Citation Nr: 18150251 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 16-35 905 DATE: November 14, 2018 REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for glaucoma is remanded. Entitlement to service connection for cataracts, presbyopia is remanded. Entitlement to service connection for orthostatic dizziness, claimed as vertigo is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for acid reflux is remanded. Entitlement to rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1971 to April 1972. The Board notes that in June 2018, the Veteran filed a notice of disagreement with a June 2017 rating decision. As the RO acknowledged the Veteran’s notice of disagreement in a July 2018 letter and has proceeded to take initial action, this situation is distinguishable from Manlicon v. West, 12 Vet. App. 238 (1999), where a notice of disagreement had not been recognized. As such, the Board need not remand the claims now. 1. Entitlement to service connection for sleep apnea is remanded The Veteran asserts that he has a sleep disorder, including sleep apnea, either directly related to service or as secondary to his psychiatric disability. See VA 21-526b, Veteran Supplemental Claim received in March 2016. While the medical evidence does not show a diagnosis of sleep apnea, the July 2016 VA treatment report reflects that the Veteran has low baseline oxygen saturation with nocturnal hypoxemia. The May 2016 VA examiner noted that the Veteran did not have sleep apnea and that the Veteran’s history of sleep disturbance and insomnia have been attributed to his PTSD by VA examiners throughout the claim period. See May 2016 VA examination report. However, no opinion has been provided regarding the etiology of the subsequently noted low baseline oxygen saturation and nocturnal hypoxemia for which the VA examiners wanted to add 1 liter of oxygen while sleeping. Thus, an addendum opinion is warranted. 2. Entitlement to service connection for glaucoma is remanded. 3. Entitlement to service connection for cataracts, presbyopia is remanded. The Veteran contends that his glaucoma, cataracts, and/or presbyopia are related directly to service or to his service-connected diabetes mellitus, Type II, specifically his retinopathy. The May 2016 VA examiner noted that it appears less likely than not that the Veteran has an eye condition caused or aggravated by his service-connected diabetes noting that in his last appointment, there was no evidence of diabetic retinopathy or other diabetic damage to the eyes. However, the Board notes that a July 2014 VA Eye Conditions examination report shows that the Veteran had mild nonproliferative retinopathy in both eyes. Therefore, an addendum opinion is warranted to clarify whether the Veteran has diabetic retinopathy and if so, whether his claimed eye disorders were incurred during or are otherwise related to his active service, or are caused or aggravated by his service-connected diabetes mellitus with retinopathy. 4. Entitlement to service connection for hypertension is remanded. The Veteran contends his hypertension is related to service, specifically Agent Orange exposure, or secondary to his service connected PTSD, diabetes, or any medications prescribed for service-connected conditions. See VA 21-526b, Veteran Supplemental Claim received in March 2016. The Veteran was afforded a VA Examination in May 2016 wherein the examiner noted that the Veteran’s hypertension was not directly related to service or related to his service-connected diabetes mellitus or PTSD, no opinion regarding whether the Veteran’s hypertension was related to his presumed in-service Agent Orange exposure. Thus, an addendum opinion is warranted. 5. Entitlement to service connection for orthostatic dizziness, claimed as vertigo is remanded. According to the May 2016 VA examination report, it was noted that the Veteran has orthostatic dizziness related to his blood pressure medication. As the remand of the hypertension claim could affect this claim, the Board finds that the claims are inextricably intertwined and a decision on this claim at this time would be premature. Harris v. Derwinski, 1 Vet. App. 180 (1991). 6. Entitlement to service connection for acid reflux is remanded. The Veteran contends that his acid reflux is related ot his service-connected disabilities. According to the May 2016 VA examination report, the examiner noted that it appears less likely than not that the Veteran’s acid reflux is secondary to or aggravated by his service-connected conditions including diabetes mellitus and PTSD or related treatment or medication. However, service connection for lymphoma was not yet in effect. Thus, an addendum opinion is warranted to determine whether the Veteran’s current acid reflux is related to his service connected lymphoma. 7. Entitlement to a rating in excess of 50 percent for PTSD is remanded. The Veteran contends that his PTSD warrants an increased rating and has worsened since the most recent April 2016 VA examination. Specifically, he reported additional symptomatology including suicidal ideation, impaired impulse control, speech intermittently illogical, obscure, or irrelevant, difficulty in adapting to stressful circumstances, and inability to maintain and establish effective relationships. See July 2016 statement. Additionally, a September 2016 VA record reflects that the Veteran was seen regarding his mental health symptomatology at which time an additional medication, Buspar, was added which has been increased over time. As the evidence suggests that his PTSD has worsened since the last April 2016 VA examination, a new VA examination is warranted to determine the current symptomatology of his service-connected PTSD. The matters are REMANDED for the following action: 1. Obtain all updated VA treatment records from his September 2018 and associate them with the claims file. 2. Then request an addendum medical opinion from the May 2016 VA examiner for the vision disorder, hypertension, acid reflux, and sleep apnea claims. If the May 2016 VA examiner is unavailable, the AOJ should obtain an opinion from an appropriate medical professional. The VA medical opinion provider shall note in the examination report that the claims folder and the REMAND have been reviewed. The need for an additional examination(s) of the Veteran is left to the discretion of the physician selected to write the addendum opinion. Following a review of the entire record, the VA medical opinion provider should offer an opinion on the following: a) Does the Veteran currently have any sleep disorder(s), other than the sleep disturbance/insomnia associated with his PTSD? If so, please note the diagnosed disorder(s). Please note consideration of prior findings, including the July 2016 VA findings of low baseline oxygen saturation with nocturnal hypoxemia. b) Does the Veteran currently have diabetic retinopathy? Please note consideration of prior July 2014 VA examination findings of mild non-proliferative diabetic retinopathy of both eyes. b) Is it at least as likely as not that any diagnosed sleep disorder, other than sleep disturbance/insomnia associated with PTSD; acid reflux; hypertension; and/or eye disorder other than diabetic retinopathy, to include glaucoma and cataracts, is related to the Veteran’s active service? The examiner should consider the Veteran’s conceded Agent Orange exposure. c) For any currently diagnosed sleep disorder, other than sleep disturbance/insomnia associated with PTSD, is it at least as likely as not such was caused OR aggravated by (i.e., permanently increased in severity beyond the natural progression) the service-connected PTSD? d) For any currently diagnosed eye disorder, other than diabetic retinopathy, is it at least as likely as not such was caused OR aggravated by (i.e., permanently increased in severity beyond the natural progression) the service-connected diabetes mellitus? Please note consideration of VA examination and treatment reports of diabetic retinopathy in July 2014 and poorly controlled diabetes in August 2016. e) For the currently diagnosed hypertension, is it at least as likely as not such was caused OR aggravated by (i.e., permanently increased in severity beyond the natural progression) the service-connected PTSD, diabetes mellitus, or any medications prescribed for treatment of any other service-connected condition including lymphoma? Please note consideration of VA treatment reports of poorly controlled diabetes in August 2016 and uncontrolled hypertension in December 2017. f) For the currently diagnosed acid reflux, is it at least as likely as not such was caused OR aggravated by (i.e., permanently increased in severity beyond the natural progression) any medications prescribed for treatment of any other service-connected condition including lymphoma? Please note consideration of April 2018 VA treatment reports of gastritis and reflux esophagitis as well as notation of taking aspirin. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should provide a complete rationale for all conclusions and should reconcile his or her opinions with any on file that may conflict. 3. Schedule the Veteran for a comprehensive VA psychiatric examination to determine the current severity of his PTSD. The entire record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. The examiner should identify the nature and severity of all current manifestations of the Veteran’s service-connected PTSD, as well as the impact that such has on his social and occupational functioning.   Please note consideration of the Veteran’s complaints of suicidal ideation, impaired impulse control, speech intermittently illogical, obscure, or irrelevant, difficulty in adapting to stressful circumstances, and inability to maintain and establish effective relationships noted in the July 2016 statement. K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Williams, Counsel