Citation Nr: 18156825 Decision Date: 12/11/18 Archive Date: 12/10/18 DOCKET NO. 16-34 158 DATE: December 11, 2018 ORDER Entitlement to an initial compensable evaluation for bilateral hearing loss is denied. Entitlement to service connection for cardiovascular disease, to include as due to exposure to herbicide agents, and/or as secondary to service-connected PTSD, is denied. REMANDED Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to an initial disability rating in excess of 10 percent for tinnitus is remanded. Entitlement to service connection for a skin disorder, to include as due to exposure ot herbicide agents, is remanded. Entitlement to service connection for hypertension to include as secondary to service-connected PTSD, is remanded. Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD, is remanded. Entitlement to service connection for residuals of a cold injury to the bilateral hands is remanded. Entitlement to service connection for residuals of a cold injury to the left lower extremity, to include the foot, ankle, knee, and hip is remanded. Entitlement to service connection for residuals of a cold injury to the right lower extremity, to include the foot, ankle, knee, and hip is remanded. FINDINGS OF FACT 1. For the entire appeal period, the Veteran had no worse than Level I hearing loss in the right and left ear. 2. The Veteran does not have a current diagnosis of cardiovascular disease. CONCLUSIONS OF LAW 1. The criteria for an initial compensable disability rating for hearing loss have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.85, 4.86, Diagnostic Code 6100. 2. The criteria to establish entitlement to service connection for cardiovascular disease, to include as due to exposure to herbicide agents, and/or as secondary to service-connected PTSD, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from July 1962 to July 1965. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision. I. Duties to Notify and Assist The Board acknowledges the Veteran’s assertion that the September 2014 VA examination that evaluated his bilateral hearing loss was inadequate. See October 2014 Notice of Disagreement. However, the Veteran has not provided any further details to explain why the examination might be inadequate. The Board finds that this examination is adequate, as it is predicated on a review of the Veteran's medical history as well as on an examination, and it fully addresses the rating criteria that are relevant to rating the Veteran's bilateral hearing loss. As the Veteran has not reported, and the record does not otherwise suggest, that there has been a material change in the severity of his disability since he was last examined in September 2014, the Board finds that another VA examination to address the current nature and severity of his bilateral hearing loss is unnecessary in this case. The Board also notes that the duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. The Board also notes that no medical examination has been conducted and that no medical opinion has been obtained with respect to the Veteran's service connection claim for cardiovascular disease. Although the Veteran has not been afforded a VA medical examination in connection with this claim, the Board concludes that one is not necessary. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). An examination or opinion is necessary if the evidence of record (A) contains competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; and (B) establishes that the veteran suffered an event, injury or disease in service; or has a presumptive disease or symptoms of such a disease manifesting during an applicable presumptive period; and (C) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service; but (D) does not contain sufficient medical evidence for the Secretary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006) (discussing the four elements to consider in determining whether a VA medical examination must be provided). However, the most probative evidence shows that there is no competent evidence of a current disability or peristent or recurrent symptoms of a disability. As such, the Board finds that an examination is not necessary. See Locklear v. Nicholson, 20 Vet. App. 410 (2006); see also McLendon, 20 Vet. App. at 83. The Veteran has not raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Law and Analysis 1. Entitlement to an initial compensable evaluation for bilateral hearing loss. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service connected disorder. 38 U.S.C. § 1155. The evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 U.S.C. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Evidence to be considered in an appeal from an initial disability rating was not limited to that reflecting the then current severity of the disorder. Fenderson v. West, 12 Vet. App. 119 (1999). In cases where an initially assigned disability evaluation has been disagreed with, it is possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson, 12 Vet. App. at 126-27; Hart v. Mansfield, 21 Vet. App. 505 (2007). Such separate disability ratings are known as staged ratings. 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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 54-55 (1990). The Veteran's bilateral hearing loss is currently assigned a noncompensable evaluation pursuant to 38 C.F.R. § 4.85, Diagnostic Code 6100. In evaluating service-connected hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. Lindenmann v. Principi, 3 Vet. App. 345, 349 (1992). Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on an organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with the average hearing threshold, as measured by puretone audiometric tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second. The rating schedule establishes 11 auditory acuity Levels designated from Level I for essentially normal hearing through Level XI for profound deafness. VA audiological evaluations are conducted using a controlled speech discrimination test together with the results of puretone audiometry tests. The vertical line in Table VI (printed in 38 C.F.R. § 4.85) represents nine categories of decibel I loss based on the puretone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to puretone decibel loss. The percentage evaluation is found from Table VII (in 38 C.F.R. § 4.85 and the statement of the case) by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate for the numeric designation of the level for the ear having the poorer hearing acuity. For example, if the better ear had a numeric designation of Level "V," and the poorer ear had a numeric designation of Level "VII," the percentage evaluation is 30 percent. 38 C.F.R. § 4.85. Regulations also provide that in cases of exceptional hearing loss, i.e., when the puretone threshold at each of the four specified frequencies (1,000, 2,000, 3,000, and 4,000 hertz) is 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. 38 C.F.R. § 4.85(a). The provisions of 38 C.F.R. § 4.86(b) further provide that when the puretone threshold is 30 decibels or less at 1,000 hertz and 70 decibels or more at 2,000 hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or VIa, whichever results in the higher numeral. That numeral will then be evaluated to the next higher Roman numeral. As noted above, the Veteran’s bilateral hearing loss was evaluated during a September 2014 VA examination. During the examination, the Veteran reported that he was unable to hear words clearly. He also described frequently needing to have others repeat things to him. The puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 35 25 45 60 41.25 LEFT 40 25 55 65 46.25 Speech audiometry using the Maryland CNC Word List revealed a speech recognition ability of 96 percent in the right and left ear. Based on these values, Table VI provides that a numeral of I should be assigned for the right and left ear. However, this paring of numerals results in a noncompensable evaluation under Table VII. In reviewing the results from the September 2014 VA examination, the Board has also considered whether Table VIa could be used to obtain a higher numeric designation for either ear. The Board notes that Table VIa assigns a Roman numeral designation for hearing impairment based only on the puretone threshold average, and is used when the examiner certifies that speech discrimination testing is not appropriate, or when indicated under the provisions of 38 C.F.R. § 4.86. 38 C.F.R. § 4.85(c). However, the examiner did not include a certification stating that use of a speech discrimination test was inappropriate. In addition, the evaluation did not show that the Veteran's puretone threshold at each of the four specified frequencies was 55 decibels or more. 38 C.F.R. § 4.86(a). The record also does not reflect that the Veteran had a puretone threshold of 30 decibels or less at 1,000 Hertz and 70 decibels or more at 2,000 Hertz in the right or left ear. 38 C.F.R. § 4.86(b). Consequently, the record does not indicate that Table VIa should be used. The regulations also provide that consideration of whether special monthly compensation (SMC) is warranted is required when evaluating any claim for impaired hearing. See 38 C.F.R. § 4.85(g). Certain levels of SMC may be awarded for deafness. However, the SMC criteria require bilateral deafness or some other service-connected disability, such as blindness, which do not apply to the Veteran's case. 38 U.S.C. § 1114; 38 C.F.R. § 3.350. Therefore, SMC is not warranted for the Veteran's bilateral hearing loss. Based on the foregoing, the Board finds that the Veteran is not entitled to a compensable evaluation for his bilateral hearing loss. The Board has considered the Veteran's lay assertions regarding the impact of his diminished hearing on his daily life. However, the assignment of disability ratings for hearing impairment are derived by a mechanical application of the Rating Schedule to the numeric designations based on the audiology examination results. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The Rating Schedule reflects that a higher rating can be awarded only when loss of hearing has reached a specified measurable level. Consequently, a compensable evaluation is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 54-55. 2. Entitlement to service connection for cardiovascular disease, to include as due to exposure to herbicide agents, and/or as secondary to service-connected PTSD. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases shall be service-connected if the requirements of section 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of section 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Section 3.307(d)(6) provides that the term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 C.F.R. § 3.307(d)(6)(i). Section 3.307(d)(6) also provides that a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(d)(6)(iii). Service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. Id. In addition, a veteran who during active military service between April 1, 1968, and August 31, 1971, served in a unit that operated in or near the Korean DMZ in an area in which herbicides are known to have been applied during that period, as determined by the DOD, shall be presumed to have been exposed during such service to a herbicide agent, unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(a)(6)(iv); 76 Fed. Reg. 4,245- 4,247 (January 25, 2011). This amendment is effective for all claims received by VA on or after February 24, 2011, and to claims pending before VA on that date, which includes the current appeal. The diseases presumed to be associated with herbicide exposure include: chloracne or other acneform diseases consistent with chloracne, type 2 diabetes (also known as type II diabetes or adult-onset diabetes), Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). For the purposes of § 3.307, the term herbicide agent means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. 38 C.F.R. § 3.307(a)(6)(i). Agent Orange is generally considered an herbicide agent and will be so considered in this decision. Service connection may also be granted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 48 (1995) (en banc). The Veteran contends that he has cardiovascular disease that is related to exposure to herbicide agents during active service and/or secondary to his service-connected PTSD. The Board will first determine if the Veteran has a current diagnosis of cardiovascular disease. The Veteran's STRs are negative for any complaints, treatment, or diagnoses related to cardiovascular disease. In the Veteran’s July 1962 enlistment examination, his heart was noted to be normal and the chest x-ray was negative. The Veteran also denied having any relevant complaints in the July 1962 Report of Medical History. There continued to be no heart abnormalities noted in the June 1965 separation examination, and the chest x-ray was still negative. The Veteran also denied having heart-related problems in the June 1965 Report of Medical History, including pain or pressure in chest and palpitation or pounding heart. After service, private treatment records indicate that the Veteran has been treated for hypertension, but they are negative for cardiovascular disease. In July 2013, a private treatment record noted that the Veteran’s heart had a regular rate and rhythm without any murmurs, gallops, or rubs. The Veteran’s lungs were clear to auscultation bilaterally, and his carotids were without bruits. The report from a subsequent November 2013 sleep study stated that the Veteran’s average heart rate during sleep was 58, and the highest was 77 during sleep and 81 during the whole recording, with a minimum heart rate of 53. The report also noted that the Veteran had a normal sinus rhythm, and any ECG findings that were considered significant or abnormal would be further discussed in the interpretation section of the report. However, the interpretation section did not include a discussion of any ECG findings. In a December 2017 letter, Dr. E. noted that the Veteran had been a patient in his practice for several years, and he received treatment for diabetes and hypertension. Dr. E. added that the Veteran also had sleep apnea and rosacea. However, the letter did not indicate that the Veteran had cardiovascular disease. In addition, the Veteran has not reported that he received a diagnosis for cardiovascular disease from a medical provider. The Board also notes that neither the Veteran nor the other evidence of record has suggested that he experiences recurrent or persistent symptoms of cardiovascular disease. Based on the foregoing, there has been no current diagnosis of cardiovascular disease at any time during the appeal period. The existence of a current disorder is a required element of a claim for VA disability compensation. 38 U.S.C. § 1110, 1131; Degmetich v. Brown, 104 F.2d 1328, 1332 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, service connection is not warranted. 38 C.F.R. §§ 3.303. The Board acknowledges the Veteran's contention that he has cardiovascular disease. However, the Board finds that as a lay person, the Veteran is not competent to diagnose cardiovascular disease because it is a complex medical determination, as opposed to a diagnosis capable of lay observation such as ringing in the ear or a broken leg. See 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002); Falzone v. Brown, 8 Vet. App. 398, 405 (1995). As the evidence of record does not demonstrate the presence of a current disability, the preponderance of the evidence is against the service connection claim for cardiovascular disease. Although the Board has considered the applicability of the benefit of the doubt doctrine, it is not applicable based on these facts. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 5356 (1990). Consequently, service connection is denied. REASONS FOR REMAND 1. Entitlement to an initial disability rating in excess of 50 percent for PTSD; entitlement to an initial disability rating in excess of 10 percent for tinnitus; and entitlement to service connection for a skin disorder, to include as due to exposure to herbicide agents, are remanded. The record shows that the September 2014 rating decision granted entitlement to service connection for PTSD and tinnitus, but denied the Veteran’s service connection claim for a skin disorder. In an October 2014 notice of disagreement (NOD), the Veteran stated that he disagreed with the entire September 2014 rating decision. It appears from a September 2016 VA Form 8 that the AOJ has interpreted this NOD as expressing disagreement with the initial disability ratings for PTSD and tinnitus as well as the denial of the Veteran’s service connection claim for a skin disorder. Although the AOJ has not yet addressed these issues in a statement of the case (SOC), they were certified to the Board. See September 2016 VA Form 8. The United States Court of Appeals for Veterans Claims (Court) has held that the filing of a substantive appeal is not a jurisdictional requirement, that the filing of a timely substantive appeal may be waived, and that where the RO takes actions to indicate that such filing has been waived (for instance by certifying the appeal), the Board has jurisdiction to decide the appeal. Percy v. Shinseki, 23 Vet. App. 37 (2009); Gonzalez-Morales v. Principi, 16 Vet. App. 556, 557-58 (2003); see also Archbold v. Brown, 9 Vet. App. 124, 132 (1996). However, these rulings are distinguishable from the instant appeal, because in Percy, Gonzalez-Morales, and Archbold, the Veteran received a SOC. Moreover, as the Veteran’s July 2016 VA Form 9 only includes a discussion of the issues that were actually adjudicated in the May 2016 SOC, it does not appear that the Veteran is proceeding under the impression that an appeal has been perfected for these other issues. A remand is therefore required for the issuance of a SOC. See Manlincon v. West, 12 Vet. App. 238 (1999). 2. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD; and entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD, are remanded. The record reflects that the Veteran has current diagnoses of hypertension and sleep apnea. See December 2017 letter from Dr. E. The Veteran contends that these disorders are secondary to his service-connected PTSD. See October 2014 NOD. The Veteran has submitted articles in support of this theory. In light of this evidence, the Board finds that a VA examination and medical opinion must be obtained. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (finding that when the medical evidence is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion, ordering a medical examination, or citing recognized medical treatises that clearly support its ultimate conclusions). 3. Entitlement to service connection for residuals of a cold injury to the bilateral hands; entitlement to service connection for residuals of a cold injury to the left lower extremity, to include the foot, ankle, knee, and hip; and entitlement to service connection for residuals of a cold injury to the right lower extremity, to include the foot, ankle, knee, and hip are remanded. The Veteran contends that he has residuals of cold injuries to the hands, feet, ankles, hips, and knees that were sustained during active service. The Veteran has asserted that the injuries occurred when he was exposed to extremely cold temperatures in the Korean DMZ. See May 2014 Statement. The Veteran is competent to report observable events and symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran’s military personnel records also reflect that he had active service in Korea. The Board finds that this evidence meets the low threshold to secure a VA medical examination and opinion. See McLendon, 20 Vet. App. at 81. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his hypertension; sleep apnea; and cold injuries to the hands, feet, ankles, hips, and knees. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding, relevant VA medical records. 2. Send the Veteran a statement of the case that addresses the issues of entitlement to an initial disability rating in excess of 50 percent for PTSD; entitlement to an initial disability rating in excess of 10 percent for tinnitus; and entitlement to service connection for a skin disorder, to include as due to exposure to herbicide agents. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issues should be returned to the Board for further appellate consideration. 3. After the preceding development in paragraph 1 is completed, schedule a VA examination to determine the nature and etiology of any hypertension that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts of the case as well as relevant medical principles is needed. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should state whether the Veteran has a current diagnosis of hypertension. If hypertension is diagnosed, the examiner should provide an opinion as to the following questions: (a) Whether it is at least as likely as not (a 50 percent probability or greater) that the disorder manifested during active service, or is otherwise causally or etiologically related to the Veteran's active service. (b) Whether it is at least as likely as not (a 50 percent probability or greater) that the disorder was caused or aggravated by the Veteran’s service-connected PTSD. 4. After the preceding development in paragraph 1 is completed, schedule a VA examination to determine the nature and etiology of any sleep apnea that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts of the case as well as relevant medical principles is needed. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should state whether the Veteran has a current diagnosis of sleep apnea. If sleep apnea is diagnosed, the examiner should provide an opinion as to the following questions: (a) Whether it is at least as likely as not (a 50 percent probability or greater) that the disorder manifested during active service, or is otherwise causally or etiologically related to the Veteran's active service. (b) Whether it is at least as likely as not (a 50 percent probability or greater) that the disorder was caused or aggravated by the Veteran’s service-connected PTSD. 5. After the preceding development in paragraph 1 is completed, schedule a VA examination to determine the nature and etiology of any residuals of cold injuries to the hands, feet, ankles, hips, and knees that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts of the case as well as relevant medical principles is needed. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should state whether the Veteran has residuals of a cold injury to the hands, feet, ankles, hips, and/or knees. For any identified residual, the examiner should opine whether it is at least as likely as not (a 50 percent probability or greater) that the residual manifested during active service, or is otherwise causally or etiologically related to the Veteran's active service. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.C. Spragins, Associate Counsel