Citation Nr: 18153486 Decision Date: 11/28/18 Archive Date: 11/27/18 DOCKET NO. 15-27 781 DATE: November 28, 2018 ORDER As new and material evidence has been received to reopen a claim of entitlement to service connection for sleep apnea, to this extent, the appeal is granted. REMANDED The claim of entitlement to service connection for sleep apnea is remanded. The claim of entitlement to service connection for hypertension is remanded. The claim of entitlement to service connection for kidney disease is remanded. The claim of entitlement to service connection for diabetes mellitus is remanded. The claim of entitlement to service connection for erectile dysfunction is remanded. The matter of whether the Veteran initiated an appeal with respect to the claim of whether new and material evidence to reopen a claim for service connection for a tear duct disability has been received is remanded. FINDINGS OF FACT 1. In a September 2005 rating decision, the Regional Office (RO) denied the claim for service connection for sleep apnea; a timely NOD was filed in March 2006, but the Veteran withdrew his appeal with respect to this issue in October 2006. 2. Additional evidence associated with the claims file since the September 2005 denial relates to unestablished facts necessary to substantiate the claim for service connection for sleep apnea and raises a reasonable possibility of substantiating the claim. CONCLUSIONS OF LAW 1. The September 2005 rating decision that denied service connection for sleep apnea is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 2. As additional evidence received since the September 2005 denial is new and material, the criteria for reopening the claim for service connection for sleep apnea are met. 38 U.S.C. §§ 5108; 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1980 to February 1988. This appeal to the Board of Veterans’ Appeals (Board) arose from a May 2013 rating decision in which the Department of Veterans Affairs (VA) RO in Baltimore, Maryland, inter alia, denied the Veteran’s claims for service connection for hypertension, kidney disease, diabetes mellitus, and erectile dysfunction, as well as his request to reopen a claim for service connection for sleep apnea. In September 2013, the Veteran filed a notice of disagreement (NOD) with these denials. A statement of the case (SOC) was issued in April 2015, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans’ Appeals) in June 2015. In January 2017, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge in Washington, D.C. A transcript of the hearing has been associated with the claims file. With respect to the sleep apnea claim, it is noted that, regardless of the RO’s actions, the Board has a legal duty under 38 U.S.C. §§ 5108 and 7104 to address the question of whether new and material evidence has been received to reopen the previously denied claim for service connection. That matter goes to the Board’s jurisdiction to reach the underlying claim and adjudicate the claim on a de novo basis. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). As the Board must first decide whether new and material evidence to reopen the claim has been received—and, given the favorable disposition of the request to reopen—the Board has characterized the appeal as encompassing both the request to reopen and the underlying service connection claim for sleep apnea, as indicated above. As for the matter of representation, the record reflects that the Veteran was previously represented by private attorney Alan J. Nuta, as reflected in an August 2007 VA Form 21-22a (Appointment of Individual as Claimant’s Representative). However, during the January 2017 Board hearing, the Veteran indicated that Mr. Nuta was no longer representing him and had not been actively participating in his appeal since approximately 2010. He further indicated that he wanted to move forward with the hearing and his appeal without representation. To date, the Veteran has not appointed another representative. Therefore, the Board recognizes the Veteran as now proceeding pro se in this appeal. Also, this appeal has been advanced on the Board’s docket, pursuant to 38 U.S.C. § 7107(a)(2) and 38 C.F.R. § 20.900(c). Request to Reopen Under legal authority in effect at the time of the prior denial of the Veteran’s claim for service connection for sleep apnea and currently, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Moreover, service connection may be granted for a disability which is proximately due to or the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. See also Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran’s initial claim for service connection for sleep apnea was denied in a September 2005 rating decision by the RO. The pertinent evidence then of record consisted of his service treatment records, private treatment records, VA treatment records, and lay statements from the Veteran. The RO denied the claim on the basis that there was no evidence that this disability was incurred in service. The Veteran was notified of the September 2005 denial in an October 2005 letter, and he filed a timely NOD with respect to this denial in March 2006. However, during an October 2006 conference with a decision review officer (DRO), the Veteran withdrew his appeal with respect to the sleep apnea claim. Moreover, no new and material evidence was received within the one-year appeal period from the date of the notice of the denial, and no additional service records, warranting reconsideration of the claim, have been received. See 38 C.F.R. § 3.156 (b), (c). Therefore, the RO’s September 2005 denial of the claim is final as to the evidence then of record and is not subject to revision on the same factual basis. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. However, under pertinent legal authority, VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of the Veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). The Veteran filed his request to reopen his previously denied claim for service connection for sleep apnea in April 2010. Regarding requests to reopen filed on and after August 29, 2001, 38 C.F.R. § 3.156(a) defines “new” evidence as evidence not previously submitted to agency decision makers and “material” evidence as 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 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 new and material evidence has been received, VA must initially decide whether evidence received since the prior final denial is, in fact, new. As indicated by the regulation cited above, and by judicial case law, “new” evidence is that which was not of record at the time of the last final disallowance (on any basis) of the claim, and is not duplicative or “merely cumulative” of other evidence then of record. This analysis is undertaken by comparing the newly received evidence with the evidence previously of record. After evidence is determined to be new, the next question is whether it is material. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but also whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. The provisions of 38 U.S.C. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-83 (1996). Here, the last final denial of the claim is the September 2005 rating decision. Furthermore, for purposes of the “new and material” analysis, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). Pertinent evidence added to the claims file since the September 2005 rating decision includes VA treatment records, private treatment records, Social Security Administration (SSA) records, a private medical opinion from Dr. C.N.B., lay statements from the Veteran, and a transcript of the January 2017 Board hearing. This evidence addresses a possible link, or nexus between the Veteran’s current sleep apnea and his service-connected sarcoidosis. In particular, the Veteran has contended in written statements and during the January 2017 Board hearing that his sleep apnea is related to his service-connected sarcoidosis. In addition, in an August 2010 private medical opinion, Dr. C.N.B. indicated the same, and stated that the Veteran’s weight gain was likely due to his steroid use for his sarcoidosis and his weight gain was the most likely cause of his sleep apnea. The Board finds that the above-described evidence, when considered in light of the evidence previously of record, provides a basis for reopening the previously-denied claim, consistent with the low threshold described in Shade. This evidence is “new” in that it was not before the RO at the time of the September 2005 denial, and is not duplicative or cumulative of the evidence previously of record. Moreover, this evidence is “material” in that it is potentially relevant to the question of etiology of the Veteran’s sleep apnea. Notably, the Veteran’s theory of service connection for sleep apnea prior to the September 2005 rating decision only included direct service connection, not secondary service connection. While not in any way dispositive, as this newly received evidence, at a minimum, triggers VA’s duty to obtain an examination and/or opinion, as explained in further detail below, the Board finds that such evidence raises a reasonable possibility of substantiating the Veteran’s service connection claim—albeit, under alternative theory of entitlement not previously considered. Under these circumstances, the Board concludes that the criteria for reopening the claim for service connection for sleep apnea are met. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156. REASONS FOR REMAND The Board’s review of the claims file reveals that further agency of original jurisdiction (AOJ) action on the reopened claim, on the merits, as well as the other remaining claims on appeal is warranted. Regarding the reopened claim for service connection for sleep apnea, at the outset, the Board notes that it has reopened the claim for service connection for sleep apnea, whereas the RO declined to reopen the claim. As the RO has not considered this claim for service connection, on the merits, remand of this matter to the AOJ for initial consideration is required to avoid any prejudice to the Veteran. See, e.g., Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Board also finds that, prior to such consideration, additional development of evidence pertinent to this claim is warranted. The Veteran contends that he currently has sleep apnea that is related to his service-connected sarcoidosis, to include medication taken for such disability. He has also indicated that his sleep apnea symptoms began in service. VA is required to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of disability, the record indicates that the disability or symptoms of disability may be associated with active service—or, as appropriate, service-connected disability—and the record does not contain sufficient information to decide on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The threshold for determining whether the record “indicates” that there “may” be a nexus between a current disability and active service or an already service-connected disability is a low one. See McLendon, 20 Vet. App. at 83. A veteran’s reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. See id. In this case, an August 2010 private opinion from Dr. C.N.B. confirms a current diagnosis of sleep apnea. Additionally, in this opinion, Dr. C.N.B. also indicated that the Veteran’s sleep apnea was related to his service-connected sarcoidosis—stating that the Veteran’s weight gain was likely due to his steroid use for his sarcoidosis and his weight gain was the most likely cause of his sleep apnea. Also, in a February 2012 statement and during the January 2017 Board hearing, the Veteran indicated that his sleep apnea symptoms began in service. However, to date, no VA examination has been conducted or medical opinion otherwise obtained addressing the nature and etiology of the Veteran’s sleep apnea. Therefore, given all the above, the Board finds that the threshold requirements discussed in McLendon are met, thus warranting VA examination. Accordingly, on remand, the AOJ should arrange for the Veteran to undergo VA sleep apnea examination, by an appropriate physician. The Veteran is hereby notified that failure to report to any scheduled examination, without good cause, may result in denial of his claim. See 38 C.F.R. § 3.655(b). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. The Board recognizes that the August 2010 private opinion by Dr. C.N.B., mentioned above, contains an opinion indicating a relationship between the Veteran’s current sleep apnea to medication taken for his service-connected sarcoidosis. However, no rationale for such opinion was provided. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Although a discussion follows this opinion, such discussion does not address or discuss sleep apnea. Thus, while the August 2010 private opinion provided a sufficient basis, in part, to reopen the service connection claim for sleep apnea and to warrant VA examination with regard to such claim (as discussed above), that opinion does not provide sufficient evidence to resolve the claim for service connection for sleep apnea, on the merits. Regarding the claims for service connection for hypertension, kidney disease, diabetes mellitus, and erectile dysfunction, the Veteran contends that all of these current disabilities are related to his service-connected sarcoidosis, to include medication taken for such disability. In connection with the kidney and hypertension claims, the Veteran underwent a VA examination in May 2010. The VA examiner diagnosed the Veteran with hypertension, and opined that the Veteran’s hypertension was less likely as not caused by or a result of treatment for his sarcoidosis. The VA examiner also found that the Veteran did not have a currently diagnosed kidney disease, and as such provided no opinion on the etiology of the Veteran’s claimed kidney disease. However, in a February 2012 VA opinion, the providing VA physician confirmed that the Veteran had stage II chronic kidney disease, and that it was due to hypertension, not sarcoidosis. In connection with the diabetes mellitus and erectile dysfunction claims, the Veteran underwent a VA examination in November 2010. The VA examiner diagnosed the Veteran with type II diabetes mellitus and erectile dysfunction. The VA examiner also opined that the Veteran’s service-connected sarcoidosis did not cause his diabetes mellitus or erectile dysfunction. However, while the above-mentioned VA examiners and VA physician addressed whether there exists a direct etiological relationship between the current disabilities at issue (hypertension, kidney disease, diabetes mellitus, and erectile dysfunction) and service-connected sarcoidosis or medication taken for such disability, the VA examiners and VA physician did not explicitly address whether the Veteran’s claimed disabilities is or has been aggravated (worsened beyond natural progression) by his service-connected sarcoidosis, to include medication taken for such disability. Notably, secondary service connection involves a two-part inquiry concerning both causation and aggravation. See 38 C.F.R. § 3.310(a); Allen, 7 Vet. App. at 448 (an opinion that something “is not related to” or “is not due to” does not answer the question of aggravation). Therefore, the Board concludes that the May 2010, February 2012, and November 2010 VA opinions are inadequate to resolve the claims for service connection for hypertension, kidney disease, diabetes mellitus, and erectile dysfunction, and that further medical opinion based on full consideration of the Veteran’s documented medical history and assertions, and supported by complete, clearly-stated rationale is needed to resolve these claims. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; McLendon, 20 Vet. App. at 81. See also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to obtain an examination or opinion when developing a service connection claim, even if not statutorily obligated to do so, it must provide or obtain one that is adequate for purposes of the determination being made). Accordingly, on remand, the AOJ should arrange to obtain addendum opinions from the May 2010 and November 2010 VA examiners, or, if necessary, from an appropriate physician based on claims file review (if possible). The AOJ should only arrange for further examination of the Veteran if such is deemed necessary in the judgment of the individuals designated to provide the addendum opinions. Prior to undertaking action responsive to the above, to ensure that all due process requirements are met, and that the record is complete, the AOJ should undertake appropriate action to obtain and associate with the claims file all outstanding, pertinent records. As for VA records, the claims file reflects that the Veteran has been receiving treatment from the VA Medical Center (VAMC) in Martinsburg, West Virginia, and that records from that facility dated through April 2013 are associated with the file; however, more recent records may exist. Therefore, the AOJ should obtain from the Martinsburg VAMC all pertinent, outstanding records of evaluation and/or treatment of the Veteran since April 2013, following the current procedures prescribed in 38 C.F.R. § 3.159(c) regarding requests for records from Federal facilities. The AOJ should also give the Veteran another opportunity to provide additional information and/or evidence pertinent to the remaining claims on appeal, explaining that he has a full one-year period to respond. See 38 U.S.C. § 5103(b)(1); but see 38 U.S.C. § 5103(b)(3) (clarifying that VA may decide a claim before the expiration of the one-year notice period). In its letter, the AOJ should specifically request that the Veteran provide, or provide appropriate authorization to obtain, any outstanding, pertinent private (non-VA) records. Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information and, if necessary, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted prior to adjudicating each claim remaining on appeal. As a final matter, with regard to the claim for a tear duct disability, in the May 2013 rating decision, the RO, inter alia, denied the Veteran’s request to reopen a claim for service connection for a tear duct disability. In April 2015, the RO issued an SOC which included discussion of the claim of whether new and material evidence to reopen a claim for service connection for a tear duct disability has been received, and in June 2015, the Veteran filed a VA Form 9 as to all the issues listed on the April 2015 SOC. However, no NOD appears to have been filed with respect to the tear duct disability claim. Notably, the only NOD of record following the May 2013 rating decision is a September 2013 NOD, and that NOD explicitly expresses disagreement with only the sleep apnea, hypertension, kidney disease, diabetes mellitus, and erectile dysfunction claims on appeal. The Board acknowledges that this issue was certified to the Board, and that the Veteran testified as to this issue during the January 2017 Board hearing. However, certification is only for administrative purposes and does not serve to confer or deprive the Board of jurisdiction. See 38 C.F.R. § 19.35. Also, the act of taking testimony did not confer Board jurisdiction of this matter. See 38 U.S.C. § 7104 (the Board only decides actual questions of fact or law in a case). Hence, a remand is required for the AOJ to consider the matter of whether the Veteran timely initiated an appeal with respect to the May 2013 denial of the Veteran’s request to reopen a claim for service connection for a tear duct disability, in the first instance, to avoid prejudice to the Veteran. See Bernard, supra. These matters are hereby REMANDED for the following action: 1. Adjudicate whether the Veteran timely initiated an appeal with respect to the May 2013 denial of the Veteran’s request reopen a claim for service connection for a tear duct disability. If it is determined that the Veteran did not initiate an appeal with respect to the above-noted matter, provide appropriate notice to the Veteran, and afford him full opportunity to appeal that jurisdictional determination regarding the request reopen a claim for service connection for a tear duct disability. 2. Obtain from the Martinsburg VAMC all outstanding records of evaluation and/or treatment of the Veteran, dated since April 2013. Follow the procedures of 38 C.F.R. § 3.159 regarding requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 3. Send to the Veteran a letter requesting that he provide sufficient information concerning, and, if necessary, authorization to enable VA to obtain, any additional evidence pertinent to the remaining claims on appeal that is not currently of record. Specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private (non-VA) records. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claims within the one-year period). 4. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 5. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo VA sleep apnea examination, by an appropriate physician. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated physician, and the examination report should reflect consideration of the Veteran’s documented medical history and lay assertions. All indicated tests and studies should be accomplished (with all findings made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner should provide an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s diagnosed sleep apnea: (a) had its onset during service, or is otherwise medically related to service; or, if not. (b) was caused OR is or has been aggravated (worsened beyond the natural progression) by his service-connected sarcoidosis, to include medication taken for such disability. Both causation and aggravation must be addressed. If aggravation is found, the examiner should attempt to quantify the additional disability resulting from aggravation, to include identifying (to the extent possible), the baseline level of disability prior to the aggravation. In addressing the above, the examiner must consider and discuss all pertinent medical and other objective evidence of record, as well as all lay assertions—to include, the Veteran’s assertions as to the nature, onset and continuity of symptoms. Notably, in addressing nexus to service, the absence of documented evidence of a specific sleep apnea diagnosis or associated symptoms during or shortly after service should not, alone, serve as the sole basis for a negative opinion. In this regard, the examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating the requested opinion. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. All examination findings/testing results, along with complete, clearly-stated rationale for the conclusions reached, must be provided. 6. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange to obtain from the May 2010 VA examiner an addendum opinion addressing the etiology of the Veteran’s hypertension and kidney disease. If that individual is no longer employed by VA or is otherwise unavailable, document that fact in the claims file, and arrange to obtain, from an appropriate physician, a medical opinion based on claims file review (if possible). Only arrange for the Veteran to undergo further VA examination, by an appropriate physician, if one is deemed necessary in the judgment of the individual designated to provide the addendum opinion. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated individual, and the addendum opinion/examination report should reflect consideration of the Veteran’s documented medical history and lay assertions. Hypertension – The examiner or physician should provide opinions, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s diagnosed hypertension: (a) was caused by the Veteran’s service-connected sarcoidosis, to include medication taken for such disability; or (b) is or has been aggravated (worsened beyond the natural progression) by the Veteran’s service-connected sarcoidosis, to include medication taken for such disability. Kidney disease – The examiner or physician should provide opinions, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s diagnosed kidney disease: (a) was caused by the Veteran’s service-connected sarcoidosis, to include medication taken for such disability; or (b) is or has been aggravated (worsened beyond the natural progression) by the Veteran’s service-connected sarcoidosis, to include medication taken for such disability. Both causation and aggravation must be addressed. If aggravation is found, the examiner or physician should attempt to quantify the additional disability resulting from aggravation, to include identifying (to the extent possible), the baseline level of disability prior to the aggravation. In addressing the above, the examiner or physician must consider and discuss all pertinent medical and other objective evidence of record, as well as all lay assertions—to include, the Veteran’s assertions as to the nature, onset and continuity of symptoms. The examiner or physician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating the requested opinions. If lay assertions in any regard are discounted, the examiner or physician should clearly so state, and explain why. All examination findings/testing results (if any), along with complete, clearly-stated rationale for the conclusions reached, must be provided. 7. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange to obtain from the November 2010 VA examiner an addendum opinion addressing the etiology of the Veteran’s diabetes mellitus and erectile dysfunction. If that individual is no longer employed by VA or is otherwise unavailable, document that fact in the claims file, and arrange to obtain, from an appropriate physician, a medical opinion based on claims file review (if possible). Only arrange for the Veteran to undergo further VA examination, by an appropriate physician, if one is deemed necessary in the judgment of the individual designated to provide the addendum opinion. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated individual, and the addendum opinion/examination report should reflect consideration of the Veteran’s documented medical history and lay assertions. Diabetes mellitus – The examiner or physician should provide opinions, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s diagnosed diabetes mellitus: (a) was caused by the Veteran’s service-connected sarcoidosis, to include medication taken for such disability; or (b) is or has been aggravated (worsened beyond the natural progression) by the Veteran’s service-connected sarcoidosis, to include medication taken for such disability. Erectile dysfunction – The examiner or physician should provide opinions, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s diagnosed erectile dysfunction: (a) was caused by the Veteran’s service-connected sarcoidosis, to include medication taken for such disability; or (b) is or has been aggravated (worsened beyond the natural progression) by the Veteran’s service-connected sarcoidosis, to include medication taken for such disability. Both causation and aggravation must be addressed. If aggravation is found, the examiner or physician should attempt to quantify the additional disability resulting from aggravation, to include identifying (to the extent possible), the baseline level of disability prior to the aggravation. In addressing the above, the examiner or physician must consider and discuss all pertinent medical and other objective evidence of record, as well as all lay assertions—to include, the Veteran’s assertions as to the nature, onset and continuity of symptoms. The examiner or physician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating the requested opinions. If lay assertions in any regard are discounted, the examiner or physician should clearly so state, and explain why. All examination findings/testing results (if any), along with complete, clearly-stated rationale for the conclusions reached, must be provided. 8. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 9. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the remaining claims on appeal considering all pertinent evidence (to include all evidence added to the electronic claims file since the last adjudication) and legal authority. JACQUELINE E. MONROE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Rothstein, Associate Counsel