Citation Nr: 18151627 Decision Date: 11/19/18 Archive Date: 11/19/18 DOCKET NO. 16-21 528 DATE: November 19, 2018 ORDER Entitlement to service connection for sleep apnea is granted. Entitlement to service connection for hemorrhoids is granted. Entitlement to an initial compensable disability rating for bilateral hearing loss is denied. REMANDED Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is remanded. Entitlement to service connection for emphysema is remanded. Entitlement to service connection for diverticulitis is remanded. Entitlement to service connection for ischemic heart disease (IHD) is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for right hand frostbite residuals is remanded. Entitlement to service connection for left hand frostbite residuals is remanded. Entitlement to service connection for right foot frostbite residuals is remanded. Entitlement to service connection for left foot frostbite residuals is remanded. Entitlement to an initial disability rating higher than 50 percent for an acquired psychiatric disorder is remanded. FINDING OF FACT 1. The Veteran’s sleep apnea had its onset during active service. 2. The Veteran’s hemorrhoids had their onset during active service. 3. Throughout the period on appeal, the Veteran’s hearing impairment has been no worse than Level I in the right ear and Level I in the left ear. CONCLUSION OF LAW 1. The criteria for service connection for sleep apnea have been met. 38 U.S.C. §§ 1110, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for service connection for hemorrhoids have been met. 38 U.S.C. §§ 1110, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. The criteria for a compensable disability rating for bilateral hearing loss have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.85, Diagnostic Code (DC) 6100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Introduction The Veteran served on active duty in the United States Army from June 1966 to May 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Accordingly, the Veteran’s mental health condition is referred to broadly, as an acquired psychiatric disorder, herein. General Legal Criteria Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d) (2017). In addition, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (2017). Disability Ratings Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2017). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321 (a), 4.1 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Burden of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Background and Analysis At the outset, the Board notes it has reviewed all of the evidence of record, with an emphasis on the evidence relevant to the Veteran’s claims. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran’s claims. The Board also notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To be considered adequate, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In addition, a medical examiner is not free to simply ignore a veteran’s lay statements recounting symptoms or events. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Service connection for sleep apnea The record shows the Veteran has been diagnosed with sleep apnea. At this juncture, the Board notes that in making all determinations, it must fully consider all lay assertions of record. A layperson is competent to report on the onset and recurrent symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is 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 at 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). The Veteran has asserted his sleep apnea symptoms, to include snoring and nocturnal cessation of breathing, first manifested during service. In an October 2015 Report of Consultation and Examination, Dr. P.Y. noted the Veteran’s report that he suffered from heavy snoring and cessation of respiration several times per night during service. On the basis of the Veteran’s reported history, Dr. P.Y. stated the onset of the Veteran’s sleep apnea occurred during active duty. In a November 2015 statement, R.A. asserted he had known the Veteran since the fall of 1966, at which time they served together in an Army unit at Fort Jackson in Columbia, South Carolina. R.A. stated that during this time, it became apparent the Veteran had a snoring problem, since many members of the unit were awakened by his snoring. R.A. recalled the Veteran’s snoring became a joke among many of the unit’s members, but that the Veteran’s symptoms became a concern because, at times, it seemed he would stop breathing. R.A. stated that he and the Veteran remained close friends after service, and that during vacations and stay overs at each other’s homes following service, it was quite apparent that the Veteran’s snoring and lapses in breathing had become worse than they were in service. The Veteran was afforded a VA examination in August 2016. The examiner diagnosed sleep apnea but opined the condition was unrelated to service. In support of his opinion, the examiner stated there was no objective evidence available in the Veteran’s service treatment records (STRs) involving sleep apnea. Upon a review of the foregoing, and having resolved all reasonable doubt in favor of the Veteran, the Board has concluded that granting of service connection for sleep apnea is warranted. In this regard, the Board finds the Veteran and his fellow service member, R.A., are competent to attest to recurrent and persistent sleep apnea symptoms, both during and after service, which are capable of lay observation. In addition, the Board notes that Dr. P.Y., as discussed above, determined the Veteran’s sleep apnea manifested during service based upon the Veteran’s reports of the nature of his in-service symptoms. The Board acknowledges the August 2016 examiner’s opinion, summarized above, but notes the examiner failed to address the Veteran’s and R.A.’s statements recalling in-service and post-service symptoms, and did not address the October 2015 report provided by Dr. P.Y. In sum, the Board has found a preponderance of the evidence shows the Veteran’s sleep apnea symptoms were present in service and have continued to the present day. As such, granting of service connection for sleep apnea is warranted. Service connection for hemorrhoids The record shows the Veteran has been diagnosed with hemorrhoids. He has contended that while stationed in Korea he started to have colon and stomach problems which were related to anxiety, but that he was too embarrassed to discuss them, and waited until after service to see a healthcare provider. He stated he subsequently had a large hemorrhoid removed, which was a result of a very poor diet while stationed in Korea, and that his symptoms, to include bleeding, had persisted to the present day. In an October 2015 Report of Consultation and Examination, Dr. P.Y. stated the Veteran suffered from hemorrhoids during active service, and was formally diagnosed with the condition shortly after discharge, at which time surgery was performed. Dr. P.Y. stated that notwithstanding the surgery, the Veteran had suffered from persistent pain, itching and bleeding to the present time, and was treated with sitz baths and medication on a daily basis. Dr. P.Y. stated the Veteran’s hemorrhoids were external and large, and that they had been diagnosed within one year of his discharge. A review of the report shows that Dr. P.Y.’s findings were informed by an examination and interview of the Veteran. Presumably on the basis of the Veteran’s account of his in-service symptomatology, Dr. P.Y. stated in his report that the Veteran suffered from hemorrhoids during active service. After careful review, there is no medical or other evidence to contradict this finding by Dr. P.Y. Thus, after having resolved reasonable doubt in favor of the Veteran, the Board finds the evidence shows the Veteran’s hemorrhoids had their onset during service, and have persisted to the present day. Accordingly, granting of service connection for hemorrhoids is in order. Increased initial rating for bilateral hearing loss Disability ratings for a hearing loss disability are derived from mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating schedule establishes 11 auditory hearing acuity levels based upon average puretone thresholds and speech discrimination. See 38 C.F.R. § 4.85 (2017). An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. Examinations will be conducted without the use of hearing aids. 38 C.F.R. § 4.85(a) (2017). Table VI, “Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination,” is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination (horizontal rows) and the puretone threshold average (vertical columns). The Roman numeral designation is located at the point where the row and column intersect. 38 C.F.R. § 4.85(b) (2017). Table VIa, “Numeric Designation of Hearing Impairment Based Only on Puretone Threshold Average,” is used to determine a Roman numeral designation (I through XI) for hearing impairment based only on puretone threshold average. Table VIa is used when the examiner certifies that the use of the speech discrimination test is not appropriate due to language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of § 4.86. 38 C.F.R. § 4.85(c) (2017). “Puretone threshold average” as used in Tables VI and VIa is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz and divided by four. This average is used in all cases (including those under § 4.86) to determine a Roman numeral designation from Tables VI and VIa. 38 C.F.R. § 4.85(d) (2017). Table VII, “Percentage Evaluations of Hearing Impairment,” is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment in each ear. The horizontal rows represent the ear having the better hearing and the vertical columns represent the ear having the poorer hearing. The percentage evaluation is located at the point where the row and the column intersect. 38 C.F.R. § 4.85(e) (2017). Provisions for evaluating exceptional patterns of hearing impairment are as follows: (a) When the puretone thresholds at each of the four specified frequencies (1000, 2000, 3000 and 4000 Hertz) are 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately; (b) When the puretone thresholds are 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral; the numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. By way of background, the Veteran was awarded service connection for bilateral hearing loss in an October 2016 rating decision, and a noncompensable initial evaluation was assigned. The Veteran has appealed the initial rating assigned. The Veteran was afforded a VA audiological examination in September 2016. On examination, puretone thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 40 50 50 LEFT 20 20 35 60 60 Speech discrimination was 96 percent in the right ear and 100 percent in the left ear. Applying the values above to Table VI results in a Level I Roman numeral designation for the right ear and a Level I Roman numeral designation for the left ear. Application of a Level I designation and a Level I designation to Table VII results in a noncompensable rating. The Board observes the readings reported in this evaluation do not meet the requirements for evaluation as an exceptional pattern of impairment under 38 C.F.R. § 4.86 (2017). The Court has held that, “in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report.” Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). In accordance with this decision, the September 2016 examiner noted that the Veteran’s hearing loss resulted in background noise drowning out speech, a process which had gradually worsened over the previous 20 years. On review of the record, the Veteran has not undergone any other audiological testing during the period of the claim which has included both an audiogram and speech discrimination testing using the Maryland CNC test. Based on the foregoing, it is evident that the criteria for a compensable rating under Diagnostic Code 6100 have not been met. Thus, although the evidence shows the Veteran has some level of hearing loss, the hearing loss has not met the criteria for a compensable rating under the rating schedule. Therefore, the Veteran’s claim must be denied. REMAND The Board finds additional development is required before the Veteran’s remaining claims are decided. Initially, the Board notes that VA must provide a medical examination or obtain a medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A(d)(2) (2012); 38 C.F.R. § 3.159(c)(4)(i) (2017). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, disease or injury is a low threshold. McLendon, 20 Vet. App. at 83. Service connection for COPD and emphysema The Veteran has claimed service connection for a pulmonary disability. He has characterized the claim as including COPD emphysema. While the record shows the Veteran has been diagnosed with COPD and asthma, the record is unclear as to whether emphysema has been diagnosed. The Veteran contends his pulmonary condition is due to exposure to toxic chemicals, extreme dust, and poor conditions during his service in Korea. The Veteran has not been afforded a VA examination to determine the nature and etiology of his claimed pulmonary disability. Under these circumstances, the Board finds the low threshold under McLendon has been satisfied such that a remand is warranted for a VA examination. Service connection for a colon condition The Veteran has claimed entitlement to service connection for a colon condition. He has characterized the claim as including diverticulitis. He has contended that while stationed in Korea, he started to have colon and stomach problems which were related to anxiety, but that he was too embarrassed to discuss them, and waited until after service to see a healthcare provider. He stated he was diagnosed with diverticulitis due to his very poor diet while stationed in Korea, and that the illness had continued to the present day. The Veteran has not been afforded a VA examination to determine the nature and etiology of his claimed colon condition. Under these circumstances, the Board finds the low threshold under McLendon has been satisfied such that a remand is warranted for a VA examination. Service connection for IHD The Veteran has been diagnosed with IHD. He has contended his IHD was caused by exposure to herbicide agents while serving in the Korean Demilitarized Zone (DMZ). Specifically, he asserted he was tasked with driving officers in and was otherwise stationed in areas that were defoliated with Agent Orange. In a November 2015 statement, he asserted these areas were sprayed on a regular basis so the land between North and South Korea would be visible. In this regard, the Board notes that presumptive service connection for IHD is warranted for veterans who served in the DMZ between April 1, 1968, and August 31, 1971. See 38 C.F.R. § 3.307(a)(6)(iv), 3.309(e) (2017). The record shows that while the Veteran served in the DMZ, his service in Korea was between November 1966 and March 1968, and thus did not fall within the period warranting presumptive service connection. In this regard, the Board notes the Veteran is not precluded from establishing service connection for his IHD due to exposure to herbicides with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). A review of the record shows the Agency of Original Jurisdiction (AOJ) has not undertaken any development to determine whether the Veteran was exposed to herbicide agents during his service in Korea, to include by sending a request to the Joint Services Records Research Center (JSRRC), if indicated. Under these circumstances, the Board finds a remand is warranted for the AOJ to undertake all indicated development to determine whether the Veteran was exposed to herbicide agents during his service in the DMZ. The Veteran should also be afforded a VA examination to address the etiology of his IHD. Service connection for hypertension The Veteran has been diagnosed with hypertension. He has attributed the condition to his service-connected acquired psychiatric disorder. Alternatively, in an October 2015 report, a private physician attributed the Veteran’s hypertension to his IHD. The Veteran has not been afforded a VA examination to determine the nature and etiology of his hypertension. Under these circumstances, the Board finds the low threshold under McLendon has been satisfied such that a remand is warranted for a VA examination. Service connection for frostbite The Veteran has claimed entitlement to service connection for residuals of frostbite of the bilateral hands and feet. He has contended he suffered from mild frostbite of the feet and hands during service, due to having been sent out on maneuvers in Korea for days at a time in extreme weather conditions. He has contended he has residual symptoms, to include neurological symptoms, which have persisted to the present day. The Veteran has not been afforded a VA examination to determine the nature and etiology of his claimed frostbite residuals. Under these circumstances, the Board finds the low threshold under McLendon has been satisfied such that a remand is warranted for a VA examination. Increased initial rating for an acquired psychiatric disorder Service connection for an acquired psychiatric disorder was granted in a December 2017 rating decision, and an initial 50 percent rating was assigned. The Veteran filed a notice of disagreement (NOD) with the initial rating assigned in January 2018. To date, the AOJ has not issued a statement of the case (SOC) addressing the Veteran’s claim of entitlement to an initial rating higher than 50 percent for his service-connected acquired psychiatric disorder. As such, the Board is required to remand this issue for issuance of a SOC. See Manlincon v. West, 12 Vet. App. 238 (1999). The matter is REMANDED for the following action: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s claims. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Undertake all indicated development to determine whether the Veteran was exposed to herbicide agents during his service in the Korean DMZ between November 1966 and March 1968, to include sending a request to the Joint Services Records Research Center (JSRRC), if indicated. If exposure to herbicide agents cannot be established, prepare a memorandum to this effect, describing all development undertaken, and associate it with the record. 3. Afford the Veteran a VA examination to determine the nature and etiology of all pulmonary disabilities present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Following the examination and a review of the relevant records and lay statements, the examiner should identify all pulmonary disabilities present during the period of the claim. The examiner should specifically confirm or rule out COPD, emphysema, and asthma. Then, with respect to each identified pulmonary disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability originated during or is otherwise etiologically related to the Veteran’s military service. In providing his or her opinion(s), the examiner should address the Veteran’s lay statements to the effect that his pulmonary symptoms are related to his exposure to toxic chemicals, extreme dust, and poor conditions during his service in Korea. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. Afford the Veteran a VA examination to determine the nature and etiology of all colon disabilities present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Following the examination and a review of the relevant records and lay statements, the examiner should identify all colon disabilities present during the period of the claim. The examiner should specifically confirm or rule out diverticulitis. Then, with respect to each identified colon disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability originated during or is otherwise etiologically related to the Veteran’s military service. In providing his or her opinion, the examiner should address the Veteran’s lay statements to the effect that while stationed in Korea he started to have colon and stomach problems, but that he was too embarrassed to discuss them, and waited until after service to see a healthcare provider, at which time he was diagnosed with diverticulitis related to his poor diet in Korea. If the examiner answers the above question in the negative, he or she should state, with respect to each identified colon disability, whether it is at least as likely as not (50 percent probability or greater) that the disability is proximately due to or has been aggravated (permanently worsened beyond its natural progression) by the Veteran’s service-connected acquired psychiatric disorder. If aggravation is found, the examiner should provide an opinion, to the extent possible, as to: a) The baseline manifestations of the Veteran’s colon disability found prior to aggravation; and b) The increased manifestations which, in the examiner’s opinion, are proximately due to his service-connected acquired psychiatric disorder. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any requested opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 5. Afford the Veteran a VA examination to determine the nature and etiology of his ischemic heart disease. All pertinent evidence of record must be made available to and reviewed by the examiner. Following the examination and a review of the relevant records and lay statements, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s ischemic heart disease originated during or is otherwise etiologically related to his military service. In providing his or her opinion, the examiner should address the Veteran’s lay statements to the effect that while stationed in Korea, he served in areas which were regularly sprayed with herbicide agents for defoliation purposes. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 6. Afford the Veteran a VA examination to determine the nature and etiology of his hypertension. All pertinent evidence of record must be made available to and reviewed by the examiner. Following the examination and a review of the relevant records and lay statements, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension is proximately due to or has been aggravated (permanently worsened beyond its natural progression) by his ischemic heart disease. In providing his or her opinion, the examiner should address the October 2015 report by Dr. P.Y. indicating the Veteran’s hypertension is causally related to his heart disease. If aggravation is found, the examiner should provide an opinion, to the extent possible, as to: a) The baseline manifestations of the Veteran’s hypertension found prior to aggravation; and b) The increased manifestations which, in the examiner’s opinion, are proximately due to his ischemic heart disease. Then, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension is proximately due to or has been aggravated (permanently worsened beyond its natural progression) by his service-connected acquired psychiatric disorder. If aggravation is found, the examiner should provide an opinion, to the extent possible, as to: a) The baseline manifestations of the Veteran’s hypertension found prior to aggravation; and b) The increased manifestations which, in the examiner’s opinion, are proximately due to his service-connected acquired psychiatric disorder. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 7. Afford the Veteran a VA examination to determine the nature and etiology of any frostbite residuals present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Following the examination and a review of the relevant records and lay statements, the examiner should identify all disabilities which constitute residuals of frostbite. If the examiner determines no frostbite residuals have been present during the period of the claim, he or she should provide a medical explanation for his or her finding. Then, with respect to each identified frostbite residuals disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability originated during or is otherwise etiologically related to the Veteran’s military service. In providing his or her opinion, the examiner should address the Veteran’s lay statements to the effect that he suffered frostbite in his hands and feet while serving in Korea due to being stationed in extreme cold conditions for days at a time, and that he has had residual symptoms which have persisted to the present day. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 8. Issue a statement of the case addressing the issue of entitlement to an initial rating higher than 50 percent for an acquired psychiatric disorder. Thereafter, the Veteran should be given an opportunity to perfect an appeal by submitting a timely substantive appeal. The Veteran should be advised that the claims file will not be returned to the Board for appellate consideration of this issue unless he perfects an appeal. 9. Undertake any other development determined to be warranted. 10. Then, readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran’s satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Hampton, Associate Counsel