R. § 3.310. The record does not reflect that the Veteran or his counsel possess the requisite expertise to provide any medical diagnosis or opinion on etiology, and his lay assertions as to the nature or etiology of the claimed condition, insofar as they are intended as such, are given no weight. See Jandreau v. Nicholson, 492 F.3d at 1374 (affirming that lay evidence is generally not competent to establish medical diagnosis or etiology). Weighing the evidence before the Board, the preponderance of the evidence indicates that there is no nexus between the Veteran’s service, to include exposure to contaminants at Camp LeJeune, and his enlarged liver with indicated fatty infiltration and cysts which appears to have manifested decades later. As such, service connection is not warranted, and the benefit of the doubt rule is inapplicable. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303; Gilbert v. Derwinski, 1 Vet. App. at 53. 4. The claim of entitlement to service connection for hepatitis C The Veteran claims service connection for hepatitis C. The Veteran’s service treatment records do not show any diagnoses related to hepatitis C or complaints of cuts. There is no evidence showing a diagnosis of such for over 25 years after active service. The Veteran’ hepatitis C appears to have shown on a computerized problem list in the VA treatment records as of 2004. There is no medical indication in the record that the condition is somehow related to his active service. Review of the VA treatment records associated with the file indicate that the Veteran has been noted to have a long history of polysubstance dependence; he was noted to have an ongoing and escalating drug use, including crack cocaine, heroin, and alcohol. See August 2010 VA treatment note. The Veteran contends, on appeal, that his hepatitis C was the result of sexual activity during active service, and sharing razors in-service. See May 2015 Correspondence. There is no evidence of the Veteran’s hepatitis C manifesting during active service or within a year after service. Service connection under 38 C.F.R. § 3.309(a) for chronic diseases is not warranted. While the Veteran may well have had sexual activity during active service, and may have shared razors, linking the condition to any two-year period of exposure appears utterly speculative. The Veteran is noted to have used heroin after service, to have been in multiple relationships, and the lengthy passage of time after service until the diagnosis weighs heavily against the claim. The Board dismisses this opinion as the Veteran is not competent and does not possess the requisite expertise to provide any opinion on medical etiology. In sum, his lay assertions, insofar as they are intended as such, are given no weight on medical etiology. See Jandreau v. Nicholson, 492 F.3d at 1374 (affirming that lay evidence is generally not competent to establish medical diagnosis or etiology). The Board does not find the Veteran’s unsupported assertions on exposure to have triggered the duty to provide a VA examination. The VA may refrain from providing assistance for a claim where there is no reasonable possibility of the assistance substantiating the claim; VA generally has no duty to provide a VA examination when there is no competent evidence suggesting the Veteran’s claimed condition may be associated with his active service. 38 C.F.R. § 3.159(d); 38 U.S.C. § 5104(d). Both exceptions apply here, and taxing the VA system for an VA medical opinion that can, at best, result in mere speculation is not warranted in this case. Weighing the evidence before the Board, the preponderance of the evidence indicates there is no nexus between the Veteran’s service and his hepatitis C which appears to have manifested decades later. As such, service connection is not warranted, and the benefit of the doubt rule is inapplicable. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303; Gilbert v. Derwinski, 1 Vet. App. at 53. REASONS FOR REMAND 1. The claim of entitlement to service connection for an acquired psychiatric disorder, to include a nervous condition and depression is remanded. 2. The claim of entitlement to service connection for PTSD is remanded. 3. The claim of entitlement to service connection for sleep apnea as secondary to PTSD is remanded. 4. The claim of entitlement to service connection for acid reflux as secondary to PTSD is remanded. 5. The claim of entitlement to service connection for erectile dysfunction as secondary to PTSD is remanded. 6. The claim of entitlement to special monthly compensation (SMC) based on loss of use of a creative organ is remanded The Veteran seeks service connection for an acquired psychiatric disorder, depression, and PTSD. He contends that the issues of sleep apnea, acid reflux, and erectile dysfunction are secondary to his psychiatric disorder. The record contains a significant psychiatric treatment history. The Veteran has provided statements contending that various events during service caused or aggravated his psychiatric condition. To date, he has not been provided with a VA examination to assess the nature and etiology of psychiatric condition. The Board notes that even if a PTSD stressor is not verified, the Veteran may still claim direct service-connection for another psychiatric condition—as noted above, his claim has been broadened, and to the extent there was a prior final decision on a psychiatric claim, reopening of such is warranted. There is ambiguity in the record as to what diagnosis or diagnoses apply to the Veteran currently, and the etiology of psychiatric conditions is a complicated question for which a medical opinion is particularly helpful. VA must provide a claimant a medical examination or obtain a medical opinion when such an examination or opinion is necessary to make a decision on a claim for compensation. 38 U.S.C. § 5103A(d)(1) (2012); 38 C.F.R. § 3.159(c)(4) (2017). As it currently stands, because the Board finds it would be helpful to have a VA examination to assess the Veteran’s current psychiatric disability or disabilities, and to have a medical opinion as to whether any confirmed diagnoses are related to his active service, remand for such is warranted. The remaining non-mental disability claims are all contended to be secondary to the Veteran’s psychiatric disorder. 38 C.F.R. § 3.310. The Veteran’s counsel has submitted several articles and pleadings suggesting a medical nexus between PTSD and the claimed conditions of obstructive sleep apnea, erectile dysfunction, or acid reflux. Also, the Veteran’s potential entitlement to SMC hinges on whether his erectile dysfunction is service-connected. See 38 C.F.R. § 3.350(a). After careful consideration, the Board finds these issues are intertwined with the remanded psychiatric claims. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a veteran’s claim for the second issue). As such, if the VA examiner opines that any psychiatric condition is as likely as not related to service, an opinion should be obtained from a VA examiner as to whether any of the Veteran’s claimed conditions of obstructive sleep apnea, erectile dysfunction, or acid reflux are as likely as not secondary to the diagnosed psychiatric condition(s). The matters are REMANDED for the following action: 1. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any psychiatric disorder. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. The examiner must opine whether the evidence of record, including the Veteran’s lay statements and the Veteran’s service records, corroborate the claim that a personal assault occurred in service (38 C.F.R. § 3.304(f)(5)). If the examiner finds that evidence indicates that a personal assault occurred during the Veteran’s active service, the examiner must opine whether any PTSD is at least as likely as not related to the in-service personal assault. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. A fully articulated medical rationale for each opinion expressed must be set forth in the medical report. The medical professional should discuss the particulars of this Veteran’s medical history and the relevant medical sciences that apply to this case, which may reasonably make clear the medical guidance in the study of this case. If any requested opinion cannot be provided without resort to mere speculation, the examiner should explain in full why this is the case and identify any additional facts or evidence (if any) that would allow for a more definitive opinion. 2. If there is a positive nexus opinion for any psychiatric disorder linking said disorder to active-service, obtain an addendum opinion as to whether any of the Veteran’s claimed conditions of obstructive sleep apnea, erectile dysfunction, or acid reflux are as likely as not secondary to the diagnosed psychiatric disorder(s). 3. After the development above has been completed, review the file and ensure that all development sought in this REMAND is completed. Arrange for any further development indicated by the results of the development requested above, ensure notification attempts for new examination(s) have been documented, and re-adjudicate the issues on appeal. If the determination remains adverse to the Veteran, the AOJ should furnish an appropriate supplemental statement of the case and afford the Veteran the opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment, as required by law for claims remanded by the Board. 38 U.S.C. §§ 5109B, 7112. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. C. King, Associate Counsel