Citation Nr: 18157963 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 16-28 181 DATE: December 13, 2018 ORDER 1. The application to reopen the claim of entitlement to service connection for a lumbar spine disability is granted. 2. Entitlement to service connection for bilateral hearing loss disability is denied. 3. Entitlement to service connection for ischemic heart disease (IHD) is denied. REMANDED 4. The reopened claim of entitlement to service connection for a lumbar spine disability is remanded. 5. Entitlement to service connection for an eye disorder, to include glaucoma and double vision, is remanded. 6. Entitlement to service connection for colon cancer, to include a pelvic disorder, is remanded. 7. Entitlement to an initial disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is remanded. 8. Entitlement to an initial compensable disability rating for hypertension is remanded. 9. Entitlement to an initial compensable disability rating for erectile dysfunction (ED) is remanded. 10. Entitlement to a temporary total evaluation because of convalescence for colon cancer surgery in 2012 is remanded. FINDINGS OF FACT 1. In a September 1972 rating decision, the Agency of Original Jurisdiction (AOJ) continued the denial of service connection for residuals of a back injury, finding a lack of evidence of a current disability. The Veteran was notified of this decision by an October 1972 letter, but he did not appeal this decision or submit new and material evidence within one year; thus, the September 1972 rating decision became final. 2. Evidence associated with the claims file since the September 1972 rating decision, when considered by itself or in connection with evidence previously assembled, relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a lumbar spine disability, and raises a reasonable possibility of substantiating the claim. 3. Right ear hearing loss disability was shown on entry into active duty service; this disability did not increase in severity during active duty service; and, the Veteran’s current right ear hearing loss disability is not otherwise related to his active duty service. 4. The Veteran’s current left ear hearing loss disability did not manifest in service or within one year of separation from active duty service and it is not otherwise related to his active duty service. 5. The preponderance of the evidence is against a finding that the Veteran has IHD or has had IHD since filing the present claim for service connection or in close proximity to filing the claim. CONCLUSIONS OF LAW 1. The September 1972 rating decision continuing the denial of entitlement to service connection for residuals of a back injury is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104(a), 20.302(a), 20.1103 (2017). 2. As evidence received since the September 1972 rating decision is new and material, the criteria for reopening the claim of entitlement to service connection for a lumbar spine disability have been met. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (2017). 3. The criteria for entitlement to service connection for bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1101, 1110, 1111, 1112, 1153, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307, 3.309, 3.385 (2017). 4. The criteria for entitlement to service connection for IHD have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from July 1966 to July 1968. The law provides that VA must broadly consider claims and when a veteran asserts service connection, he does so for symptoms regardless of how those symptoms are diagnosed or labeled. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009). Thus, the Board has re-characterized the issue of entitlement to glaucoma as it is listed on the title page of this decision. 1. Application to Reopen the Claim of Entitlement to Service Connection for a Lumbar Spine Disability In an October 1968 rating decision, the AOJ denied service connection for residuals of a back injury based on a finding that there was no current disability. The AOJ informed the Veteran of the denial that same month. In June 1972, the Veteran filed an application to reopen the claim for service connection for residuals of a back injury. In a September 1972 rating decision, the RO continued the denial of service connection for residuals of a back injury because the evidence of record still did not show that the Veteran had a current back disability. The Veteran was notified of this decision by an October 1972 letter, but he did not appeal this decision or submit new and material evidence within one year. Thus, the September 1972 rating decision is final as to the evidence of record, and is not subject to revision on the same factual basis. See 38 U.S.C. § 7105(b); see also 38 C.F.R. §§ 3.104, 3.156(a), 20.302, 20.1103. The Veteran submitted an application to reopen the claim of entitlement to service connection for a lumbar spine disability in September 2011. VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of a veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); see Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). VA defines “new” evidence as evidence not previously submitted to agency decision makers and “material” evidence as evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. When determining whether the claim should be reopened, the credibility of the newly submitted evidence is presumed. See Justus v. Principi, 3 Vet. App. 510 (1992). The newly presented evidence need not be probative of all the elements required to award the claim, just probative of each element (or at least one element) that was a specified basis for the last disallowance of the claim. See Evans v. Brown, 9 Vet. App. 273, 283 (1996). Since the 1972 rating decision, new evidence has been associated with the claims file that shows the presence of a current lumbar spine disability. For example, an October 2012 VA examination report showed that the Veteran was diagnosed with thoracolumbar spondylosis following a magnetic resonance imaging (MRI) scan. Given that the threshold for substantiating a claim to reopen is low, this evidence, when considered by itself or in connection with evidence previously assembled, relates to an unestablished fact necessary to substantiate the claim, namely, pertains to the presence of a current lumbar spine disability, and raises a reasonable possibility of substantiating the claim. Thus, the claim of entitlement to service connection for a lumbar spine disability is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. The Board is remanding the reopened claim for additional development, which is described below. Service Connection, Generally The Veteran contends that his current bilateral hearing loss disability and IHD disorders are caused by his active duty service, to include his service in the Republic of Vietnam. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304(b); see Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111. Where a disorder is noted on service entrance, a veteran is not presumed sound as to the disorder that was noted and 38 U.S.C. § 1153 (2012) applies. A pre-existing injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153. Aggravation is not conceded, however, where the disability underwent no increase in severity during service based on all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). Service connection may also be established under 38 C.F.R. § 3.303(b), if a chronic disease is shown in service, and subsequent manifestations of the same chronic disease at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331, 1340 (Fed. Cir. 2013). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as sensorineural hearing loss (an organic disease of the nervous system), become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113 (2012); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. However, where the evidence does not warrant presumptive service connection, a veteran is not precluded from establishing service connection with proof of direct causation. See Combee, 34 F.3d at 1043. When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (2017). In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a) (2012). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). 2. Service Connection for Bilateral Hearing Loss Disability The Veteran contends that his current bilateral hearing loss disability was caused or aggravated by his active duty service. Specifically, he contended throughout the appeal that his right ear hearing loss disability, which preexisted his active duty service, was aggravated by service and that his current left ear hearing loss disability was caused by his duties associated with his military occupational specialty (MOS) of being a light and heavy vehicle driver and a light truck driver. Under VA regulations, hearing impairment constitutes a disability for VA purposes when auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The record shows that the Veteran has a current bilateral hearing loss disability. For example, he underwent a VA audiological examination in October 2012, which showed the following pure tone thresholds, in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 40 30 35 65 65 LEFT 40 30 70 70 65 The Veteran’s Maryland CNC speech recognition scores showed speech recognition of 84 percent in each ear. The examiner determined that the Veteran had sensorineural hearing loss in both ears. Thus, the Veteran has current bilateral hearing loss disability, and the first element of service connection is met. Regarding the second element of service connection, the Veteran’s personnel records show that his MOS was as a heavy vehicle driver. His July 1966 service induction Report of Medical Examination showed that the audiometer results, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 30 30 30 30 35 LEFT 30 15 15 15 30 These findings show that the Veteran had a right ear hearing loss disability for VA purposes upon entry into service, and that his left ear hearing was abnormal at the 500 Hz and 4000 Hz frequencies. See 38 C.F.R. § 3.385. While this regulation did not exist in 1966, under summary of defects, the examiner wrote that the Veteran had defective hearing in the right ear. As a result of these findings, the analysis for right ear hearing loss disability is different than that for left ear hearing loss disability, and the Board will address them separately. Regardless, the Board concedes that the Veteran was exposed to acoustic trauma during service, and thus the second element of service connection, evidence of a disease or injury in service, is met. Right ear hearing loss disability The Board finds as fact that the Veteran entered service with a right ear hearing loss disability, as documented in the July 1966 Report of Medical Examination. Thus, the presumption of soundness does not apply to this disability, and service connection is warranted only if the right ear hearing loss disability was aggravated during service. The Board finds that the Veteran’s right ear hearing loss disability was not aggravated during service. For example, the service treatment records do not show complaints of or treatment for abnormal hearing symptoms during active duty service. His July 1968 service separation Report of Medical Examination showed the following audiometer results, in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT -5 (10) 10 (20) 10 (20) X 0 (5) LEFT -5 (10) 10 (20) 10 (20) X 0 (5) Between January 1967 and January 1970, audiometric results were reported in standards set forth by the American Standards Association (ASA) or the International Standards Organization (ISO)-American National Standards Institute (ANSI). The Veteran’s July 1968 audiogram is assumed to reflect ASA standards; thus, the Board has converted the ASA standards into ISO standards, as reflected in the parentheses above. An “X” denotes that the audiometer results were not tested or available at the applicable frequency. The evaluator assigned a “1” rating assessing the Veteran’s hearing under the PULHES profile system, indicating that the Veteran’s hearing was then in a high level of fitness. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992). The PULHES profile reflects the overall physical and psychiatric condition of a veteran on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service), with the “P” standing for stamina, “U” standing for upper extremities, “L” standing for lower extremities, “H” standing for hearing, “E” standing for eyes, and “S” standing for psychiatric symptoms. In the Report of Medical History that the Veteran completed at service discharge, he specifically denied a history of hearing loss and ear, nose, or throat trouble. Thus, the Veteran’s right ear hearing loss was not shown to have been aggravated during service. This conclusion is supported by an October 2012 VA medical opinion. The examiner noted that the Veteran enlisted into active duty service with a hearing loss disability in the right ear and noted that the Veteran’s service separation evaluation showed normal hearing sensitivity in the right ear. This examiner found that the Veteran’s hearing loss disability existed prior to service and that it did not get worse. In fact, the examiner noted that the record showed that the Veteran’s hearing loss was markedly improved from his service enlistment physical, which showed that he had a hearing loss disability, to having normal hearing, which indicated that whatever was causing the hearing loss at service entrance had resolved by the Veteran’s service separation evaluation. The Board is aware that in an August 2012 private opinion by a general medicine doctor, she listed that the Veteran had bilateral hearing loss and checked the box that indicated was “as most likely caused by or the result of” and she added “military service.” She also noted that the Veteran “[a]lso suffers hearing impairment that can be related back to his military years.” This opinion does not assist in the award of service connection for right ear hearing loss disability for two reasons. One, the examiner did not acknowledge that the Veteran had a right ear hearing impairment upon entry into service. Two, she did not provide a rationale for her opinion. Thus, her opinion is accorded no probative value. As stated above, aggravation is not conceded where the disability underwent no increase in severity during service based on all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). As specifically noted by the VA examiner, the Veteran’s hearing loss in the right ear was improved at discharge, and thus there was no aggravation shown in service, and service connection for a right ear hearing loss disability is denied. Left ear hearing loss disability The Board finds that the preponderance of the evidence is against a finding that the current left ear hearing loss disability is related to service. In an October 2012 VA medical opinion, the examiner opined that the Veteran’s left ear hearing loss disability was not at least as likely as not (50 percent probability or greater) caused by or the result of an event during active duty service. The examiner explained that the Veteran’s enlisted into active duty service with a hearing loss in the left ear at 4000 and 6000 Hz. The examiner noted that the Veteran’s service separation evaluation showed normal hearing sensitivity in both ears and that the evidence did not support a delayed onset of noise-induced hearing loss. The Board does not find that the abnormal finding in the left ear made by the October 2012 VA examiner is evidence that a left ear hearing loss disability existed prior to service. The entrance examination specifically addressed defective hearing in the right ear only. Thus, the Veteran’s left ear hearing is presumed sound. The Board acknowledges the Veteran’s contentions that his current hearing loss disability is related to his in-service noise exposure, to include as due to his duties as light and heavy vehicle driver and a light truck driver. While the Veteran is competent to report symptoms that he perceived through his own senses, he is not competent to offer an opinion as to the cause or aggravation of his current bilateral hearing loss disability due to the medical complexity of the matter involved. Hearing loss requires specialized training for a determination as to diagnosis, causation, and progression, and is therefore not susceptible to lay opinions on causation or aggravation. Thus, the Veteran is not competent to render an opinion or attempt to present lay assertions to establish the causation of his current bilateral hearing loss disability. Additionally, the Veteran specifically denied a history of hearing loss at service separation. As to the August 2012 private doctor’s opinion that the Veteran’s bilateral hearing loss was related to service, the Board finds that this medical opinion lacks any probative value for multiple reasons. The doctor did not provide an audiological evaluation or indicate she had reviewed the Veteran’s service treatment and other pertinent records and did not provide a rationale for her opinion. However, the Board finds the October 2012 VA examiner’s opinion as highly probative evidence regarding the cause of the left ear hearing loss disability because of the examiner’s expertise, training, education, proper support and explanations, and thorough review of the Veteran’s records and self-reported symptoms. Additionally, this examiner specifically addressed the August 2012 private doctor’s medical opinion regarding the cause of the Veteran’s current bilateral hearing loss disability. Given this evidence, the Board finds that the current left ear hearing loss disability did not manifest in service or within one year of separation from active duty service. The first diagnosis of left ear hearing loss disability was in approximately 2012, which is decades following the Veteran’s service discharge. Thus, presumptive service connection is not warranted. Additionally, the evidence shows that the left ear hearing loss disability is not otherwise related to his active duty service. Therefore, as the preponderance of the evidence is against entitlement to service connection for bilateral hearing loss disability, the benefit of the doubt doctrine does not apply, and the Veteran’s claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 3. Service Connection for IHD The Veteran contends that he has a current IHD disability that was caused by his exposure to herbicide agents while stationed in the Republic of Vietnam during the Vietnam War Era. The Board notes that for the diseases listed in 38 C.F.R. § 3.309(e), including IHD, the evidentiary requirements for establishing entitlement to service connection benefits are more relaxed. The regulations provide that when exposure to herbicide agents is established during active duty, diseases associated with herbicide exposure that manifest at any date, however remote, after service are entitled to service connection, unless they are clearly attributable to causes unrelated to service (“intercurrent causes”). See 38 C.F.R. § 3.307(d). The diseases listed at 38 C.F.R. § 3.309(e) must become manifest to a degree of 10 percent or more at any time after service, except for certain diseases, which are required to have manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during the active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). The Veteran’s service personnel records, including his DD Form 214, show that he had service in the Republic of Vietnam during the Vietnam Era. Thus, the presumptive provisions of 38 C.F.R. § 3.309(e) as to herbicide agent exposure apply. However, the Board finds that the preponderance of the evidence is against a finding that the Veteran has IHD or has had such a disability since filing the present claim for service connection or in close proximity to filing the claim. The reasons for this conclusion follow. The Veteran filed a claim for service connection for IHD in April 2012. In an August 2012 medical opinion, a private internal medicine doctor noted that the Veteran’s current diagnoses included IHD, as well as PTSD, prostate cancer, tinnitus, diabetes mellitus, bilateral hearing loss, and ED. She also “checked off” a box indicating that these disorders were as most likely caused by or a result of the Veteran’s military service. However, apart from a generic statement that the private doctor examined the Veteran, a thorough review of this one-page nexus statement does not show how the private doctor determined that the Veteran had IHD. Specifically, she did not cite to any medical records, studies, or treatment notes in which the Veteran was treated for any heart disorder. Contrarily, in an October 2012 VA examination report, an examiner determined that the Veteran did not have IHD after reviewing the Veteran’s pertinent records, performing an in-person examination, and noting the Veteran’s self-reported symptoms and history. The examiner explained that the Veteran did not take any medication for a heart disorder and that he did not have a history of percutaneous coronary intervention, myocardial infarction, coronary bypass surgery, a heart transplant, implanted cardiac pacemaker or automatic implanted cardioverter defibrillator, or congestive heart failure. A June 2012 chest x-ray and June 2012 electrocardiogram (EKG), as well an October 2012 echocardiogram, did not show any diagnosable heart disability. The examiner concluded after reviewing the Veteran’s claims file that he did not have IHD. The examiner also noted that the August 2012 private doctor’s comment that the Veteran had IHD was not based on objective findings, nor was that diagnosis based on procedures, such as a stress test or a cardiac catheterization. After a thorough review of the Veteran’s claims file, including the post-active duty service private and VA treatment records, the preponderance of the record is against a finding that the Veteran has a heart disability or has had a heart disability since filing his claim for service connection in April 2012 or in close proximity to filing the claim. The only evidence indicating the presence of this disability during the appeal period comes from the August 2012 private doctor’s opinion. However, as noted in the October 2012 VA examination report, the private doctor did not state any reason as to why an IHD diagnosis was warranted for the Veteran’s cardiac symptoms, including any studies or procedures. The Board finds the October 2012 VA examiner’s opinions as highly probative evidence regarding the lack of a current or previous heart disorder, to include IHD, because of the examiner’s expertise, training, education, proper support and explanations, thorough review of the Veteran’s records and self-reported symptoms, and citation to diagnostic tests, such as an October 2012 echocardiogram and June 2012 chest x-ray and EKG. Moreover, this examiner specifically addressed the August 2012 private doctor’s diagnosis. Overall, the Veteran’s VA and private medical treatment records since the October 2012 VA examination do not show a diagnosis of any heart disability. In fact, the Veteran denied having any cardiac issues or problems in a March 2013 VA psychiatry multidiscipline note. Apart from generally disagreeing with the denial of entitlement to service connection for IHD in a February 2014 notice of disagreement (NOD) and the June 2016 substantive appeal to the Board (VA Form 9), the Veteran and his representative have not identified any competent evidence showing the presence or diagnosis of IHD during the appeal. Thus, the Board finds that the preponderance of the evidence is against a finding that the Veteran has IHD, and the benefit-of-the-doubt rule does not apply. Absent a current disability, the claim of entitlement to service connection for IHD is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND The Board remands the claims of entitlement to service connection for a lumbar spine disability, an eye disorder, and colon cancer for addendum VA medical opinions. The Board also remands the increased rating claims for PTSD, hypertension, and ED, as well as the claim of entitlement to a temporary total evaluation, for additional procedural development. The record shows that the Veteran was afforded a VA examination for his lumbar spine claim in October 2012, during which the examiner diagnosed the Veteran with thoracolumbar spondylosis and indicated that arthritis was documented in the lumbar spine following an MRI scan. This examiner opined that the Veteran’s lumbar spine disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury of falling from a truck in January 1968. The examiner explained that the Veteran’s service treatment records only include a Request for Information by VA dated July 26, 1968, which mentioned the alleged back injury after the Veteran fell from a truck on January 4, 1968. The examiner noted that there was no evidence in the service treatment records of a back injury, and that the Veteran’s service separation evaluation was negative for a low back disorder. The examiner stated that there was no evidence of a lumbar spine disability until the 2000s, which was more than 40 years after separation from active duty service. The Board determines that this medical opinion is inadequate to adjudicate the Veteran’s service connection claim for a lumbar spine disability because the examiner did not discuss the Veteran’s complaints of a lumbar spine disability within the same month of separating from active duty service, as well as the fact that he filed a claim for service connection for a back disorder in July 1968, during which he alleged that he fell from the back of a truck in January 1968. The October 2012 VA medical opinion also does not discuss a September 1968 VA examination report during which the Veteran was diagnosed with a lumbar strain. Given that the Veteran has a current arthritic disorder in his lumbar spine, and that he was diagnosed with lumbar strain within one year of separation from active duty service, the Board determines that an addendum VA medical opinion is necessary to answer whether the Veteran’s current lumbar spine disability, to include thoracolumbar spondylosis, manifested in service or within one year of separation from active duty service, or is otherwise related to his active duty service. The Board must also remand the claim of entitlement to service connection for an eye disorder, to include glaucoma and double vision, for an addendum VA medical opinion. While the Veteran was afforded a VA examination for his eyes in October 2012, during which he was diagnosed with glaucoma suspect (anatomic narrow angle), the VA examiner did not provide an opinion regarding the cause of this disorder or its relationship to the Veteran’s active duty service. Furthermore, the Board notes that the Veteran alleged in several statements, including in October 2012, that he had symptoms of double vision, or diplopia, due to his service-connected hypertension. Because the claims file does not contain a medical opinion discussing the causal link between the Veteran’s current eye disorder and his active duty service and/or his service-connected hypertension, a remand is necessary. The Board must remand the Veteran’s claim for service connection for colon cancer, to include a pelvic disorder, for an addendum VA medical opinion and because the record shows that new medical evidence was associated with the claims file since the issuance of the statement of the case (SOC) in June 2016. Specifically, in an October 2012 VA examination, the Veteran was diagnosed with rectum cancer. While the examiner provided an opinion that the Veteran’s 2012 status-post resection of rectal adenocarcinoma was not caused by or related to his instances of abdominal pain, diarrhea with red blood, and mucous stool while in service in 1967, the examiner did not discuss or provide an opinion as to whether the Veteran’s presumed exposure to herbicide agents, including Agent Orange, while stationed in Vietnam caused his current colon cancer. The Board notes that while colon cancer is not one of the diseases listed in 38 C.F.R. § 3.309(e), where the evidence does not warrant presumptive service connection, a veteran is not precluded from establishing service connection with proof of direct causation. See Combee, 34 F.3d at 1043. Additionally, the claims file includes an August 2018 VA examination report in which a VA examiner wrongfully noted in the examination report that the Veteran was service connected for fecal incontinence as a result of the 2012 colon cancer surgery. As the record currently stands, the Veteran is not service connected for fecal incontinence. Thus, this medical opinion is based on an inaccurate factual predicate, and the Board will seek an addendum VA medical opinion to determine whether the Veteran’s colon cancer was caused by or otherwise related to his presumed exposure to herbicide agents while stationed in Vietnam. The Board must remand the service connection claim for colon cancer, as well as the increased rating claims for PTSD, hypertension, and ED, because new, relevant medical evidence was associated with the claims file since the issuance of the June 2016 SOC. Specifically, as noted above, an August 2018 VA examination of the rectum and anus shows that the VA examiner stated that the Veteran’s fecal incontinence was service connected and that this disability was due to rectal cancer diagnosed in 2012. Additionally, the claims file includes numerous VA treatment records since June 2016 that discuss and treat the current severity of the Veteran’s PTSD, hypertension, and ED symptoms. For example, these disorders were discussed in August 2016, March 2017, September 2017, November 2017, April 2018, August 2018, and September 2018 VA treatment records. Generally, the Board may not consider additional evidence not previously reviewed by the AOJ unless a waiver of initial AOJ review is obtained from a claimant. Disabled American Veterans, et. al. v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003); 38 C.F.R. § 20.1304(c) (2017). Although 38 U.S.C. § 7105(e) provides an automatic waiver of initial AOJ review if a claimant submits evidence to the AOJ or the Board with, or after submission of a substantive appeal to the Board (VA Form 9), this provision is only applicable to cases where the VA Form 9 was filed on or after February 2, 2013. 38 U.S.C. § 7105(e) (2012). While the Veteran filed his VA Form 9 in August 2016, 38 U.S.C. § 7105(e) does not apply to VA-generated evidence, such as VA treatment records and VA examination reports. As there is no indication that the Veteran has waived initial AOJ adjudication, a remand is required in the case for the AOJ to consider the new evidence relevant to the service connection claim for colon cancer and the increased rating claims for PTSD, hypertension, and ED. The claim for a temporary total evaluation due to convalescence for colon cancer surgery in 2012 is inextricably intertwined with the claim for entitlement to service connection for colon cancer, to include a pelvic disorder, and thus the Board will defer this issue until after that issue is decided, as the outcome of the service-connection claim would impact whether a temporary total evaluation based on convalesce for surgery for this disorder is warranted. The matters are REMANDED for the following actions: 1. Return the claims file to the October 2012 VA examiner who examined the Veteran’s thoracolumbar spine, and request that she re-review the claims file and respond to the below inquiries regarding the Veteran’s service connection claim for a lumbar spine disability. If that examiner deems it necessary or is otherwise unavailable, schedule the Veteran for an appropriate VA examination to assist in determining the nature and cause of his current lumbar spine disability symptoms. All appropriate tests, studies, and consultations should be accomplished and all clinical findings should be reported in detail. Based upon a review of the relevant evidence, history provided by the Veteran, the October 2012 VA examination report, and sound medical principles, the VA examiner should provide an opinion as to: (a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s current lumbar spine disability, to include thoracolumbar spondylosis, manifested in service or within one year of separation from service, or was caused by or otherwise related to the Veteran’s active duty service from July 1966 to July 1968, to include falling from a truck in January 1968. In rendering an opinion, the examiner should discuss the significance of the Veteran’s July 1968 application for compensation or pension in which he filed a claim for service connection for a back disorder, as well as a September 1968 VA examination report that showed a diagnosis of lumbar strain. See VBMS entry with document type, “VA 21-526 Veterans Application for Compensation or Pension,” receipt date 07/19/1968, at pages 1-4; VBMS entry with document type, “VA Examination,” receipt date 08/28/1968, at pages 1-12. The examiner is asked to provide a rationale for each opinion given with reference to relevant evidence of record and/or medical principles, as appropriate. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 2. Return the claims file to the October 2012 VA examiner who examined the Veteran’s eyes, and request that he re-review the claims file and respond to the below inquiries regarding the Veteran’s service connection claim for an eye disorder. If that examiner deems it necessary or is otherwise unavailable, schedule the Veteran for an appropriate VA examination to assist in determining the nature and cause of his current eye disorder, to include glaucoma and double vision symptoms. All appropriate tests, studies, and consultations should be accomplished and all clinical findings should be reported in detail. Based upon a review of the relevant evidence, history provided by the Veteran, the October 2012 VA examination report, and sound medical principles, the VA examiner should provide an opinion as to: (a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s current eye disorder, to include glaucoma and double vision, was caused by or otherwise related to the Veteran’s active duty service from July 1966 to July 1968. (b.) If the answer to (a.) is no, is at least as likely as not (50 percent probability or greater) that the Veteran’s current eye disorder, to include glaucoma and double vision, was caused by his service-connected hypertension? (c.) If the answer to (b.) is no, is it at least as likely as not that the Veteran’s eye disorder was permanently aggravated beyond the natural progression by the service-connected hypertension? (d.) If the examiner finds that the service-connected hypertension aggravates/aggravated the Veteran’s eye disorder, to include glaucoma and/or double vision, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the eye disorder prior to aggravation. If the examiner is unable to establish a baseline for the eye disorder prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. The examiner is asked to provide a rationale for all conclusions reached with reference to relevant evidence of record and/or medical principles, as appropriate. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 3. Return the claims file to the October 2012 VA examiner who examined the Veteran’s colon cancer disorder, and request that he re-review the claims file and respond to the below inquiries regarding the Veteran’s service connection claim for colon cancer, to include a pelvic disorder. If that examiner deems it necessary or is otherwise unavailable, schedule the Veteran for an appropriate VA examination to assist in determining the nature and cause of his current colon cancer disorder symptoms. All appropriate tests, studies, and consultations should be accomplished and all clinical findings should be reported in detail. Based upon a review of the relevant evidence, history provided by the Veteran, the October 2012 VA examination report, and sound medical principles, the VA examiner should provide an opinion as to: (a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s current colon cancer, to include status-post low anterior resection surgery (LAR), is caused by or otherwise related to the Veteran’s active duty service from July 1966 to July 1968, to include being exposed to herbicide agents in the Republic of Vietnam. In rendering an opinion, the examiner is informed that in the August 2018 VA examination report, the examiner wrote that the Veteran was service-connected for fecal incontinence due to rectal cancer diagnosed in 2012 and status-post proctectomy, laparoscopically by total mesorectal excision with splenic flexor takedown and coloanal anastomosis, when, in fact, the Veteran is NOT service connected for such disability. This is why an addendum medical opinion is being requested, as it was based on an inaccurate medical history. See VBMS entry with document type, “C&P Exam,” receipt date 08/21/2018, at pages 1-11. The examiner is asked to provide a rationale for all conclusions reached with reference to relevant evidence of record and/or medical principles, as appropriate. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 4. Readjudicate the claims of entitlement to: (1) service connection for a lumbar spine disability; (2) service connection for an eye disorder, to include glaucoma and double vision; (3) service connection for colon cancer, to include a pelvic disorder; (4) an initial disability rating in excess of 70 percent for PTSD; (5) an initial compensable disability rating for hypertension; (6) an initial compensable disability rating for ED; and, (7) a temporary total evaluation because of convalescence for colon cancer surgery in 2012 in light of the new evidence, including the new medical evidence associated with the claims file after June 2016. If any benefit sought on appeal remains denied, a supplemental statement of the case (SSOC) should be furnished to the Veteran and his representative, and they should be afforded a reasonable opportunity to respond. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Hodzic, Counsel