Citation Nr: 18157920 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 15-16 619 DATE: December 13, 2018 ORDER Service connection for temporomandibular joint dysfunction is granted. Service connection for an anxiety disorder is granted. Service connection for migraine headaches is granted. Service connection for hemorrhoids with anal fissure is granted. Service connection for obstructive sleep apnea is denied. Entitlement to nonservice-connected pension benefits is dismissed. REMANDED Service connection for a shoulder disability is remanded. Service connection for a back disability is remanded. Service connection for an acquired psychological disability other than anxiety (to include depression and chronic paranoid psychosis) is remanded. Service connection for a gastrointestinal disability (to include irritable bowel syndrome) is remanded. Service connection for hypertension is remanded. Service connection for a sleep disability other than sleep apnea (to include insomnia and sleep dysfunction with arousal disturbance) is remanded. Service connection for tinnitus is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, his temporomandibular joint dysfunction (TMD) began during active duty for training service. 2. Resolving reasonable doubt in the Veteran’s favor, his anxiety disorder began during active service. 3. Resolving reasonable doubt in the Veteran’s favor, his migraine headaches are proximately due to his service-connected TMD and anxiety disorder. 4. Resolving reasonable doubt in the Veteran’s favor, his hemorrhoids with anal fissure began during active service. 5. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of sleep apnea. 6. In a February 2017 written communication, prior to promulgation of a decision in the matters, the Veteran indicated that he wished to withdraw his claim for nonservice-connected pension benefits. CONCLUSIONS OF LAW 1. The criteria for service connection for temporomandibular joint dysfunction are met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 2. The criteria for service connection for anxiety disorder are met. 38 U.S.C. §§ 1110, 1153, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.306(a) (2017). 3. The criteria for secondary service connection for migraine headaches are met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.310(a) (2017). 4. The criteria for service connection for hemorrhoids with anal fissure are met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 5. The criteria for service connection for sleep apnea are not met. 38 U.S.C. §§ 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 6. The criteria for withdrawal of an appeal are met as to the claim seeking nonservice-connected pension; the Board has no further jurisdiction in this matter. 38 U.S.C. §§ 7104, 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran honorably served on active duty for training from April 2001 to May 2001, from July 2001 to September 2001, and from July 2005 to September 2006. The Veteran honorably served on active duty from December 2003 to July 2005 and from October 2008 to April 2009. This matter is before the Board of Veterans’ Appeals (Board) on appeal from May 2014 and April 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Board notes that the evidence indicates that the Veteran is currently homeless; thus, the case is being advanced on the Board’s docket. The Board notes that the Veteran has submitted claims for service connection for depression, anxiety, and posttraumatic stress disorder. See September 2013 Veteran’s Application for Compensation or Pension (VA Form 21-526). However, the medical evidence indicates that the Veteran’s claimed symptoms of paranoia from posttraumatic stress disorder are related to his diagnosed chronic paranoid psychosis. See March 2014 Veteran’s Statement in Support of Claim for PTSD (VA Form 21-0781); November 2014 Primary Care Outpatient Note. The Veteran does not presently have a diagnosis of PTSD. Therefore, the Board will broadly construe the claim for service connection for anxiety, depression, and PTSD as a claim for service connection for an acquired psychological disability to include anxiety, depression, and chronic paranoid psychosis. Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (holding that the Board must consider any disability that “may reasonably be encompassed by” the description of the claim and symptoms or other submitted information.). This decision splits the issue of entitlement to an acquired psychological disability to include anxiety, depression, and chronic paranoid psychosis into two issues: (1) service connection for an anxiety disorder and (2) service connection for an acquired psychological disability other than anxiety disorder (to include depression and chronic paranoid psychosis). This permits a grant of service connection for anxiety disorder, to which the evidence of record shows the Veteran is entitled, without the delay of awaiting additional adjudication relating to whether he is also entitled to service connection for an acquired psychological disability other than anxiety disorder. See Locklear v. Shinseki, 24 Vet. App. 311 (2011) (splitting a claim generally is within VA’s discretion). The Board also notes that the Veteran filed a claim for sleep apnea. See February 2017 Veteran’s Application for Compensation or Pension (VA Form 21-526EZ). However, his treatment records reflect that, in seeking a diagnosis of sleep apnea, he reported being “up and down” all night, daytime sleepiness, snoring, arousals, and other symptoms. See April 2017 Neurology Consult. After a polysomnogram, the Veteran was not diagnosed with sleep apnea, but was diagnosed with sleep dysfunction with arousal disturbance and the Veteran has also been diagnosed with insomnia. Therefore, the Board will broadly construe the claim for service connection for sleep apnea as a claim for service connection for a sleep disability (to include sleep apnea, sleep dysfunction with arousal disturbance, and insomnia). Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (holding that the board must consider any disability that “may reasonably be encompassed by” the description of the claim and symptoms or other submitted information.). This decision then splits the issue of service connection for a sleep disability (to include sleep apnea, sleep dysfunction with arousal disturbance, and insomnia) into two issues: (1) service connection for sleep apnea and (2) service connection for a sleep disability other than sleep apnea (to include sleep dysfunction with arousal disturbance and insomnia). This permits adjudication on the issue of sleep apnea without the delay of awaiting additional adjudication relating to whether he is entitled to service connection for other sleep disabilities. See Locklear v. Shinseki, 24 Vet. App. 311 (2011) (splitting a claim generally is within VA’s discretion). Service Connection Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires evidence showing: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury incurred or aggravated in service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding the merits of an issue, the benefit of the doubt shall be given to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. If the preponderance of the evidence is against the claim, the claim is to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. Service connection for temporomandibular joint dysfunction (TMD). The Veteran reports that he has had persisting pain in his jaw since having a tooth extracted during a period of active duty for training (ADT). See March 2014 VA Examination (Temporomandibular Joint Conditions) by W.R., Dentist.; October 2005 Service Treatment Record by J.S., Physician. The March 2014 examiner provided the Veteran with a TMD diagnosis and opined that the Veteran’s TMD was at least as likely as not caused or aggravated by the October 2005 extraction. See March 2014 VA Examination (Temporomandibular Joint Conditions) by W.R., Dentist. A private medical provider in April 2018 agreed with the March 2014 examiner that the TMD was at least as likely as not caused or aggravated by the October 2005 extraction. See April 2018 Private Provider Report by R.W., M.D. The Board concludes that the Veteran has a current diagnosis of temporomandibular joint dysfunction that began during ADT and is related to the in-service extraction. Accordingly, service connection for TMD is warranted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Because this is a period of ADT in which the Veteran was disabled from a disease or injury incurred or aggravated in line of duty, he has now established Veteran status for this period of service, which applies to all other disabilities that may be claimed in regard to this period of service. See 38 U.S.C. § 101(24)(B); Hill v. McDonald, 28 Vet. App. 243 (2016). 2. Service connection for an anxiety disorder. The Veteran reports that he began experiencing anxiety due to being escorted around his technical training by armed security shortly after the September 11th terrorist attacks. Then, when he was activated for active duty in February 2003, he became overwhelmed by anxiety in part because he feared being deployed to Iraq and because he was required to conduct post- and pre-deployment screenings, which made him feel responsible for his fellow airmen’s lives. During this time, he was afraid that he would be discharged from the Air Force if he reported this anxiety and depression. Lastly, he reports that his January 2006 period of active duty required him to witness severely injured and wounded servicemembers returning from deployment, which caused him to have nightmares and insomnia. See March 2014 Veteran’s Statement in Support of Claim for PTSD (VA Form 21-0781). The Veteran’s wife reports that his psychological struggles became really noticeable when he was in his last periods of active duty, although the Veteran’s sister noted changes in approximately 2004. See March 2017 Spouse’s Lay Statement; September 2017 Sister’s Lay Statement. October 2013 through July 2018 VA treatment records show the Veteran has a current diagnosis of anxiety, and the January 2018 private psychological provider opined that the Veteran’s anxiety disorder at least as likely as not began during his active duty for training or active service and has continued uninterrupted into the present. See January 2018 Psychological Report by H.G., Ph.D. The opinion is probative because it is based on a clinical interview with the Veteran, review of the entire claims file, and medical journal evidence. See id. Notably, on examination for active duty mobilization for the Veteran’s first period of active duty, he was noted to have anxiety treated with Paxil and was not qualified for mobilization. See February 2003 Mobilization Examination by T.A. M.Sgt. The Board finds that the lay statements from the Veteran and his family provide competent and credible evidence that the Veteran worsened over the course of this and subsequent periods of active duty. See March 2014 Veteran’s Statement in Support of Claim for PTSD (VA Form 21-0781); March 2017 Spouse’s Lay Statement; September 2017 Sister’s Lay Statement. Accordingly, the Veteran’s anxiety is presumed to have been aggravated by active duty service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). Accordingly, the Board concludes that the Veteran has a current diagnosis of anxiety disorder that began during active duty for training service or was aggravated by active service and which has persisted to the present. Therefore, service connection for anxiety is warranted. 38 U.S.C. §§ 1110, 1153, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.306(a); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 3. Service connection for migraine headaches. Establishing secondary service connection requires evidence of: (1) a current disability (for which secondary service connection is sought); (2) a service-connected disability; and (3) that the current disability was either caused or aggravated by the service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). The April 2018 private provider’s report shows the Veteran has a current diagnosis of migraine headaches and the private provider opined that it is at least as likely as not proximately due to or the result of his now service-connected TMD and anxiety disorders. See April 2018 Private Provider Report by R.W., M.D. Accordingly, because it is at least as likely as not that the Veteran’s migraine headaches are proximately due to his service-connected disabilities, the claim for service connection for migraine headaches must be granted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310(a); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 4. Service connection for hemorrhoids with anal fissure. The Veteran reports recurrent chronic pain due to hemorrhoids with anal fissure. See March 2013 Veteran’s Statement in Support of Claim (VA Form 21-4138); April 2014 VA Examination (Rectum and Anus Conditions) by M.T., Chief of Staff. VA treatment records reflect diagnoses of hemorrhoids and anal fissures. See, e.g., April 2015 Gastroenterology Consult Note by T.W., N.P. The April 2014 VA examiner opined that the Veteran’s hemorrhoids with anal fissure at least as likely as not began during active service and continued because the Veteran’s recurrent symptoms are consistent with the medical presentation and manifestation of hemorrhoids and rectal fissure. See April 2014 VA Examination (Rectum and Anus Conditions) by M.T., Chief of Staff. Accordingly, the Board concludes that the Veteran has a current diagnosis of hemorrhoids with anal fissure that began during active service and which has recurred into the current period on appeal. Therefore, service connection for hemorrhoids with anal fissure is warranted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 5. Service connection for sleep apnea In the absence of a current disability, service connection cannot be granted for such disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or at any time during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007). In this case, the Veteran does not have a diagnosis of sleep apnea. After filing his claim, the Veteran had a polysomnogram that reflected no apnea episodes and he was noted as not having sleep apnea. See June 2017 Neurology Sleep Study Final Report; see also June 2017 Sleep Center Normal Study Letter (“Your recent sleep study reveals that you do not have sleep apnea.”); March 2018 Primary Care Outpatient Note (“Had sleep study in June 2017, no sleep apnea.”). Accordingly, because the preponderance of the evidence is against a finding that the Veteran has sleep apnea, the claim for service connection for sleep apnea must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 6. Entitlement to nonservice-connected pension benefits. The Board has jurisdiction where there is a question of law or fact in a matter on appeal to the Secretary. 38 U.S.C. § 7104. Under 38 U.S.C. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 C.F.R. § 20.202. The withdrawal of an appeal must be either in writing or on the record at a hearing. 38 C.F.R. § 20.204. If the appeal involves multiple issues, the withdrawal must specify that the appeal is withdrawn in its entirety, or list the issue(s) withdrawn from the appeal. Id. In the present case, the Veteran perfected an appeal as to the issue of entitlement to nonservice-connected pension benefits. See May 2015 Veteran’s Appeal to the Board (VA Form 9). In a February 2017 writing, the Veteran explicitly and unambiguously withdrew the claim for nonservice-connected pension benefits. See February 2017 Veteran’s Statement in Support of Claim (VA Form 21-4138). The Board finds that there remain no allegations of error of fact or law for appellate consideration. Accordingly, the Board has no further jurisdiction to review the appeal with respect to the issue of entitlement to nonservice-connected pension benefits and the appeal must be dismissed. REASONS FOR REMAND 1. The issues of service connection for a shoulder disability and a back disability are remanded. The Board finds that further development of the record is necessary to meet VA’s duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully-informed decision on the claim at this time because the record does not include an opinion that adequately addresses the facts and circumstances presented by the Veteran’s case. In particular, the Veteran reported that his back and shoulder pain began in September 2005, for which he has now established Veteran status. In treatment records, the Veteran reported that his back and shoulder pain began after a motor vehicle accident in 2007. See July 2008 Clinic Note by A.B., M.D. This latter incident would also raise the issue of service connection by aggravation in his subsequent active duty periods. VA is required to provide an examination when there is insufficient medical evidence to decide the claim, but the record otherwise contains competent evidence of a current disability or recurrent symptoms, evidence of an in-service event, and evidence of an indication of a nexus. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 2. Service connection for an acquired psychological disability other than anxiety (to include depression and chronic paranoid psychosis) is remanded. The Board finds that further development of the record is necessary to meet VA’s duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully-informed decision on the claim at this time because the record does not include an opinion that addresses the Veteran’s other psychological diagnoses of depression and chronic paranoid psychosis. VA is required to provide examination when there is insufficient medical evidence to decide the claim, but the record otherwise contains competent evidence of a current disability or recurrent symptoms, evidence of an in-service event, and evidence of an indication of a nexus. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); 38 C.F.R. § 3.159(c)(4)(i). Additionally, the Veteran has reported to VA treatment providers that he is on Social Security Administration (SSA) disability benefits in connection with chronic paranoid psychosis. See July 2018 Clinic Note by A.C., M.D. Because the Veteran’s SSA records may reasonably contain information relating to the Veteran’s issues on appeal, remand is required to obtain his SSA records. See Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010). 3. Service connection for a gastrointestinal disability (to include irritable bowel syndrome) is remanded. The Board finds that further development of the record is necessary to meet VA’s duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The record reflects that there is outstanding, relevant medical evidence from Malcolm Grow Clinic at Andrews Joint Base. See September 2013 Authorization and Consent to Release Information (VA Form 21-4142). In March 2014, the RO was notified that outpatient records from Malcolm Grow Clinic were retired to the NPRC, see March 2014 Air Force Memorandum by M.P., but it does not appear that any attempt was made to obtain records from the NPRC. Additionally, the Veteran has not been diagnosed with irritable bowel syndrome, but has reported symptoms that the VA examiner said were “consistent with Irritable Bowel Syndrome – 564.1” See March 2014 VA Examination (Intestinal Conditions) by W.H., P.A. There is no explanation for why the examiner declined to provide a diagnosis. The Veteran should be afforded an opportunity for another examination to obtain a diagnosis. 4. Service connection for hypertension is remanded. The Board finds that further development of the record is necessary to meet VA’s duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully-informed decision on the claim at this time because the record does not include an examination of this condition and it is not clear when the Veteran developed hypertension. For example, the Veteran was prescribed lisinopril in October 2008, which was during a period of active duty service, but there is no clear diagnosis of hypertension until after service. See June 2009 Primary Care Note (Service Department Facility) (Listing lisinopril as prescribed in October 2008 and February 2009). VA is required to provide examination when there is insufficient medical evidence to decide the claim, but the record otherwise contains competent evidence of a current disability or recurrent symptoms, evidence of an in-service event, and evidence of an indication of a nexus. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); 38 C.F.R. § 3.159(c)(4)(i). 5. Service connection for a sleep disability other than sleep apnea (to include insomnia and sleep dysfunction with arousal disturbance) is remanded. The Board finds that further development of the record is necessary to meet VA’s duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully-informed decision on the claim at this time because the record does not include an opinion that addresses the issue of secondary service connection to the Veteran’s now service-connected anxiety disorder. VA is required to provide examination when there is insufficient medical evidence to decide the claim, but the record otherwise contains competent evidence of a current disability or recurrent symptoms, evidence of an in-service event, and evidence of an indication of a nexus. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); 38 C.F.R. § 3.159(c)(4)(i). The Veteran did not include any statements as to the onset of his sleep disorder symptoms to suggest that a sleep disorder was incurred in service. See February 2017 Veteran’s Application for Disability Compensation (VA Form 21-526EZ); April 2017 Neurology Consult Note (placing onset of symptoms approximately 4-5 years prior). However, the evidence also reflects that the Veteran’s sleep symptoms are intertwined with his psychological symptoms. See, e.g., April 2018 Psychiatry Clinic Note by J.W., N.P. Accordingly, a remand is required to obtain an opinion on secondary service connection. 6. Service connection for tinnitus is remanded. The Board finds that further development of the record is necessary to meet VA’s duty to assist the Veteran in developing evidence to substantiate his claim. See 38 C.F.R. § 3.159. The Board cannot make a fully-informed decision on the the claim at this time because the record does not include an opinion that adequately explains the conclusion that the Veteran’s tinnitus is not related to service because he has no hearing loss. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion… must support its conclusion with an analysis that the Board can consider and weigh.”). Whenever VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: 1. Obtain the Veteran’s complete treatment records from the Malcolm Grow Clinic (Joint Base Andrews). In correspondence received March 2014, Joint Base Andrews’s medical group informed the RO that outpatient records for the relevant timeframe were retired to the NPRC. All attempts to fulfill this development should be documented in the claim file. If the records are unavailable, it should so be noted on the record and the reason for unavailability should be provided. 2. Request directly from the Social Security Administration all records, including determinations and medical records, regarding any claim for disability benefits. All attempts to fulfill this development should be documented in the claim file. If the records are unavailable, it should so be noted on the record and the reason for unavailability should be provided. 3. After completion of directives one and two, schedule the Veteran for an examination by an appropriate clinician to determine the nature and cause of the Veteran’s shoulder pain condition(s). Based on the factual evidence of record and the examination, the examiner must provide an opinion that responds to the following: (a.) Please identify the Veteran’s shoulder condition(s) by diagnosis(es). (b.) If no diagnosis(es) is given, please state whether the Veteran has pain with functional impairment that is not attributable to any diagnosed disability. [The Board notes that the Veterans Court recently held that pain, even without a diagnosis, does count as a disability for VA compensation purposes if the pain causes functional impairment]. (c.) For EACH of the diagnosed conditions or conditions of pain with functional impairment, is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current shoulder condition(s) was incurred in active air service, to include as beginning in active duty air service? The Veteran’s active duty air service was from February 27, 2003 to August 22, 2004; from August 24, 2004 to July 8, 2005; from July 10, 2005 to September 30, 2006*; and from October 1, 2008 to April 1, 2009. *By law, Veteran status has been established for this period by virtue of a grant for service connection for a disability incurred during this period. (d.) If the answers to (c) above is negative, for EACH of the diagnosed conditions or conditions of pain with functional impairment, is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current shoulder condition(s) was incurred during active duty for training air service? The Veteran’s active duty for training service was from April 4, 2001 to May 21, 2001 and from July 2, 2001 to September 28, 2001. (e.) If the answers to (c) and (d) above are negative and if it is determined that the Veteran had a condition that pre-existed any period of active air duty (not active duty for training), is there clear and unmistakable (obvious, manifest, and undebatable) evidence that this condition WAS NOT aggravated during service OR that it is clear and unmistakable (obvious, manifest, and undebatable) that any increase in symptoms was due to natural progress? The examiner is advised that AGGRAVATION is defined as a permanent increase in severity of the disability beyond its natural progression. In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. 4. After completion of directives one and two, schedule the Veteran for an examination by an appropriate clinician to determine the nature and cause of the Veteran’s back pain condition(s). Based on the factual evidence of record and the examination, the examiner must provide an opinion that responds to the following: (a.) Please identify the Veteran’s back condition(s) by diagnosis(es). (b.) If no diagnosis(es) is given, please state whether the Veteran has pain with functional impairment that is not attributable to any diagnosed disability. [The Board notes that the Veterans Court recently held that pain, even without a diagnosis, does count as a disability for VA compensation purposes if the pain causes functional impairment]. (c.) For EACH of the diagnosed conditions or conditions of pain with functional impairment, is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current back condition(s) was incurred in active air service, to include as beginning in active duty air service? The Veteran’s active duty air service was from February 27, 2003 to August 22, 2004; from August 24, 2004 to July 8, 2005; from July 10, 2005 to September 30, 2006*; and from October 1, 2008 to April 1, 2009. *By law, Veteran status has been established for this period by virtue of a grant for service connection for a disability incurred during this period. (d.) If the answers to (c) above is negative, for EACH of the diagnosed conditions or conditions of pain with functional impairment, is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current back condition(s) was incurred in the during active duty for training air service? The Veteran’s active duty for training service was from April 4, 2001 to May 21, 2001 and from July 2, 2001 to September 28, 2001. (e.) If the answers to (c) and (d) above are negative and if it is determined that the Veteran had a back condition that pre-existed any period of active air duty (not active duty for training), is there clear and unmistakable (obvious, manifest, and undebatable) evidence that this condition WAS NOT aggravated during service OR that it is clear and unmistakable (obvious, manifest, and undebatable) that any increase in symptoms was due to natural progress? The examiner is advised that AGGRAVATION is defined as a permanent increase in severity of the disability beyond its natural progression. In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. 5. After completion of directives one and two, schedule the Veteran for an examination by an appropriate clinician to determine the nature and cause of the Veteran’s psychological condition(s), including the Veteran’s diagnosed depression and chronic paranoid psychosis. Based on the factual evidence of record and the examination, the examiner must provide an opinion that responds to the following: (a.) Please identify the Veteran’s psychological condition(s) by diagnosis(es). Please provide a complete explanation (rationale) if the diagnoses of depression and/or chronic paranoid psychosis are not given. (b.) For EACH* of the diagnosed psychological conditions(s), is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current psychological condition(s) was incurred in active duty air service, to include as beginning in active duty service? *Please do not provide an opinion on anxiety disorder; this is already service-connected. The Veteran’s active duty air service was from February 27, 2003 to August 22, 2004; from August 24, 2004 to July 8, 2005; from July 10, 2005 to September 30, 2006*; and from October 1, 2008 to April 1, 2009. *By law, Veteran status has been established for this period by virtue of a grant for service connection for a disability incurred during this period. (c.) If the answer to (b) above is negative, for EACH* of the diagnosed psychological conditions(s), is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current psychological condition(s) was incurred during active duty for training air service, to include as beginning in active duty for training air service? *Please do not provide an opinion on anxiety disorder; this is already service-connected. The Veteran’s active duty for training service was from April 4, 2001 to May 21, 2001 and from July 2, 2001 to September 28, 2001. (d.) Is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s psychological conditions (to include chronic paranoid psychosis and depression) were proximately caused by or aggravated by the Veteran’s service-connected anxiety? The examiner is advised that AGGRAVATION is defined as a permanent increase in severity of the disability beyond its natural progression. (e.) If the answers to (b) through (d) above are negative and if it is determined that the Veteran had a psychological condition that pre-existed any period of active air duty (not active duty for training), is there clear and unmistakable (obvious, manifest, and undebatable) evidence that this condition WAS NOT aggravated during service OR that it is clear and unmistakable (obvious, manifest, and undebatable) that any increase in symptoms was due to natural progress? The examiner is advised that AGGRAVATION is defined as a permanent increase in severity of the disability beyond its natural progression. Please note that the Veteran and others have submitted statements, including statements received in March 2014 and in April 2018, that directly address the Veteran’s psychological symptoms and their onset. In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. 6. After completion of directives one and two, schedule the Veteran for an examination by an appropriate clinician to determine the nature and cause of the Veteran’s gastrointestinal condition(s). Based on the factual evidence of record and the examination, the examiner must provide an opinion that responds to the following: (a.) Please identify the Veteran’s gastrointestinal condition(s) by diagnosis(es). Please complete all diagnostic studies required to diagnose the Veteran. (b.) If no diagnosis(es) is given, please state whether the Veteran has pain with functional impairment that is not attributable to any diagnosed disability. [The Board notes that the Veterans Court recently held that pain, even without a diagnosis, does count as a disability for VA compensation purposes if the pain causes functional impairment]. (c.) For EACH of the diagnosed conditions or conditions of pain with functional impairment, is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current gastrointestinal condition(s) was incurred in active air service, to include as beginning in active duty air service? The Veteran’s active duty air service was from February 27, 2003 to August 22, 2004; from August 24, 2004 to July 8, 2005; from July 10, 2005 to September 30, 2006*; and from October 1, 2008 to April 1, 2009. *By law, Veteran status has been established for this period by virtue of a grant for service connection for a disability incurred during this period. (d.) If the answers to (c) above is negative, for EACH of the diagnosed conditions or conditions of pain with functional impairment, is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current gastrointestinal condition(s) was incurred during active duty for training air service? The Veteran’s active duty for training service was from April 4, 2001 to May 21, 2001 and from July 2, 2001 to September 28, 2001. (e.) Is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s gastrointestinal condition(s) was proximately caused by or aggravated by the Veteran’s service-connected anxiety? The examiner is advised that AGGRAVATION is defined as a permanent increase in severity of the disability beyond its natural progression. (f.) If the answers to (c) through (e) above are negative and if it is determined that the Veteran had a gastrointestinal condition that pre-existed any period of active air duty (not active duty for training), is there clear and unmistakable (obvious, manifest, and undebatable) evidence that this condition WAS NOT aggravated during service OR that it is clear and unmistakable (obvious, manifest, and undebatable) that any increase in symptoms was due to natural progress? The examiner is advised that AGGRAVATION is defined as a permanent increase in severity of the disability beyond its natural progression. In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. 7. After completion of directives one and two, schedule the Veteran for an examination by an appropriate clinician to determine the nature and cause of the Veteran’s hypertension. Based on the factual evidence of record and the examination, the examiner must provide an opinion that responds to the following: (a.) Is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current hypertension was incurred in active air service, to include as beginning in active duty air service? The Veteran’s active duty air service was from February 27, 2003 to August 22, 2004; from August 24, 2004 to July 8, 2005; from July 10, 2005 to September 30, 2006*; and from October 1, 2008 to April 1, 2009. *By law, Veteran status has been established for this period by virtue of a grant for service connection for a disability incurred during this period. (b.) Is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current hypertension was manifest to a compensable degree within one year of the end of any period of active duty air service? In this case, compensable means: the diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. The Veteran’s active duty air service was from February 27, 2003 to August 22, 2004; from August 24, 2004 to July 8, 2005; from July 10, 2005 to September 30, 2006*; and from October 1, 2008 to April 1, 2009. *By law, Veteran status has been established for this period by virtue of a grant for service connection for a disability incurred during this period. (c.) If the answers to (a) and (b) above are negative, is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current hypertension was incurred during active duty for training air service? The Veteran’s active duty for training service was from April 4, 2001 to May 21, 2001 and from July 2, 2001 to September 28, 2001. (d.) If the answers to (a) through (c) above are negative and if it is determined that the Veteran had a hypertension c that pre-existed any period of active air duty (not active duty for training), is there clear and unmistakable (obvious, manifest, and undebatable) evidence that this condition WAS NOT aggravated during service OR that it is clear and unmistakable (obvious, manifest, and undebatable) that any increase in symptoms was due to natural progress? The examiner is advised that AGGRAVATION is defined as a permanent increase in severity of the disability beyond its natural progression. The Veteran’s active duty air service was from February 27, 2003 to August 22, 2004; from August 24, 2004 to July 8, 2005; from July 10, 2005 to September 30, 2006*; and from October 1, 2008 to April 1, 2009. The examiner’s attention is drawn to the following evidence (the following is a brief factual background and not intended to be a substitute for your review of the Veteran’s claims folder): *January 2001 blood pressure reading (BP) showing BP of 90/60 (taken prior to joining active duty for training of “ADT”). *July 2001 BP of 134/80 (while in ADT). *September 2001 BP of 146/85 (while in ADT). *January 2004 BP of 125/98 (while in active duty or “AD”). *March 2005 BP of 132/80 (while in AD). *August 2005 BP of 145/91 (while in AD). *December 2005 BP of 138/82 (while in AD). *January 2007 BP of 138/90 (neither in ADT, nor AD, but within one year of AD). *January 2008 BP of 121/98 (neither in ADT, nor AD). *October 2008 Veteran prescribed lisinopril (while in AD). *January 2009 BP of 118/90 (while in AD). *February 2009 Veteran prescribed lisinopril (while in AD). *June 2009 BP of 155/106 (neither in ADT, nor AD, but within one year of AD). *July 2009 BP of 141/100 (neither in ADT, nor AD, but within one year of AD). *January 2010 BP of 140/90 (neither in ADT, nor AD, but within one year of AD). In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. 8. After completion of directives one and two, schedule the Veteran for an examination by an appropriate clinician to determine the nature and cause of the Veteran’s sleep disorder condition(s), including the Veteran’s diagnosed insomnia and sleep dysfunction with arousal disturbance. Based on the factual evidence of record and the examination, the examiner must provide an opinion that responds to the following: (a.) Please identify the Veteran’s sleep disorder condition(s) by diagnosis(es). Please provide a complete explanation (rationale) if the diagnoses of insomnia and sleep dysfunction with arousal disturbance are not given. (b.) Is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s sleep disorder condition(s) was proximately caused by or aggravated by Veteran’s service-connected anxiety disorder? The examiner is advised that AGGRAVATION is defined as a permanent increase in severity of the disability beyond its natural progression. In forming any opinions, the Board emphasizes that the Veteran is competent to report what his symptoms are and when they began. If the Veteran’s statements are inconsistent with the medical evidence, the examiner must provide a comprehensive report including a complete explanation (rationale) for all opinions and conclusions reached, citing the objective medical findings or other evidence leading to the conclusion that his statements are inconsistent with the medical evidence. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. 9. Obtain an addendum opinion from an appropriate clinician regarding the nature cause of the Veteran’s tinnitus condition(s). The addendum opinion should address whether it is at least as likely as not related to active service or active duty for training. The addendum opinion should explain the relevance of hearing loss on tinnitus. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). If the examiner cannot provide answers because further information, examination, or diagnostic studies are required, all reasonable steps to obtain this information, examination, or diagnostic studies should be exhausted before concluding that the answer cannot be provided. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Lambert, Associate Counsel