Citation Nr: 18157827 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 15-07 717 DATE: December 13, 2018 ORDER New and material evidence having been received, the claim of entitlement to service connection for a low back disorder is reopened; the appeal is granted to this extent only. New and material evidence having been received, the claim of entitlement to service connection for a left knee disorder is reopened; the appeal is granted to this extent only. Service connection for high cholesterol is denied. REMANDED Entitlement to service connection for a left shoulder disorder, to include arthritis and residuals of ligamental tears, is remanded. Entitlement to service connection for a right shoulder disorder, to include arthritis and residuals of ligamental tears, is remanded. Entitlement to service connection for a left arm disorder, to include arthritis, is remanded. Entitlement to service connection for a right arm disorder, claimed as arthritis, is remanded. Entitlement to service connection for a low back disorder, to include arthritis, is remanded. Entitlement to service connection for a left leg disorder, to include arthritis, is remanded. Entitlement to service connection for a right leg disorder, to include arthritis, is remanded. Entitlement to service connection claim for a left knee disorder, to include arthritis, is remanded. Entitlement to service connection claim for a right knee disorder, to include arthritis, is remanded. Entitlement to service connection for a cardiac disorder is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to an initial rating in excess of 10 percent for hiatal hernia with gastroesophageal reflux disease (GERD) and residuals of a duodenal ulcer, to include duodenitis, esophagitis, and gastritis, is remanded. Entitlement to service connection for a left foot disorder is remanded. Entitlement to service connection for a right foot disorder is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for chronic sinusitis is remanded. Entitlement to service connection for allergic rhinitis is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for tinea cruris is remanded. FINDINGS OF FACT 1. An April 1984 rating decision that denied service connection for low back and left knee disorders is final. 2. Evidence added to the record since the final April 1984 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for a low back disorder. 3. Evidence added to the record since the final April 1984 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran’s claim of entitlement to service connection for a left knee disorder. 4. High cholesterol is a blood serology finding, not a disability in and of itself subject to service connection. CONCLUSIONS OF LAW 1. The April 1984 rating decision that denied service connection for low back and left knee disorders is final. 38 U.S.C. § 4005(c) (1982) [38 U.S.C. § 7105(c) (2012)]; 38 C.F.R. §§ 3.104, 19.129, 19.192 (1983) [(38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2017)]. 2. New and material evidence has been received to reopen the claim of entitlement to service connection for a low back disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. New and material evidence has been received to reopen the claim of entitlement to service connection for a left knee disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 4. The criteria for service connection for high cholesterol have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303; 61 Fed. Reg. 20,440 (May 7, 1996). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1964 to March 1984. This matter comes before the Board on appeal from rating decisions issued in July 2010 and November 2017 by a Department of Veterans Affairs (VA) Regional Office (RO). While the Veteran initially requested a Board hearing before a Veterans Law Judge in connection with his appeal of the July 2010 rating decision, he later withdrew his request in October and November 2018 correspondences. The Board acknowledges that the Agency of Original Jurisdiction (AOJ) adjudicated and certified for appeal a separate claim for service connection for “arthritis.” However, the Veteran does not report, and the evidence does not suggest, that he has a diffuse form of arthritis, such as rheumatic arthritis, affecting numerous joints. Rather, he reports a degenerative form of arthritis affecting his bilateral shoulders, arms, back, legs, and knees. Thus, in order to more accurately reflect the benefits sought, the Board has either created new issues reflecting these separate claimed orthopedic disabilities (and incorporating his arthritis claim therein), or incorporated his claimed arthritis into other orthopedic claims certified to the Board for review, and recharacterized those claims accordingly. The Board further acknowledges that additional evidence relevant to the claims on appeal has been associated with the record since the AOJ’s most recent adjudication. However, the Board is reopening the Veteran’s previously-denied claims for low back and left knee disorders, which is completely favorable, and denying the claim for service connection claim for high cholesterol as a matter of law, thus any newly-associated evidence relevant to this claim is irrelevant. Furthermore, the AOJ will have an opportunity to review the newly received evidence in the readjudication of the remaining claims on remand. As to the Veteran’s claims seeking service connection for bilateral foot disorders, bilateral hearing loss, chronic sinusitis, allergic rhinitis, erectile dysfunction, and tinea cruris, which have not yet been perfected for appeal, the Board has assumed jurisdiction of these claims for the limited purpose of remanding them for the issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). 1. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a low back disorder. 2. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a left knee disorder. The RO denied the Veteran’s original service connection claims for low back and left knee disorders in an April 1984 rating decision. While the notification letter accompanying this rating decision, which would include the Veteran’s appellate rights, is not of record, the Board nevertheless concludes he was appropriately notified of this April 1984 rating decision and his appellate rights, pursuant to the presumption of regularity regarding the official acts of public officers. See Mindenhall v. Brown, 7 Vet. App. 271, 274 (1994) (presumption of regularity applies to RO's mailing of a VA decision to a veteran). However, he did not enter a notice of disagreement with such decision. Further, no additional evidence was received or constructively of record within one year of the issuance of such decision, and no relevant service department records have since been associated with the record. In this regard, while the Veteran’s service personnel records were received in August 2017, such do not contain relevant information as to the Veteran’s claimed low back and left knee disorders. Therefore, the April 1984 rating decision is final. 38 U.S.C. § 4005(c) (1982) [38 U.S.C. § 7105(c) (2012)]; 38 C.F.R. §§ 3.104, 19.129, 19.192 (1983) [(38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2017)]. Generally, a claim which has been denied in an unappealed Board decision or an unappealed AOJ decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. 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). New evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary’s duty to assist by providing a medical opinion. See Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). As reflected in the April 1984 rating decision, the AOJ denied the Veteran’s service connection claims for low back and left knee disorders based on the lack of current diagnoses of related chronic disabilities. However, the evidence received since such decision includes current diagnoses of lumbar spine degenerative disc disease and left knee degenerative joint disease. As this evidence establishes current diagnoses of chronic low back and left knee disorders, the evidence relates directly to the basis of the denial of the Veteran’s claims. Moreover, when coupled with service treatment records already of record reflecting the Veteran’s in-service treatment for low back and left knee complaints, this new evidence triggers VA’s duty to obtain a sufficient medical opinion regarding the potential relationship between these current chronic low back and left knee disorders and service, which is not currently of record. See Shade, supra. Specifically, while the AOJ obtained a medical opinion exploring such a potential medical nexus, the Board (as further discussed below) has determined that this medical opinion is legally insufficient. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Accordingly, as the newly associated evidence reflecting current diagnoses of chronic low back and left knee disorders was not previously of record, it is new; and as it triggers VA’s duty to obtain a new medical opinion, which, in turn, may substantiate the Veteran’s claims, the evidence is also material, sufficient to reopen the previously-denied claims. These reopened service connection claims are further addressed in the remand portion of this decision, below. 3. Entitlement to service connection for high cholesterol. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, 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). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran is seeking service connection for high cholesterol, and his medical treatment of record records this finding in both his service and current medical records. However, an elevated cholesterol level represents a laboratory finding and is not considered a disability for VA purposes. In language provided in the Federal Register, VA noted that, while veterans were “receiving diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol... [t]he diagnoses listed are actually laboratory test results, and are not, in and of themselves, disabilities. They are, therefore, not appropriate entities for the rating schedule to address.” See Schedule for Rating Disabilities; Endocrine System Disabilities, 61 Fed. Reg. 20,440, 20,445 (May 7, 1996). Accordingly, given that the Veteran’s claimed condition is not a disability eligible for service connection, the Board concludes his claim of service connection for high cholesterol must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994) (when the law and not the evidence is dispositive, a claim for entitlement to VA benefits should be denied or the appeal to the Board terminated because of the absence of legal merit or the lack of entitlement under the law). REASONS FOR REMAND As relevant to all claims appealed from the July 2010 rating decision, the Board finds that, while on remand, the Veteran should be given an opportunity to identify any records relevant to the claims on appeal that have not been obtained. Thereafter, all identified records, to include updated VA treatment records, should be obtained for consideration in his appeal. 4. Entitlement to service connection for a left shoulder disorder, to include arthritis and residuals of ligamental tears. 5. Entitlement to service connection for a right shoulder disorder, to include arthritis and residuals of ligamental tears. With regard to the Veteran’s claims for service connection for a bilateral shoulder disorder, he is currently diagnosed with bilateral shoulder degenerative joint disease, as well as residuals of shoulder ligamental tears, with his right shoulder ligamental tears surgically repaired in 2004 and his left shoulder ligamental tears, discovered and deemed “very old” in 2007, deemed too severe to be surgically repaired. Moreover, the Veteran sought treatment for left shoulder pain during service, and sought treatment for right shoulder pain not long after service, and he asserts that his current bilateral shoulder disorders resulted from the cumulative impact of his in-service duties. However, while an April 2010 VA medical opinion addressed the potential nexus between the Veteran’s bilateral shoulder disorders and service, the VA examiner summarily concluded that his shoulder (and other joint) disorders were due to age-related arthritis, and there is no significant in-service injury that could have caused or accelerated these arthritic processes. However, as this medical opinion fails to adequately address or consider the Veteran’s in-service left shoulder treatment for diagnosed bursitis; the fact that when discovered, his left shoulder rotator cuff tear was deemed “extremely old”; the Veteran’s right shoulder treatment relatively soon after service; or his contention that the cumulative impact of his in-service duties contributed to the development of his shoulder disorders; the Board finds that this medical opinion fails to adequately consider the Veteran’s complete medical history and contentions, thereby failing to establish that the medical opinion was fully informed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (holding that to have probative value, the opinion provider must be fully informed of the pertinent factual premises, provide a fully articulated opinion, and provide a supportive reasoned analysis); Barr, supra. Accordingly, a new VA opinion regarding the etiology of the Veteran’s current bilateral shoulder disorders is required. 6. Entitlement to service connection for a left arm disorder, to include arthritis. 7. Entitlement to service connection for a right arm disorder, claimed as arthritis. With regard to the Veteran’s claimed bilateral arm disorders, he has current diagnoses of bilateral elbow degenerative joint disease, as reflected in the aforementioned April 2010 VA joints examination. Moreover, the related medical opinion likewise fails to address the Veteran’s documented in-service left elbow treatment or consider his contentions that the cumulative impact of his in-service duties resulted in the arthritis affecting his various joints, including his arm joints. Accordingly, a new medical opinion is required to adequately address this relevant evidence of record. See id. 8. Entitlement to service connection claim for a low back disorder, to include arthritis. 9. Entitlement to service connection for a left leg disorder, to include arthritis. 10. Entitlement to service connection for a right leg disorder, to include arthritis. The Veteran is currently diagnosed with lumbar degenerative disc disease, as well as related spinal radiculopathies affecting his lower extremities, as reflected in the April 2010 VA examination report and in records of private and VA medical treatment rendered during the appeal period. Moreover, on multiple occasions, the Veteran was treated for lower back pain, radiating to his legs, during service (although no chronic lumbar spine disability was detected during service). However, the aforementioned April 2010 VA medical opinion summarily stating that the Veteran’s current lumbar spine disability (and related radiculopathies) are age-related and therefore unrelated to service fails to address or consider the Veteran’s in-service low back treatment, his documented lower back treatment relatively soon after service, reports of continuity of symptoms since service, or his contentions that the cumulative impact of his in-service duties resulted in the arthritis affecting his various joints, including his back and legs. Accordingly, a new medical opinion is required to adequately address this relevant evidence of record. See id. 11. Entitlement to service connection for a left knee disorder, to include arthritis. 12. Entitlement to service connection for a right knee disorder, to include arthritis. The Veteran is currently diagnosed with bilateral knee degenerative joint disease, as reflected in the April 2010 VA joints examination report. Moreover, he was treated for left knee injuries and pain on multiple occasions during service, and he asserts that his current bilateral knee arthritis is due to the cumulative impact of his in-service duties during his 20 years of service. However, as with the Veteran’s other claimed joint disorders, the April 2010 VA medical opinion fails to address in-service treatment specific to these claimed disabilities. In that regard, the examiner failed to address the Veteran’s in-service left knee pain or documented left knee injury; rather, the examiner concluded that the Veteran incurred no in-service knee injuries of sufficient severity to trigger his post-service development of arthritis, without referencing or discussing this documented treatment. The examiner further failed to address the Veteran’s theory of entitlement, namely that his current bilateral knee disorders have resulted from the cumulative impact of his in-service duties. Based on these deficiencies, the Board determines that a new VA medical opinion considering this relevant evidence must be obtained. Id. 13. Entitlement to service connection for a cardiac disorder. During service, the Veteran was diagnosed with mitral valve prolapse (MVP), and after service, he developed atrial fibrillation (a-fib), with his most recent a-fib episode of record occurring in May 2008, within one year prior to the receipt of his claim seeking service connection for a cardiac disorder, thereby satisfying the threshold service connection requirement of evidence of current diagnosis of a cardiac disorder. See Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). However, the June 2010 VA medical opinion exploring whether the Veteran has a current cardiac disorder related to service fails to provide an adequate rationale for the determination that his a-fib is unrelated to service, as the examiner summarily stated that the Veteran’s a-fib “does not seem related to service” without further explanation. Given this evidence of in-service and current cardiac disorders, an adequate medical opinion, predicated on a complete review of the record and supported by an adequate rationale, must be obtained. See Barr, supra. 14. Entitlement to service connection for hypertension. The Veteran is currently diagnosed with hypertension, as reflected in private and medical treatment rendered during the appeal period, and his service treatment records document elevated blood pressure readings, as defined by VA regulation. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). Further, as he served in Vietnam, his exposure to herbicide agents is presumed. In this regard, National Academy of Science (NAS) Institute of Medicine’s Veterans and Agent Orange: Update 11 (2018) upgraded hypertension from its previous classification in the category of “limited or suggestive” evidence of an association with exposure to Agent Orange to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. Accordingly, given this evidence of elevated blood pressure readings during service, as well as exposure to herbicide agents, and a current diagnosis of hypertension, a VA medical opinion exploring the potential relationship between this current disorder and service is required. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (holding that an examination is necessary if, inter alia, evidence indicates that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or service-connected disability). 15. Entitlement to an initial rating in excess of 10 percent for hiatal hernia with GERD and residuals of a duodenal ulcer, to include duodenitis, esophagitis, and gastritis. The Veteran is appealing with respect to the propriety of his initially assigned 10 percent rating for hiatal hernia and related disabilities. In order to warrant the assignment of the next higher rating of 30 percent, the evidence of record must establish that such disability is productive of dysphagia (difficulty swallowing), pyrosis (heartburn), and regurgitation, accompanied by substernal arm or shoulder pain, which is productive of considerable impairment of health. See 38 C.F.R. § 4.114, Diagnostic Code 7346. The record reflects that the Veteran was afforded a VA examination in November 2017, which incidentally was performed after his GERD increased rating claim was most recently adjudicated in a November 2017 rating decision. However, the November 2017 VA examination report fails to adequately state whether the Veteran does indeed have all of the symptoms required for the assignment of the next higher rating of 30 percent. In that regard, while the examination report lists the Veteran’s current symptoms attributable to GERD, it is unclear whether this list of symptoms indicates affirmative evidence that he does not have the other symptoms not listed (which are required for the assignment of the next higher rating). Accordingly, the Board finds that a new examination, in which the Veteran either affirms or denies the presence of all symptoms required for the assignment of a 30 percent rating, must be obtained, after which the Veteran’s claim should be readjudicated. See Barr, supra. 16. Entitlement to service connection for a left foot disorder. 17. Entitlement to service connection for a right foot disorder. 18. Entitlement to service connection for bilateral hearing loss. 19. Entitlement to service connection for chronic sinusitis. 20. Entitlement to service connection for allergic rhinitis. 21. Entitlement to service connection for erectile dysfunction. 22. Entitlement to service connection for tinea cruris. In a November 2017 rating decision, the AOJ denied service connection for bilateral foot disorders, bilateral hearing loss, chronic sinusitis, allergic rhinitis, erectile dysfunction, and tinea cruris, and the Veteran entered a notice of disagreement as to such denials in December 2017. Such issues have not been recorded in the Veterans Appeals Control and Locator System. When there has been an initial AOJ adjudication of a claim and a notice of disagreement as to its denial, the claimant is entitled to a statement of the case. 38 C.F.R. § 19.26. Thus, remand for issuance of a statement of the case as to such issues is necessary. Manlincon v. West, 12 Vet. App. 238 (1999). However, they will be returned to the Board after issuance of the statement of the case only if perfected by the filing of a timely substantive appeal. See Smallwood v. Brown, 10 Vet. App. 93, 97 (1997). The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records, to include updated VA treatment records dated from May 2017 to the present, should be obtained. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Forward the record to an appropriate clinician to obtain an addendum opinion addressing the etiology of the Veteran’s claimed orthopedic disabilities, namely his bilateral shoulder, bilateral arm, low back, bilateral leg, and bilateral knee disorders. The Veteran need not be reexamined, unless deemed necessary to render the requested opinions. Following a review of the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s currently diagnosed bilateral shoulder, bilateral arm, low back, bilateral leg, and bilateral knee disorders had their onset in service, manifested within one year of separation from service (for arthritis), or are otherwise directly related to service, to include his in-service complaints and/or duties. (a.) When rendering the opinion regarding the etiology of the Veteran’s bilateral shoulder disorders, the examiner is asked to consider and comment on the clinical significance of the following relevant evidence: • July 1981 in-service treatment for left shoulder pain; • December 1983 in-service treatment for left shoulder pain, with an assessment of bursitis; • February 1990 post-service treatment for ongoing right shoulder pain; • September 1993 right shoulder magnetic resonance imaging (MRI) report revealing degenerative changes; • March 2004 right shoulder surgery, with post-operative diagnoses of impingement and rotator cuff and biceps tendon tears; • March 2007 report of bilateral shoulder pain after a recent motor vehicle accident; • July 2007 diagnoses of multiple left shoulder tendon tears, including a large “very old” rotator cuff tear, and degenerative joint disease; • August 2007 recommendation for left shoulder surgery to debride shoulder and repair rotator cuff tear, if possible; • Subsequent treatment for ongoing bilateral shoulder pain and degenerative joint disease; • The Veteran’s assertions that his bilateral shoulder disorders are related to the cumulative impact of his in-service duties during his 20 years of active service. (b.) When rendering the opinion regarding the etiology of the Veteran’s bilateral arm disorders, the examiner is asked to consider and comment on the clinical significance of the following relevant evidence: • December 1977 in-service treatment for left forearm pain after a left elbow injury, at which time the Veteran was diagnosed with a left forearm strain, and left arm/elbow x-rays were deemed normal; • July 1981 in-service treatment for left arm and shoulder pain; • July 1982 (and numerous subsequent) in-service treatment for left arm tingling and numbness, attributed to various etiologies during service, but ultimately determined to likely be an atypical neurological manifestation of migraine headaches; • December 1983 in-service treatment for left arm and shoulder pain, assessed as left shoulder bursitis; • April 2009 post-service treatment for right arm pain, determined to likely be due to carpal tunnel syndrome; • April 2010 VA examination report diagnoses of bilateral elbow degenerative joint disease; • The Veteran’s assertions that his bilateral arm/elbow disorders are related to the cumulative impact of his in-service duties during his 20 years of active service. (c.) When rendering the opinion regarding the etiology of the Veteran’s low back and related lower leg disorders, the examiner is asked to consider and comment on the clinical significance of the following relevant evidence: • April 1970 in-service treatment for low back pain; • March 1976 in-service treatment for low back pain; • December 1977 in-service treatment for low back pain; • December 1980 in-service treatment for low back pain radiating to legs; • November 1982 in-service treatment for low back pain, pain on urination, and pain on ejaculation, with an assessment of low back pain of unknown etiology/rule out muscle spasm, and normal lumbar spine x-rays; • April 1989 post-service treatment for acute onset of low back pain and an inability to walk; • August 1991 lumbar spine x-ray noting disc space narrowing and MRI report noting degenerative changes; • February 2006 lumbar spine x-rays taken due to complaints of left leg pain, at which time spondylosis was detected; • March 2007 assessment of lumbar degenerative disc disease and mechanical low back pain; • July 2009 MRI report noting multiple degenerative changes, including degenerative disc disease, lumbar facet arthropathy, and spinal stenosis; • April 2010 VA examination report noting diagnosis of lumbar degenerative joint disease and degenerative disc disease radiating to legs, with a prior diagnosis of sciatica recorded; • The Veteran’s assertions that his lower back and leg disorders are related to the cumulative impact of his in-service duties during his 20 years of active service. (d.) When rendering the opinion regarding the etiology of the Veteran’s bilateral knee disorders, the examiner is asked to consider and comment on the clinical significance of the following relevant evidence: • March 1975 in-service treatment for a left knee injury, diagnosed as a left knee contusion; • April 1975 in-service treatment for continued left knee pain, with left knee x-rays ordered to determine the potential presence of osteochondritis, and with the Veteran excused from aerobic exercise for three weeks; • April 1978 in-service treatment for left knee pain with effusion; • August 1980 in-service treatment continued left knee pain under the patella after a June 1980 motor vehicle accident including a left knee injury, an assessment of possible osteochondritis, and a normal left knee x-ray; • April 2009 treatment for right knee pain; • April 2010 diagnosis of bilateral knee degenerative joint disease; • The Veteran’s assertions that his bilateral knee disorders are related to the cumulative impact of his in-service duties during his 20 years of active service. A rationale for any opinion offered should be provided. 3. Forward the record to an appropriate clinician to obtain an addendum opinion addressing the etiology of the Veteran’s claimed cardiac disorder and hypertension. The Veteran need not be reexamined, unless deemed necessary to render the requested opinions. Following a review of the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s atrial fibrillation and hypertension had their onset in service, manifested within one year of separation from service (for hypertension), or are otherwise directly related to service, to include his exposure to herbicide agents therein. (a.) When rendering the opinion regarding the etiology of the Veteran’s cardiac disorder, the examiner is asked to consider and comment on the clinical significance of the following relevant evidence: • February 1980 in-service diagnosis of mitral valve prolapse (MVP); • April 1980 in-service notation of MVP; • March 1981 in-service notation of current MVP; • February 1983 in-service notation of a two-year history of transient ischemic attacks, Barlow’s syndrome, and MVP; • December 1992 post-service work-up for atypical chest pain, resulting in diagnosis of a-fib/flutter; • October 1994 notation of a normal EKG, a normal cardiac catheter test in 1991, and a normal cardiac stress test in 1993; • September 2002 EKG noting no evidence of MVP; • June 2007 treatment for a recurrence of a-fib, as well as a notation of MVP, apparently by history; • May 2008 a-fib diagnosis; • June 2010 VA examination report noting no evidence of MVP or coronary artery disease, with a conclusion (without explanation) that current a-fib is unrelated to service; • The Veteran’s contention that his current cardiac disorder had its onset in or is related to his in-service noted cardiac impairment. (b.) When rendering the opinion regarding the etiology of the Veteran’s hypertension, the examiner is asked to consider and comment on the clinical significance of the following evidence: • March 1979 in-service blood pressure reading of 144/94; • January 1980 in-service blood pressure reading of 130/90; • March 1980 in-service blood pressure reading of 126/90; • Subsequent March 1980 in-service blood pressure reading of 120/90; • August 1980 in-service blood pressure reading of 131/93; • December 1980 in-service blood pressure reading of 140/90; • February 1981 in-service blood pressure reading of 136/90; • June 2007 first post-service diagnosis of hypertension of record, and subsequent continued diagnoses of hypertension; • NAS Institute of Medicine’s Veterans and Agent Orange: Update 11 (2018) that upgraded hypertension from its previous classification in the category of “limited or suggestive” evidence of an association with exposure to Agent Orange to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. A rationale for any opinion offered should be provided. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected hiatal hernia and related disabilities. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria, to specifically include a determination as to whether the Veteran has each of the following symptoms: dysphagia (difficulty swallowing), pyrosis (heartburn), regurgitation, and/or substernal arm or shoulder pain and indicate whether these symptoms are productive of a considerable impairment of health. The examiner should also address the functional impact that the Veteran’s hiatal hernia and related disabilities have on his daily life. A rationale for any opinion offered should be provided. 5. Provide the Veteran and his representative with a statement of the case regarding the issues of entitlement to service connection for bilateral foot disorders, bilateral hearing loss, chronic sinusitis, allergic rhinitis, erectile dysfunction, and tinea cruris. Advise them of the time period in which to perfect an appeal. If the Veteran perfects his appeal of such issue in a timely fashion, then return the case to the Board for its review, as appropriate. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Nicole L. Northcutt, Counsel