Citation Nr: 18154078 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 15-34 836 DATE: November 29, 2018 ORDER 1. The appeal to reopen a claim of service connection for asthma is granted. 2. The appeal to reopen a claim of service connection for sleep apnea is denied. 3. The appeal to reopen a claim of service connection for hypertension is denied. 4. The appeal to reopen a claim of service connection for high cholesterol is denied. 5. The appeal to reopen a claim of service connection for residuals of traumatic brain injury (TBI) is granted. 6. The appeal to reopen a claim of service connection for migraine headaches is granted. 7. Service connection for obesity is denied. REMANDED 8. Entitlement to service connection for asthma (on de novo review) is remanded. 9. Entitlement to service connection for residuals of TBI (on de novo review) is remanded. 10. Entitlement to service connection for migraine headaches (on de novo review) is remanded. 11. Entitlement to service connection for erectile dysfunction (ED) is remanded. 12. Entitlement to increases in the (50 percent prior to June 17, 2015, and 70 percent from that date) ratings assigned for posttraumatic stress disorder (PTSD) with secondary alcohol dependence is remanded. FINDINGS OF FACT 1. An unappealed February 2009 rating decision denied service connection for asthma, finding that the evidence did not show that the Veteran had asthma; an unappealed May 2012 rating decision declined to reopen the claim of service connection for asthma. 2. Evidence received since the May 2012 rating decision includes a medical opinion relating the Veteran’s asthma to his service; relates to an unestablished fact necessary to substantiate the claim of service connection for asthma; and raises a reasonable possibility of substantiating such claim. 3. An unappealed May 2012 rating decision denied the Veteran service connection for sleep apnea, finding that there was no evidence of a link between sleep apnea and his military service. 4. Evidence received since the May 2012 rating decision is cumulative or does not tend to show that the Veteran’s sleep apnea is related to his service; does not relate to an unestablished fact necessary to substantiate the claim of service connection for sleep apnea; and does not raise a reasonable possibility of substantiating such claim. 5. An unappealed February 2009 rating decision denied service connection for hypertension, finding that the disease was not related to the Veteran’s service; an unappealed May 2012 rating decision declined to reopen a claim of service connection for hypertension. 6. Evidence received since the May 2012 rating decision is cumulative or does not tend to relate the Veteran’s hypertension to his service; does not relate to an unestablished fact necessary to substantiate the claim of service connection for hypertension; and does not raise a reasonable possibility of substantiating such claim. 7. An unappealed February 2009 rating decision denied the Veteran service connection for high cholesterol, finding that it is a laboratory finding and not a disability subject to service connection, and there was no evidence of a chronic disability underlying the high cholesterol. 8. Evidence received since the February 2009 rating decision is cumulative or does not tend to show that the Veteran’s high cholesterol, of itself, is a disability due to disease or injury subject to service connection, or identify an underlying chronic disability; does not relate to an unestablished fact necessary to substantiate a claim of service connection for high cholesterol; and does not raise a reasonable possibility of substantiating such claim. 9. An unappealed May 2012 rating decision denied service connection for residuals of TBI, finding that the evidence did not show a related injury in service, and there was no evidence of a link between the claimed disability and the Veteran’s service. 10. Evidence received since the May 2012 rating decision includes a medical opinion relating residuals of TBI to the veteran’s service; relates to an unestablished fact necessary to substantiate the claim of service connection for residuals of TBI; and raises a reasonable possibility of substantiating such claim. 11. An unappealed February 2009 rating decision denied service connection for headaches, finding that the Veteran’s headaches pre-existed, and were not permanently worsened by, his service; an unappealed May 2012 rating decision declined to reopen the claim of service connection for headaches. 12. Evidence received since the May 2012 rating decision includes a medical opinion statement suggesting that the Veteran’s headaches were aggravated by his service; relates to an unestablished fact necessary to substantiate the claim of service connection for headaches; and raises a reasonable possibility of substantiating such claim. 13. The Veteran’s obesity was not manifested in service, and of itself is not a disability due to disease or injury; it is not a compensable disability. CONCLUSIONS OF LAW 1. New and material evidence has been received and the claim of service connection for asthma may be reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 2. New and material evidence has not been received, and the claim of service connection for sleep apnea may not be reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 3. New and material evidence has not been received, and the claim of service connection for hypertension may not be reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 4. New and material evidence has not been received, and the claim of service connection for high cholesterol may not be reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 5. New and material evidence has been received and the claim of service connection for residuals of TBI may be reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 6. New and material evidence has been received and the claim of service connection for migraine headaches may be reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 7. Service connection for obesity is not warranted. 38 U.S.C. §§ 1110, 5107; 38 U.S.C. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from January 1992 to April 1992, from October 1992 to November 1994, and from October 2003 to February 2005. These matters are before the Board on appeal from a June 2014 rating decision. In his September 2015 substantive appeal, the Veteran requested a hearing before the Board. He failed to appear for a scheduled October 2018 hearing, and his hearing request is therefore considered withdrawn. Service Connection Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. § 7105. However, a claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 U.S.C. § 5108. “New” evidence means existing evidence not previously submitted to agency decision-makers. “Material” evidence means 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). When determining whether the claim should be reopened, the credibility of newly submitted evidence is presumed. Fortuck v. Principi, 17 Vet. App. 173, 179-80 (2003). Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disability first diagnosed after discharge may be service connected if all the evidence establishes that it was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Service connection is warranted for a disability that was caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310. The requirement of new and material evidence raising a reasonable possibility of substantiating the claim is a low threshold one. The U. S. Court of Appeals for Veterans Claims (CAVC) interpreted the language of 38 C.F.R. § 3.156(a) and viewed the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding opening”. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Board notes that pursuant to Robinson v. Nicholson, 21 Vet. App. 545 (2008), it is required to consider all issues raised either by the claimant or the evidence of record. However, under Velez v. Shinseki, 23 Vet. App. 199 (2009), in determining whether new and material evidence is required, the focus of the Board’s analysis must be on whether the evidence presented truly amounts to a new claim based upon distinctly diagnosed diseases or injuries. Although the Veteran has put forth a new (secondary service connection) theory of entitlement for hypertension (addressed in the discussion below), there is no distinctly diagnosed disease or disability upon which that claim may be addressed as new. Therefore, it must be addressed as a previously denied service connection claim for which new and material evidence is required to reopen. 1. Whether new and material evidence has been received to reopen a claim of service connection for asthma is granted. A February 2009 rating decision denied the Veteran service connection for asthma, finding essentially that he was not shown to have such disability. He was informed of, and did not appeal, that decision, or submit new and material evidence within a year following, and that decision is final. 38 U.S.C. § 7105. A May 2012 rating decision determined that new and material evidence was not received, and declined to reopen a claim of service connection for asthma. The Veteran was informed of, and did not appeal, that decision, or submit new and material evidence within a year following, and that decision is final. 38 U.S.C. § 7105. The evidence of record at the time of the May 2012 rating decision included the Veteran’s STRs, his lay statements, a VA examination report, and VA and private treatment records. Evidence received since the May 2012 rating decision includes VA and private treatment records, a medical opinion, and lay statements by the Veteran. In a September 2012 statement, Dr. Gallaher indicated that he had been treating the Veteran since June 2007, noting that at that time, the Veteran “had just returned from Iraq” and was experiencing some dyspnea. Dr. Gallaher opined, “I felt that he may have had some asthma induced by exposure to noxious materials during his tour of duty.” He stated that the Veteran took his asthma medications regularly and was compliant. Evidence received since the May 2012 rating decision was not before agency decision-makers at that time, is new, and directly addresses an unestablished fact necessary to substantiate the claim of service connection for asthma. It (specifically, a September 2012 private medical opinion) suggests that the Veteran has asthma that may be related to his service/environmental exposures therein. Considering the “low threshold” standard for reopening endorsed by the CAVC in Shade, the Board finds that the evidence is both new and material, and that the claim of service connection for asthma may be reopened. De novo consideration of the claim is addressed in the remand below. 2. Whether new and material evidence has been received to reopen a claim of service connection for sleep apnea is denied. A May 2012 rating decision denied service connection for sleep apnea, based on a finding that there was no evidence of a link between the claimed medical condition and the Veteran’s military service. He was informed of, and did not appeal, the decision, or submit new and material evidence within the following year, and that decision is final. 38 U.S.C. § 7105. The pertinent evidence of record at the time of the May 2012 rating decision included the Veteran’s STRs, VA and private treatment records, and the Veteran’s statements. The STRs are silent for complaints, findings, treatment, or diagnosis of sleep apnea. On a January 2005 post-deployment self-health assessment, he reported that he developed symptoms of still feeling tired after sleeping during his deployment. On June 2007 pulmonary consultation, the impressions included probable sleep apnea, and an overnight sleep study was recommended. Based on an August 2007 overnight polysomnogram, the impressions included mild sleep apnea and a possibility of upper airway resistance syndrome. Evidence received since the May 2012 rating decision includes VA and private treatment records, and statements by the Veteran. The additional treatment records show treatment for sleep apnea, but do not include an opinion regarding its etiology. Because service connection for sleep apnea was previously denied based on a finding that any such disability was unrelated to service, for evidence to be new and material in this matter, it would have to tend to relate the Veteran’s sleep apnea to his service. The Veteran’s additional lay statements describing symptoms in service are cumulative, and not new, evidence. His reports of continuing complaints postservice likewise are cumulative, and not new, evidence. To the extent that he may be seeking to relate his current sleep apnea to service by his own assertions to that effect, such assertions likewise are cumulative (and not new) evidence. While the treatment records added to the record since the May 2012 rating decision are new evidence in the sense that they were not considered in that decision, they are not material evidence. They do not show or suggest that the Veteran’s sleep apnea was incurred in or caused by his service; records showing that the Veteran has diagnoses of, and receives treatment for, sleep apnea do not tend to show that such disability may be related to service. Therefore, they do not relate to the unestablished fact necessary to substantiate the claim; do not raise a reasonable possibility of substantiating the claim; and are not material. In summary, the evidence received since May 2012 pertaining to the Veteran’s sleep apnea is cumulative and duplicate, it is not new evidence that tends to establish that such disability is related to his service. Therefore, the Board must find that the additional evidence received since May 2012 is not material evidence that addresses an unestablished fact necessary to substantiate the claim of service connection for sleep apnea, i.e., nexus of the disability to service; does not raise a reasonable possibility of substantiating such claim; and is not new and material. Accordingly, even the low threshold for reopening endorsed by the CAVC in Shade v. Shinseki, 24 Vet. App. 110 (2010) is not met, and the claim of service connection for sleep apnea may not be reopened. 3. Whether new and material evidence has been received to reopen a claim of service connection for hypertension is denied. The Veteran seeks to reopen a claim of service connection for hypertension, which he contends is either directly related to his service or, in the alternative, is secondary to his service-connected psychiatric disability, to include medication prescribed for the treatment thereof. A February 2009 rating decision denied the Veteran service connection for hypertension, finding essentially that such disease was not related to his service. He was informed of, and did not appeal, that decision, or submit new and material evidence within a year following, and that decision too is final. 38 U.S.C. § 7105. A May 2012 rating decision declined to reopen the claim of service connection for hypertension. The Veteran was informed of, and did not appeal, that decision, or submit new and material evidence within a year following, and that decision is final. 38 U.S.C. § 7105. The pertinent evidence of record at the time of the May 2012 rating decision included the Veteran’s STRs, VA and private treatment records, and the Veteran’s statements. The STRs are silent for findings, treatment, or diagnosis of hypertension. On August 2008 treatment, hypertension was initially diagnosed and Norvasc was prescribed. Additional treatment records showed ongoing treatment for hypertension, but do not include evidence pertaining to its etiology. Evidence received since the May 2012 rating decision includes VA and private treatment records, and statements by the Veteran. The additional treatment records show continuing treatment for hypertension, but do not include an opinion regarding its etiology. Because service connection for hypertension was previously denied essentially based on a finding that such disability was unrelated to service, for evidence to be new and material in this matter, it would have to tend to show that the Veteran’s hypertension is indeed related to his service or (as alleged) was caused or aggravated by a service-connected disability or medication prescribed for the treatment thereof. The Veteran’s additional lay statements describing symptoms in service or within one year following service are cumulative, and not new, evidence. His reports of continuing complaints postservice likewise are cumulative, and not new, evidence. To the extent that he may be seeking to relate his current hypertension to service or to treatment after service, by his own assertions to that effect, such assertions likewise are cumulative (and not new) evidence. While the treatment records added to the record since the May 2012 rating decision are new evidence in the sense that they were not considered in that decision, they are not material evidence. They do not show or suggest that hypertension was incurred in or caused by service, or was caused or aggravated by a service-connected disability or medication prescribed for treatment thereof; records showing that the Veteran has diagnoses of, and receives treatment for, hypertension do not tend to show that any such disability may be related to service or to a service-connected disability. Therefore, they do not relate to the unestablished fact necessary to substantiate the claim; do not raise a reasonable possibility of substantiating the claim; and are not material. In summary, the evidence pertaining to hypertension received since May 2012 is cumulative and duplicate, and is not new evidence that tends to support that such disability is related to the Veteran’s service or is secondary to a service-connected disability (or medication for a service-connected disability). Therefore, the Board must find that the additional evidence received since May 2012 is not material evidence that addresses an unestablished fact necessary to substantiate the claim of service connection for hypertension, i.e., nexus of the disability to service or to a service-connected disability to include medication used for the treatment thereof; does not raise a reasonable possibility of substantiating such claim; and is not new and material. Accordingly, even the low threshold standard for reopening endorsed by the CAVC in Shade v. Shinseki, 24 Vet. App. 110 (2010) is not met, and the claim of service connection for hypertension may not be reopened. 4. Whether new and material evidence has been received to reopen a claim of service connection for high cholesterol is denied. A February 2009 rating decision denied the Veteran service connection for high cholesterol, finding that high cholesterol is a laboratory finding and not a disability subject to service connection, and there was no evidence of a chronic disability underlying the high cholesterol. He was informed of, and did not appeal, the decision, or submit new and material evidence within the following year, and that decision is final. 38 U.S.C. § 7105. The pertinent evidence of record at the time of the February 2009 rating decision included the Veteran’s STRs, VA and private treatment records, and the Veteran’s statements. The STRs are silent for findings, treatment, or diagnosis of high cholesterol. On August 2008 treatment, hyperlipidemia was diagnosed and medication was prescribed for treatment thereof. Additional treatment records reflect assessments of high cholesterol/hyperlipidemia with no opinion offered regarding etiology. Evidence received since the February 2009 rating decision includes VA and private treatment records, and statements by the Veteran. The additional treatment records show assessments of high cholesterol/hyperlipidemia, with no further opinion regarding etiology, and no evidence of a chronic disability associated with high cholesterol. Because service connection for high cholesterol was previously denied based on a finding that of itself it is a laboratory finding, and not a disability subject to service connection (and that an underlying disease manifested by high cholesterol was not shown), for evidence to be new and material in the matter, it would have to tend to show that there is a chronic disability associated with high cholesterol related to the Veteran’s service. The Veteran’s additional lay statements describing symptoms in service are cumulative, and not new, evidence. His reports of continuing complaints postservice likewise are cumulative, and not new, evidence. To the extent that he may be seeking to relate his current high cholesterol to service by his own assertions to that effect, such assertions likewise are cumulative (and not new) evidence. While treatment records added to the record since the February 2009 rating decision are new evidence in that they were not considered in that decision, they are not material evidence. They do not show or suggest that a current chronic disability manifested by high cholesterol was incurred in or caused by service; records showing that the Veteran has assessments of, and receives treatment for, high cholesterol do not tend to show that he has a chronic disability manifested by high cholesterol, that may be related to his service. Therefore, they do not relate to the unestablished fact necessary to substantiate the claim; do not raise a reasonable possibility of substantiating the claim; and are not material evidence. In summary, the evidence received since February 2009 pertaining to the Veteran’s high cholesterol is cumulative and duplicate; it is not new evidence that tends to support that that he has a chronic disability manifested by cholesterol that may be related to his service. Therefore, the Board must find that the additional evidence received since February 2009 is not material evidence that addresses an unestablished fact necessary to substantiate the claim of service connection for high cholesterol; does not raise a reasonable possibility of substantiating such claim; and is not new and material. Accordingly, even the low threshold standard for reopening endorsed by the CAVC in Shade v. Shinseki, 24 Vet. App. 110 (2010) is not met, and the claim of service connection for high cholesterol may not be reopened. 5. Whether new and material evidence has been received to reopen a claim of service connection for residuals of TBI is granted. A May 2012 rating decision denied the Veteran service connection for residuals of TBI, finding essentially that the evidence did not show any related event or injury in service, and there was no evidence of a link between the claimed medical condition and military service. He was informed of, and did not appeal, that decision, or submit new and material evidence within a year following, and that decision is final. 38 U.S.C. § 7105. The evidence of record at the time of the May 2012 rating decision included the Veteran’s STRs, his lay statements, and VA and private treatment records. Evidence received since the May 2012 rating decision includes VA and private treatment records, a medical opinion, and lay statements by the Veteran. In July 2013, the Veteran submitted a January 2012 statement by Dr. John, who indicated that he has been treating the Veteran since 2003, at which time he had no medical problems. He stated that the Veteran was sent to serve in Iraq in 2004 to 2005 with roles that included Troop Convoy services with occasional combat and, during these encounters, the Veteran suffered several concussions for which he did not seek medical care because he perceived them to be minor. Dr. John stated that after service, the Veteran could not work consistently as a medical transporter due to headaches and increasing anxiety with nightmares and night terrors. Dr. John stated that the Veteran was found by neurologist Dr. Reynolds to have suffered TBI from recurrent trauma (multiple concussions during combat service) and refractory migraine headaches. The evidence received since the May 2012 rating decision was not before agency decision-makers at that time, is new, and directly addresses an unestablished fact necessary to substantiate the claim of service connection for asthma. It (specifically, a private medical opinion received in July 2013) suggests that the Veteran has residuals of TBI that may be related to his service/events therein. Considering the “low threshold” standard for reopening endorsed by the CAVC in Shade, the Board finds that the evidence is both new and material, and that the claim of service connection for residuals of TBI may be reopened. De novo consideration of the claim is addressed in the remand below. 6. Whether new and material evidence has been received to reopen a claim of service connection for migraine headaches is granted. A February 2009 rating decision denied the Veteran service connection for headaches, finding essentially that the disability pre-existed service and was not permanently worsened by service. He was informed of, and did not appeal, that decision, or submit new and material evidence within a year following, and that decision is final. 38 U.S.C. § 7105. A May 2012 rating decision determined that new and material evidence was not received, and declined to reopen a claim of service connection for headaches. The Veteran was informed of, and did not appeal, that decision, or submit new and material evidence within a year following, and that decision is also final. 38 U.S.C. § 7105. The evidence of record at the time of the May 2012 rating decision included the Veteran’s STRs, his lay statements, and VA and private treatment records. Evidence received since the May 2012 rating decision includes VA and private treatment records, a medical opinion statement, and lay statements by the Veteran. In July 2013, the Veteran submitted a January 2012 statement by Dr. John indicating that he has been treating the Veteran since 2003 (when he had no medical problems). Dr. John noted that the Veteran was sent to serve in Iraq in 2004 to 2005 and sustained several concussions for which he did not seek medical care because he perceived them to be minor. Dr. John opined that after service, the Veteran could not work consistently as a medical transporter due to headaches. He stated that the Veteran suffers from daily debilitating headaches and was found by neurologist Dr. Reynolds to have suffered TBI (from repeat trauma in service) and refractory migraine headaches. The evidence received since the May 2012 rating decision was not before agency decision-makers at that time, is new, and directly addresses an unestablished fact necessary to substantiate the claim of service connection for headaches. It (specifically, a private medical opinion submitted in July 2013) suggests that the Veteran has migraine headaches that may be related to/aggravated by his service/events therein. Considering the “low threshold” standard for reopening endorsed by the CAVC in Shade, the Board finds that the evidence is both new and material, and that the claim of service connection for migraine headaches may be reopened. De novo consideration of the claim is addressed in the remand below. 7. Service connection for obesity is denied. The Veteran contends that he starved himself in Iraq most days because meals were limited, and the soldiers were served beef but he is a vegetarian; he now eats what he wants, when he wants, thinking that his food supply will be limited in some way like it was in Iraq. He alternatively contends that his obesity is related to his PTSD or to medication prescribed for his service-connected psychiatric disability. In a January 2012 statement, Dr. John stated that after service, the Veteran had great difficulty returning to civilian life and could not work consistently due to headaches and increasing anxiety with nightmares and night terrors; he stated that the Veteran’s finances struggled due to his under-employment and his self-neglect led to significant weight gain. There is no evidence in the record suggesting that the Veteran’s obesity arose in service; he was not obese on separation. Furthermore, obesity of itself is a manifestation and not a disability due to disease or injury; it is not of itself a compensable disability entity. If it was shown to be a symptom of a compensable disability, any related functional impairment would be considered in rating the underlying disability. The Veteran has not presented any medical evidence supporting that his obesity is a disability entity due to disease or injury or caused or aggravated by a service connected disability, and has not presented a valid claim of service connection for obesity. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Accordingly, the appeal in this matter must be denied. REASONS FOR REMAND 1. Entitlement to service connection for asthma (on de novo review) is remanded. In a September 2012 statement, noted above, Dr. Gallaher opined that the Veteran may have had asthma induced by exposure to noxious materials during service. The low threshold standard for determining when an examination is necessary is met. The Veteran has not been afforded a VA examination in connection with this this claim. An examination to secure a medical advisory opinion is necessary. 2. Entitlement to service connection for residuals of TBI (on de novo review) is remanded. 3. Entitlement to service connection for migraine headaches (on de novo review) is remanded. In January 2012 Dr. John stated that a neurologist, Dr. Reynolds, found the Veteran to have a TBI from repeat trauma (multiple concussions) sustained in combat, and refractory migraine headaches. A review of the claims file found that the AOJ has not yet sought the Veteran’s records of treatment by these private providers. Development, with the Veteran’s assistance, to ensure that all pertinent treatment records are located and associated with the record is necessary. In the January 2012 statement, Dr. John further noted that the Veteran had no medical problems when he began treating him in 2003 and that, after his service in Iraq, he suffered from daily debilitating headaches that interfered with his ability to work. The Board notes that on his October 1991 enlistment examination, the Veteran reported a history of frequent or severe headaches, occurring twice a week for the previous 2 to 3 years. The Veteran contends that his headache disability which pre-existed his service was permanently worsened by service. Additional medical guidance is necessary. If the outstanding records show a diagnosis of TBI (or residuals) a medical advisory opinion in the matter would be needed. 4. Entitlement to service connection for ED is remanded. The Veteran contends that his ED was caused by medication prescribed for his service-connected psychiatric disability. On January 2011 VA psychiatric examination, the Veteran reported medical problems including ED, for which he was treated with vardenafil. On June 2012 VA treatment, the Veteran reported decreased erections and decreased libido; the assessments included “ED related to mental illness vs. treatment of same”. The Veteran has not been afforded a VA examination in connection with this claim. An examination is necessary. 5. Entitlement to increases in the (50 percent prior to June 17, 2015, and 70 percent from that date) ratings assigned for PTSD with secondary alcohol dependence is remanded. In an October 2018 statement, the Veteran’s representative contends that the most recent [April 2014] VA examination is too old to reflect the current status of the Veteran’s psychiatric disability, and requested a contemporaneous examination. Given the length of the intervening period since the Veteran was last examined and the allegation of worsening, a contemporaneous examination to assess the disability is necessary. The record reflects that there may be outstanding pertinent VA treatment records. Any such records are constructively of record, and must be secured. The matters are REMANDED for the following: 1. Obtain for the record the Veteran’s complete updated (from June 2014 to the present) records of VA treatment for the disabilities remaining on appeal. 2. Ask the Veteran to complete a VA Form 21-4142 for neurologist Dr. Reynolds, authorizing VA to obtain his treatment records from that provider. Secure complete clinical records of his treatment from Dr. Reynolds. If there is no response to the request for records, make a second request (unless it is clear after the first request that a second request would be futile0. 3. Then arrange for the Veteran to be examined by an appropriate clinician to determine the nature and likely etiology of his migraine headache disability, and in particular whether or not it was incurred in or aggravated by his service. The Veteran’s entire record (to include this remand) must be reviewed by the examiner in conjunction with the examination. On examination and interview of the Veteran and review of his record, the examiner should provide opinions that respond to the following: (a.) Identify the Veteran’s headache disability by diagnosis. (b.) Opine whether at least as likely as not (a 50% or better probability) that the diagnosed headache disability is etiologically related to the Veteran’s service (was incurred therein)? (c.) If the answer to (a) is no, is it at least as likely as not (a 50% or better probability) that any pre-existing headache disability increased in severity during any of the Veteran’s periods of active duty service? If a headache disability increased in severity during service, please opine further whether there is any evidence in the record (if so, identifying the evidence) that renders it indisputable from a medical standpoint that the pre-existing headache disability was not aggravated during service, or that any increase in severity therein was due to natural progression. If an increase in severity of headaches during service is found but attributed to natural progression, must cite to the factual evidence or medical literature that supports such conclusion. (d.) If the evidence obtained pursuant to remand directive #2 includes a diagnosis of TBI/residuals of TBI, arrange for a TBI protocol examination of the Veteran to determine whether he has a disability residual from a head injury/TBI in service. The Veteran’s claims file must be reviewed by the examiner in connection with such examination, and the examiner should be advised of any head trauma/injury(ies) acknowledged by VA. Any tests or studies indicated should be completed. If cognitive impairment is found, but determined to be unrelated to head trauma (or other etiological factor) in service, the provider should identify the etiology considered to be more likely (and cite to the factual data/medical literature that support such conclusion. The examiner(s) must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. 4. Arrange for a respiratory diseases examination of the Veteran to confirm he has asthma, and if so ascertain its etiology. The Veteran’s entire record (to include this remand) must be reviewed by the examiner in conjunction with the examination. On examination/interview of the Veteran and review of his record, the examiner should provide opinions that respond to the following: (a.) Does the Veteran have asthma? (b.) Identify the likely etiology of each respiratory disability entity diagnosed. Specifically, is it at least as likely as not (a 50% or greater probability) that it was incurred in service, to include as due to environmental exposures therein? (c.) If asthma is not diagnosed, but respiratory symptoms/impairment are noted, opine whether the Veteran has an undiagnosed respiratory disability. Include rationale with all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. 5. Also arrange for the Veteran to be examined by an appropriate physician to determine the likely etiology of his ED, and in particular whether it is related to (was caused or aggravated by) his service-connected psychiatric disability, to include medications prescribed for treatment thereof. The Veteran’s entire record (including this remand) must be reviewed by the examiner in conjunction with the examination. On examination/interview of the Veteran and review of his record, the examiner should provide opinions that respond to the following: (a.) Is it at least as likely as not (a 50% or greater probability) that the Veteran’s ED was incurred during his active duty service? (b.) If ED is determined to not have been incurred in service, please opine further whether it is at least as likely as not (a 50% or greater probability) that it was caused or aggravated by (increased in severity due to) the Veteran’s service-connected psychiatric disability, to include as due to medication prescribed for treatment thereof? The opinion must address aggravation. (c.) If the opinion is to the effect that the Veteran’s ED was not caused or aggravated by his service or by a service-connected disability/its medication, identify the etiology considered more likely. The examiner must explain rationale with all opinions. 6. Also arrange for a psychiatric evaluation of the Veteran to assess the severity of his PTSD with secondary alcohol dependence. The examiner should review the Veteran’s claims file and the schedular criteria for rating mental disorders. The examiner should describe in detail all signs and symptoms of PTSD with secondary alcohol dependence, noting the presence or absence of all symptoms listed in the schedular criteria for a 100 percent rating, as well as any symptoms of equivalent nature and severity found that are not listed in the schedular criteria. The examiner should describe the impact the PTSD with secondary alcohol dependence has on the Veteran’s occupational and daily activity living functioning. The examiner should include rationale with all opinions GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Schechner, Counsel