Citation Nr: 18150944 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 16-32 741 DATE: November 16, 2018 ORDER New and material evidence has been received to reopen the claim of entitlement to service connection for right knee condition. The appeal is granted to that extent only. New and material evidence has been received to reopen the claim of entitlement to service connection for residuals of right hand injury. The appeal is granted to that extent only. New and material evidence has been received to reopen the claim of entitlement to service connection for gastroesophageal reflux disease (GERD). The appeal is granted to that extent only. New and material evidence has been received to reopen the claim of entitlement to service connection for posttraumatic stress disorder (PTSD). The appeal is granted to that extent only. Entitlement to service connection for right knee condition is denied. Entitlement to service connection for left knee condition is denied. Entitlement to service connection for stomach condition is denied. Entitlement to service connection for benign skin neoplasms is denied. REMANDED Entitlement to service connection for skin condition is remanded. Entitlement to service connection for PTSD is remanded. Entitlement to service connection for residuals of right hand injury is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to a temporary total rating based on hospitalization over 21 days for PTSD. FINDINGS OF FACT 1. By a June 2006 rating decision, the Veteran’s claim of entitlement to service connection for right knee condition was denied. 2. Additional evidence has been received which is not cumulative or redundant of the evidence of record at the time of the June 2006 rating decision and relates to an unestablished fact necessary to substantiate the claim for service connection for a right knee condition. 3. By a June 2006 rating decision, the Veteran’s claim of entitlement to service connection for residuals of right hand injury was denied. 4. Additional evidence has been received which is not cumulative or redundant of the evidence of record at the time of the June 2006 rating decision and relates to an unestablished fact necessary to substantiate the claim for service connection for residuals of a right hand injury. 5. By a June 2006 rating decision, the Veteran’s claim of entitlement to service connection for GERD was denied. 6. Additional evidence has been received which is not cumulative or redundant of the evidence of record at the time of the June 2006 rating decision and relates to an unestablished fact necessary to substantiate the claim for service connection GERD. 7. By a July 2009 rating decision, the Veteran’s claim of entitlement to service connection for PTSD was denied. 8. Additional evidence has been received which is not cumulative or redundant of the evidence of record at the time of the July 2009 rating decision and relates to an unestablished fact necessary to substantiate the claim for service connection for PTSD. 9. The preponderance of the evidence is against finding that the Veteran’s right knee condition is etiologically related to active service. 10. The preponderance of the evidence is against finding that the Veteran’s left knee condition is related to an in-service injury, event, or disease. 11. The preponderance of the evidence is against finding that GERD is etiologically related to active service. 12. The preponderance of the evidence is against finding that benign skin neoplasms are related to an in-service injury, event, or disease. CONCLUSIONS OF LAW 1. The June 2006 rating decision denying service connection for right knee condition is final. 38 U.S.C. §§ 7104 (2012); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103 (2017). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for right knee condition, and the claim is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The June 2006 rating decision denying service connection for residuals of right hand injury is final. 38 U.S.C. §§ 7104 (2012); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103 (2017). 4. New and material evidence has been received to reopen the claim of entitlement to service connection for residuals of right hand injury, and the claim is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 5. The June 2006 rating decision denying service connection for GERD is final. 38 U.S.C. §§ 7104 (2012); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103 (2017). 6. New and material evidence has been received to reopen the claim of entitlement to service connection for GERD, and the claim is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 7. The July 2009 rating decision denying service connection for PTSD is final. 38 U.S.C. §§ 7104 (2012); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103 (2017). 8. New and material evidence has been received to reopen the claim of entitlement to service connection for PTSD. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 9. The criteria for service connection for right knee condition have not been satisfied. 38 U.S.C. §§ 1110, 1131, 1153, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.306 (2017). 10. The criteria for service connection for left knee condition have not been satisfied. 38 U.S.C. §§ 1110, 1131, 1153, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.306 (2017). 11. The criteria for service connection for GERD have not been satisfied. 38 U.S.C. §§ 1110, 1131, 1153, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.306 (2017). 12. The criteria for service connection for benign skin neoplasms have not been satisfied. 38 U.S.C. §§ 1110, 1131, 1153, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.306 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from January 1974 to February 1979. In June 2017, the Veteran testified at a Board hearing. The transcript is of record. Some of the issues have been recharacterized to comport with the evidence of record. The issue of entitlement to service connection for PTSD has been recharacterized as service connection of a psychiatric disorder in accordance with Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board notes that the Veteran’s claim of entitlement to service connection for migraines was granted in a May 2016 rating decision. As such, this issue is no longer on appeal and the Board does not have jurisdiction. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (holding that where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of the claim concerning "downstream" issues, such as the compensation level assigned for the disability and the effective date); see also 38 C.F.R. § 20.200 (2017). I. New and Material Evidence A claim may 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). 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) (in determining whether evidence is new and material, the “credibility” of newly presented evidence is to be presumed unless the evidence is inherently incredible or beyond the competence of the witness). The language of 38 C.F.R. § 3.156(a) creates a low threshold for finding new and material evidence, and views the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” Evidence “raises a reasonable possibility of substantiating the claim,” if it would trigger VA’s duty to provide an examination in adjudicating a non-final claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). A. Right Knee In the June 2006 rating decision, the Veteran’s claim for service connection was denied based on the finding that the right leg condition was not caused by service. At the time of that decision the pertinent evidence of record included the service treatment records and post-service treatment records. The evidence received since the June 2006 rating decision includes a VA examination dated May 2016. This evidence is new and material as it pertains to whether the Veteran’s right knee condition is related to his active service, which is an unsubstantiated fact that is necessary to substantiate the claim. Therefore, the claim is reopened. B. Residuals of Right Hand Injury In the June 2006 rating decision, the Veteran’s claim for service connection was denied based on the finding that the residuals of right hand injury were not incurred in or a result of service. At the time of that decision the pertinent evidence of record included the service treatment records and post-service treatment records. The evidence received since the June 2006 rating decision includes a VA examination dated May 2016. This evidence is new and material as it pertains to whether the Veteran’s residuals of right hand injury incurred in or is a result of service which is an unsubstantiated fact that is necessary to substantiate the claim. Therefore, the claim is reopened. C. GERD In the June 2006 rating decision, the Veteran’s claim for service connection was denied based on the finding that the GERD was not caused by service. At the time of that decision the pertinent evidence of record included the service treatment records and post-service treatment records. The evidence received since the June 2006 rating decision includes a VA examination dated May 2016. This evidence is new and material as it pertains to whether the Veteran’s GERD is related to his active service, which is an unsubstantiated fact that is necessary to substantiate the claim. Therefore, the claim is reopened. D. PTSD In the July 2009 rating decision, the Veteran’s claim for service connection was denied based on the finding that the claimed stressor was not verifiable. At the time of that decision the pertinent evidence of record included the service treatment records, post-service treatment records, statement in support of PTSD claim dated February 9, 2009, and Joint Services Record Research Center (JSRRC) memorandum on lack of information required to verify stressor in connection to PTSD dated May 5, 2009. The evidence received since the July 2009 rating decision includes a decision from the Social Security Administration awarding the Veteran disability benefits for PTSD, statements in support of the claim dated May 20, 2012, and January 18, 2013, and a memorandum from JSRRC. This evidence is new and material as it pertains to whether the Veteran’s PTSD is related to his active service, which is an unsubstantiated fact that is necessary to substantiate the claim. Therefore, the claim is reopened. II. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. “To establish a right to compensation for a present disability, a veteran must show: ‘(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service’ – the so-called “nexus” requirement.” Holton v. Shineski, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). For a veteran who served 90 days or more of active service after December 31, 1946, certain chronic diseases, such as hypertension and arthritis, may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303 (b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. See also, Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013). A. Right Knee Condition The Veteran has a current diagnosis of right knee effusion and degenerative arthritis. The evidence shows that the Veteran was diagnosed with gonococcal arthritis of the right knee in service; however, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of knee effusion and degenerative arthritis began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). In May 2016 the Veteran attended a VA examination and reported that he had an infection in his knee during active service, which required hospitalization for ten days. According to the Veteran, he has not had a reoccurrence since service. The VA examiner noted the service treatment records reflect a visit to the emergency room in October 1975 resulting in hospitalization for gonococcal arthritis, a bacterial infection. The examiner opined that it is less likely than not that the Veteran’s current degenerative arthritis incurred in or is caused by the gonococcal arthritis that occurred in-service. The examiner explained that the Veteran’s gonococcal arthritis was appropriately treated in service and re-evaluated to ensure resolution of the illness. Review of the records did not reveal any further complaints or treatments relating to the right knee, indicating that the Veteran’s infection resolved without sequelae, complications or residual. Furthermore, the examiner noted that, once properly treated, gonococcal arthritis does not have a causal relationship to degenerative arthritis. The Veteran’s post-service medical records do not indicate any reoccurrences of gonococcal arthritis. In January 1996, the Veteran reported waking up with right knee pain that lasted about a year, with no known injuries or trauma. At that time, he had multiple x-rays, which revealed no cause for the pain. Moreover, the Veteran testified that he has not had any reoccurrences of his knee infection since service. When making a decision, the Board must consider all the evidence of record, to include the Veteran’s testimony and lay statements. 38 U.S.C. § § 5107(b), 7104(a); 38 C.F.R. § 3.303(a). While the Veteran is competent to report having experienced symptoms of knee pain since service, he is not competent to determine that these symptoms were manifestations of his bacterial infection, gonococcal arthritis. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). As such, the Board gives greater weight to the opinion of the VA examiner. The VA examiner reviewed the record, conducted a physical examination and provided an adequate rationale with citations to the evidence of record explaining that properly treated gonococcal arthritis is not causally related to degenerative arthritis. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Additionally, the Board notes that arthritis is a chronic disease under 38 C.F.R. § 3.309; however, the evidence of record does not establish that the Veteran’s degenerative arthritis manifested to a compensable degree within one year of separation from service. While the Veteran testified that he has had pain in his knee since service, the post-service medical records reflect that the Veteran reported a history of knee pain lasting about a year in 2006, well after separation from service. Furthermore, x-rays taken at that time did not reveal arthritis. Therefore, the evidence is insufficient to establish presumptive service connection for right knee arthritis. As such, the Board finds that service connection for right knee condition is not warranted. B. Left Knee Condition The Board concludes that, while the Veteran has a diagnosis of left knee effusion with mild degenerative changes the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran alleges he is entitled to service connection for his left knee condition; however, the service treatment records are silent for any complaints, treatments, or diagnoses related to the left knee. Post-service medical records reflect that the Veteran suffered two separate gunshot wounds to his left leg in 2002 and 2004; however, this occurred decades after active service. To the extent that the Veteran alleges his left knee condition is a result of active service, this allegation is without probative value. There is no objective evidence establishing that the Veteran suffered an in-service injury, event or illness involving his left knee. Moreover, at the hearing, the Veteran testified that he did not have problems with his left knee until after active service. The Board notes that the VA’s duty to provide a VA examination is not triggered in this instance. In determining whether VA’s duty to assist requires a VA medical examination or medical opinion, four factors are for consideration: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012); 38 C.F.R. § 3.159 (c)(4) (2017); see McLendon v. Nicholson, 20 Vet. App. 79 (2006). As the evidence of record does not establish that the Veteran had a left knee injury during active service, a VA examination or opinion is not necessary. Alternatively, the Veteran testified that his left knee condition is related to his right knee condition. Secondary service connection may be established for a disability that is proximately due to, the result of, or aggravated beyond its natural progression by a service connected condition and shall be service connected on a secondary basis. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). Establishing secondary service connection requires evidence of: (1) a current disability (for which secondary service connection is sought); (2) an already service-connected disability; and (3) that the claimed disability was either caused or aggravated by the already service-connected disability. Id. However, as discussed above, service connection for right knee condition is not warranted. Secondary service connection cannot be established if the underlying disability is not service connected. Thus, secondary service connection for left knee condition is not warranted. 38 C.F.R. § 3.310(a). Therefore, the Board finds that entitlement to service connection for left knee condition is not warranted. C. GERD The Board concludes that the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of GERD began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran attended a VA examination in May 2016. Based on review of the record and physical examination, the examiner opined that it is less likely than not that the Veteran’s GERD incurred in or is related to active service. The service treatment records reflect that the Veteran was diagnosed with acute gastroenteritis and lactose intolerance during service. The Veteran denied frequent indigestion or stomach trouble on his May 1978 separation examination. The examiner noted that the Veteran’s gastroenteritis resolved without any residuals, sequelae, or complications. Furthermore, the examiner reported that GERD was diagnosed in 1991, which is several years after separation from service and explained that current medical literature does not support a causal relationship between acute gastroenteritis and GERD. The Board must consider all the evidence of record, to include testimony and lay statements. 38 U.S.C. § § 5107(b), 7104(a); 38 C.F.R. § 3.303(a). The Board acknowledges that the Veteran believes that his GERD is related to an in-service injury, event, or disease, to include his acute gastroenteritis and lactose intolerance; however, he is not competent to provide a nexus opinion in this case. This issue requires knowledge and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to opinion of the VA examiner, who provided a well-reasoned rationale explaining the conclusion that GERD is not related to active service. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As there is no medical evidence linking the Veteran’s current diagnosis of GERD to active service, the claim must be denied. Therefore, service connection for GERD is not warranted. D. Benign Skin Neoplasms The medical evidence of record establishes that the Veteran underwent a lumpectomy in May 2004 and has a benign testicular mass. Therefore, a current diagnosis of benign skin neoplasms is shown; however, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The service treatment records are silent for any complaints or treatments for skin neoplasms or lipomas. To the extent that the Veteran alleges that his benign skin neoplasms are related active service, this allegation is without probative value. The record does not contain objective evidence establishing that there was an in-service event, injury, or illness resulting in benign skin neoplasms. The Board notes that the VA’s duty to provide a VA examination is not triggered. In determining whether VA’s duty to assist requires a VA medical examination or medical opinion, four factors are for consideration: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012); 38 C.F.R. § 3.159 (c)(4) (2017); see McLendon v. Nicholson, 20 Vet. App. 79 (2006). The evidence of record does not establish that the Veteran had a skin neoplasm or lipoma during active service. As such, a VA examination or opinion is not necessary. While the Veteran believes his benign skin neoplasms are related to active service, the Board reiterates that the preponderance of the evidence weighs against findings that an in-service injury, event, or disease occurred. Therefore, the Board finds that entitlement to service connection for benign skin neoplasms is not warranted. REASONS FOR REMAND Dermatitis The Veteran attended a VA examination in May 2016. The VA examiner opined it is less likely than not that the claimed skin condition was incurred in or is caused by active service. The examiner noted that, apart from scars, there are no current diagnoses of a skin condition based on review of the records and physical examination and reported that the Veteran’s diagnoses of tineas versicolor, corporis, and pedis resolved in-service without sequelae, residuals, or complications. The Veteran’s post-service dermatology records from 2012 include a diagnosis of eczema with failed treatments and the medical records reflect several complaints of red raised breakouts with hypopigmented areas and treatment that includes topical creams and phototherapy. Furthermore, the Board notes that the Veteran is competent to identify his skin conditions. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Therefore, a VA examination is needed to identify the Veteran’s skin diagnoses during the period on appeal and discuss the nature and etiology of all identified skin disorders. Residuals of Right Hand Injury The Veteran attended a VA examination in May 2016 and reported intermittent numbness in his hand as a result of his injury where his hand was crushed in a refueling door. The examiner diagnosed the Veteran with a superficial laceration of the distal middle finger of the right hand and opined that it is less likely than not that the residuals from the right hand injury incurred in or resulted from active service. The examiner noted that the Veteran’s superficial laceration resolved without sequelae, residuals or complications and that the Veteran did not complain of numbness in his fourth and fifth digits, as was previously noted, and had a positive Phalen’s and Tinel’s sign. However, the VA examination report included x-ray findings of degenerative or traumatic arthritis in multiple joints of the right hand, to include the thumb and fingers. Additional abnormalities were noted in the x-ray findings. The examiner concluded that these findings are not related to the superficial laceration that occurred during active service but failed to provide a rationale explaining this conclusion. The examiner’s rationale pertaining to the Veteran’s arthritis is conclusory and does not consider and address the Veteran’s lay statements alleging symptoms of numbness since service. The VA examiner’s rationale is inadequate for adjudicative purposes. Once VA undertakes the effort to provide an examination, it must provide an adequate one; therefore, a remand is necessary. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). PTSD The VA has a duty to assist, which includes providing a medical examination when necessary to make a decision on a claim. 38 C.F.R. § 3.159(c)(4)(i) (2017). The VA will provide a medical examination or obtain a medical opinion if the record, including lay or medical evidence, contains competent evidence of a disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease that occurred in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79, 86 (2006). As the Veteran’s claim for service connection for PTSD has been expanded to include any acquired psychiatric disorder, the Board finds the evidence of record is insufficient to decide the claim of entitlement to service connection for an acquired psychiatric disorder. Additionally, the service treatment records reveal that the Veteran underwent a mental examination during active service at the request of his Commanding Officer and post-service medical records reflect several mental health diagnoses with extensive ongoing treatment. Therefore, the Board finds that a VA examination is necessary to evaluate all potential acquired psychiatric disorders. Temporary Total Rating Based on Hospitalization over 21 days for PTSD The Veteran’s entitlement to a temporary total rating for PTSD is inextricably intertwined with the entitlement to service connection for PTSD claim on appeal. Therefore, the Board finds that the claim for a temporary total rating for PTSD must be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). Hypertension and Erectile Dysfunction At the hearing, the Veteran testified that his hypertension and erectile dysfunction are secondary to the medications taken for his service connected disabilities. There are no medical opinions that address this theory. Additionally, the Board finds that hypertension and erectile dysfunction are inextricably intertwined with the entitlement to service connection for PTSD claim on appeal, as the outcome of that claim may have a significant impact on the claims for entitlement to service connection based on a secondary basis for medications due to service connected disabilities. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). Therefore, a remand is necessary for addendum opinions to address secondary service connection for hypertension and erectile dysfunction. The matter is REMANDED for the following action: 1. Obtain updated VA and/or private treatment records. If such records are unavailable, the Veteran’s claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Schedule the Veteran for a VA examination with a medical professional with appropriate expertise to determine the nature and etiology of any diagnosed skin disorder. The examiner should review the Veteran’s claims file, including a copy of this remand. Based on a review of the record, the examiner must address the following: Identify all the Veteran’s skin diagnoses noted in the medical evidence of record. Whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed skin disorder is related to active service, or is caused by or aggravated by military service. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. The examiner should elicit a full history from the Veteran and consider and address the testimony and any lay statements of record. If there is a medical basis to support or doubt the history provided, the examiner should provide a fully reasoned explanation. A complete rationale for all medical opinions is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 3. Obtain an addendum medical opinion on the nature and etiology of the Veteran’s residuals of right hand injury from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file, including a copy of this remand. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s residuals of right hand injury, claimed as right-hand numbness is related to his active service, or is caused by or aggravated by military service. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms of right-hand numbness from the time of his in-service injury to the present. The examiner must specifically consider and discuss the Veteran's testimony, in addition to the lay statements of record, regarding his in-service injury and continuity of symptomology since service and the opinion and rationale should reflect such consideration. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 4. Schedule the Veteran for a VA examination with a VA psychiatrist or psychologist to determine the nature and etiology of any acquired psychiatric disorder, to include PTSD. The examiner should review the Veteran’s claims file, including a copy of this remand. Any medically indicated tests should be accomplished, and all pertinent symptomatology and findings must be reported in detail. The examiner should list all psychiatric disorders present during the time period of the claim. With regard to each identified acquired psychiatric disorder present during the claim, the VA examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any diagnosed psychiatric disorder originated during or is otherwise etiologically related to the Veteran’s military service. If PTSD is diagnosed, the specific stressors upon which the diagnosis are based must be identified. In providing the requested opinions, the examiner is advised that the term "at least as likely as not" does not mean within the realm of possibility, but that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. The examiner must specifically consider and discuss the lay statements of record and the opinion and rationale should reflect such consideration. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 5. Obtain an addendum medical opinion to determine the nature and etiology of the Veteran’s erectile dysfunction from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file, including a copy of this remand. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s erectile dysfunction is related to his active service, or is caused by or aggravated by military service. (b.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that erectile dysfunction is proximately due to or the result of the Veteran’s service-connected disabilities and/or the medications taken for the Veteran’s service connected disabilities? (c.) If the answer to (b) is negative, is it at least as likely as not that erectile dysfunction is aggravated (i.e., permanently or temporarily worsened) by the Veteran’s service connected disabilities? (d.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. The term “aggravation” means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. The examiner should consider and address the Veteran’s testimony and lay statements of record. If there is a medical basis to support or doubt the history provided, the examiner should provide a fully reasoned explanation. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 6. Schedule a VA examination to determine the nature and etiology of the Veteran’s hypertension from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file, including a copy of this remand. Based on review of the record, and a new examination if necessary, the examiner must address the following: (a.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that hypertension is proximately due to or the result of the Veteran’s service-connected disabilities and/or the medications taken for the Veteran’s service connected disabilities? (b.) If the answer to (a) is negative, is it at least as likely as not that hypertension is aggravated (i.e., permanently or temporarily worsened) by the Veteran’s service connected disabilities? (c.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. The term “aggravation” means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. The examiner should consider and address the Veteran’s testimony and lay statements of record. If there is a medical basis to support or doubt the history provided, the examiner should provide a fully reasoned explanation. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. A. Prinsen, Associate Counsel